Ann RC oll Surg Engl 2008; 90:6 94-695 694 A40-year-old man was admitted with a1-day history of sudden onset of left-sided chest pain radiating down to his left abdomen. The pain was constant in nature and he denied any previous episodes. He described one episode of vomiting but his bowelh abitw as normal and, in particular, he denied any episodes of rectal bleeding or diarrhoea. On functional enquiry,h ed escribed episodes of exertional dyspnoea whichwas new in onset. There was no pastmedical history of note, nor had he had recent trauma or surgery.On examination, he looked unwell and dyspnoeic. He was apyrexial and haemodynamically stable. Examination of the respiratory system revealed decreased air entry in the left lung base. He was noted to have as oft abdomen with some tenderness in the epigastrium. An ECG was normal. Initial laboratory investigations revealed aw hite cell count of 13.9. Arterial blood gases on air revealed ap O 2 of 9.01 and mildly raised lactate of 2.73. Initial chest radiography confirmed left lower lobe consolidation. Pleural tap and septic screen were sent.Eight hours after admission, the patient became progressively more tachycardic and complained of increasing abdominal pain. As urgical review was requested and this revealed tenderness in the LUQ. It was still felt that his abdominal signs were secondary to ap rimary chest infection. However,a sh is pain was disproportionate to his abdominal signs, aCTscan was arranged to exclude further pathology.T his revealed evidence of herniation of small bowel loops through al eft-sided anterior diaphragmatic hernia. Af luid collection was seen at the superior aspect of the hernia with collapse of the underlying lung and shift of the mediastinum to the right (Fig. 1).Tw elve hoursa fter admission, the patient was taken to theatre. Initial laparoscopy revealed as trangulated 3-cm left diaphragmatic hernia containings mall bowela nd transverse colon. The contents of the hernia were difficult to reduce laparoscopically; therefore, an emergency laparo- We report an unusual case of strangulated diaphragmatic (Morgagni) hernia resulting in ischaemia of the small and large bowel, which was initially diagnosed as ap neumonia. This case highlights the importance of being aware of this rare, but potentially fatal condition when assessing patients with respiratory symptoms and abdominal pain. CASE REPORT

Drains have been used in surgery for several years to remove body fluids thereby preventing the accumulation of serous fluid and improving wound healing. Drains may be classified as closed or open systems, and active or passive depending on their intended function. Closed vacuum drains apply negative suction in a sealed environment, producing apposition of tissues and thus promoting healing. Correct assessment of clinical indications might reduce unnecessary usage. This article will introduce the principles and practice of various types of drains and highlight the importance of understanding how surgical drains promote quality patient care.

Methicillin-resistant Staphylococcus aureus (MRSA) is a serious threat to patients in health care facilities and the community. A MRSA infection can be much more severe than other bacterial infections and can be life-threatening. Resistance to common antibiotics makes treating MRSA costly and difficult. Prolonged hospitalization requiring specialized IV antibiotics also has cost implications. Treatment of MRSA can include use of antibiotics; topical therapies such as honey, topical silver, and gentian violet; and bacteriophages. Research is being conducted on new antibiotics and a MRSA vaccine.

High- and low-pressure vacuum drains are commonly used after surgical procedures. High-pressure vacuum drains (ie, sealed, closed-circuit systems) are efficient and allow for easy monitoring and safe disposal of the drainage. Low-pressure vacuum drains use gentle pressure to evacuate excess fluid and air, and are easy for patients to manage at home because it is easy to reinstate the vacuum pressure. Perioperative nurses should be able to identify the various types of commonly used drains and their surgical applications. Nurses should know how to care for drains, how to reinstate the vacuum pressure when necessary, and the potential complications that could result from surgical drain use.