Lower Abdominal Pain In Women Research Articles

Laparoscopic management of ischemic right fallopian tube torsion mimicking perforated appendicitis.

BackgroundIsolated fallopian tube torsion is a rare cause of acute lower abdominal pain in females. A history of hemosalpinx, hydrosalpinx, or ovarian or paraovarian cysts might all be risk factors. Diagnosis is frequently delayed until it's too late to salvage the tube.Case presentationA 32-year-old lady with no prior medical and surgical history presented to our emergency department with a four days history of severe right lower abdomen pain and tenderness accompanied by nausea. Clinically, she was feverish, with elevated C reactive protein levels, negative serum Beta HCG, and normal urine analysis. Computed tomography demonstrated a 5x3cm collection in the right lower quadrant of the abdomen. A diagnostic laparoscopy was performed upon exploration a Twice-fold twisted ischemic right fallopian tube with hydrosalpinx was found and Salpingectomy was performed.ConclusionsTorsion of the fallopian tube is an uncommon cause of acute lower abdominal pain in women. The exact process that causes isolated tubal torsion is unknown. Early diagnostic laparoscopy and surgical intervention are essential in a nulliparous young woman.

Analgesia by Sacral Surface Electrical Stimulation for Primary Dysmenorrhoea.

ObjectiveTo evaluate the effects of analgesia by sacral surface electrical stimulation on lower abdominal pain in women with primary dysmenorrhoea.DesignExplorative study.ParticipantsEleven female university students, who regularly experience difficulty in their university work due to menstrual pain, or who use analgesics for more than one day each month, were recruited.MethodsSacral surface electrical stimulation, 5 Hz for 15 min, was performed after the onset of menstruation. Electrodes were placed on the skin, directly above the second and fourth sacral foramina. Visual analogue scale and degree of pain (calculated by using a low current to assess pain) were determined before and after electrical stimulation.ResultsVisual analogue scale score and degree of pain decreased significantly immediately after electrical stimulation (p < 0.001). A correlation was observed between visual analogue scale score and degree of pain before and after electrical stimulation (r=0.516, p <0.001). No side-effects were observed in any participant.ConclusionSacral surface electrical stimulation may provide immediate pain relief in women with dysmenorrhoea and lower abdominal pain.LAY ABSTRACTEleven female university students, who regularly experience difficulty performing their university work due to menstrual pain, or who use analgesics for more than one day each month, received electrical stimulation for relief of lower abdominal pain. Electrodes were placed on the skin over the lower region of the spine, while participants were in the prone position. Stimulation was performed for 15 min at a frequency of 5 Hz. Lower abdominal pain associated with menstruation decreased immediately after electrical stimulation; no side-effects were observed in any participant. For women who do not wish to take analgesics, electrical stimulation could be an option for complementary therapy. These findings indicate that electrical stimulation of the skin over the lower spine may provide immediate relief of menstrual pain.

Ultrasonographic Diagnosis of Lower Abdominal Pain

Lower abdominal pain is one of the most common symptoms prompting patients to visit hospitals. It can be caused mainly by gastrointestinal diseases such as appendicitis, an appendiceal tumor, diverticulitis, enterocolitis, epiploic appendagitis, Crohn’s disease, ulcerative colitis, and colon cancer. In case of lower abdominal pain in women of reproductive age, gynecological causes must always be considered. Distal ureteral stones must be ruled out in patients with lower abdominal pain and hematuria. Rectus sheath hematomas should be considered in patients with trauma, anticoagulants, or recent strenuous exercise. Correct and prompt diagnosis, primarily by imaging techniques such as abdominal ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI), is essential for the appropriate management of patients. As compared with CT or MRI, abdominal US is easily performed at the bedside, minimally invasive, and emits no ionizing radiation. Nonetheless, diagnostic sensitivity for lower abdominal disease, including appendicitis, is lower than with CT or MRI, so a complementary study may be performed if the diagnosis remains unclear. Keywords: Ultrasonography; Appendicitis; Abdominal pain 중심 단어: 초음파; 충수염; 복통

Emergent complication of assisted reproductive technology: Clinical analysis of 17 pregnant women with adnexal torsion

BackgroundThe purpose of this study was to evaluate the clinical symptoms, surgical management, and outcomes of pregnant women with adnexal torsion due to assisted reproductive technology. MethodsIt was a retrospective study that include 17 pregnant women with adnexal torsion, in which the maternal age, type of fertilization, gestational age, clinical symptoms, ultrasonic findings, side affected by the disease, surgical method, and pregnancy outcomes were evaluated. ResultsA total of 17 patients with adnexal torsion were included in this study, of which 8 patients conceived by in vitro fertilization-embryo transfer (IVF-ET), 1 by artificial insemination (AIH), and the other 8 conceived naturally after ovulation induction. About 14 were reported to have occurred in the first trimester of pregnancy, 1 case in the second trimester, and the other 2 in the third trimester. Clinical symptoms were abdominal pain with or without nausea and vomiting. 14 cases occurred in the right adnexa and the other 3 in the left. 5 of the patients underwent laparoscopy, and the other 12 underwent laparotomy. 8 cases were of full- term delivery, 6 twins gave birth prematurely, and 3 patients had inevitable abortion. ConclusionsAdnexal torsion is an acute onset of lower abdominal pain in women, which seldom occurs during pregnancy. However, because of the wide application of assisted reproductive technology (ART), its incidence has increased. Early diagnosis and treatment can lead to better results.

Adalimumab mitigates ovarian ischemia-reperfusion injury in rats by regulating oxidative stress, apoptosis and resolution of inflammation.

Ovarian torsion is a rare but an important reason of acute lower abdominal pain in women and associated with serious morbidity and mortality, if not treated promptly. The aim of this study was to evaluate the effects of an antitumor necrosis factor-α antibody on ovarian torsion in a rat model of ischemia-reperfusion (I/R) injury. Forty female Wistar Albino rats were used in the present study. The rats were randomly divided into four groups: group I (sham), group II (I/R), group III (I/R + isotonic saline) and group IV (I/R + adalimumab). The I/R model was induced by torsion of both ovaries. Immunohistochemical staining for interleukin-1β (IL-1β), nuclear factor-κB (NF-κB), and inducible nitric oxide synthase was performed. Tissue and serum oxidative stress markers in conjunction with apoptotic index (AI) with the terminal deoxynucleotidyl transferase dUTP nick end labeling method were also calculated. Tissue total oxidant status, oxidative stress index and nitric oxide values were significantly decreased, and tissue total antioxidant status was found to be increased in group IV. Inflammation, vascular congestion and hemorrhagia were significantly lower in adalimumab-treated group. Serum oxidative stress markers and tissue malondialdehyde levels did not differ in study groups. The AI was significantly increased in groups 2 and 3. Adalimumab treatment significantly decreased the AI. Adalimumab therapy in rats attenuated I/R induced ovarian injury, possibly suppressing inflammation, inhibiting oxidative stress, and altering apoptotic pathways.

The treatment of sexually transmitted infections

The high level of sexually transmitted infections (STIs) in South Africa can be attributed to a large number of factors including low socio-economic conditions, social stigma, gender inequalities, inability to access adequate health care systems and lack of preventative programmes. The main curable STIs consist of chlamydia, gonorrhoea, syphilis and trichomoniasis, most of which occur in the developing world. The inability to adequately treat the infections leads to morbidity and has wide-ranging consequences on reproductive health and the health of infants. Due to the inefficient treatment of STIs, the World Health Organisation (WHO) recommended and promoted the syndromic management of STIs in developing countries at the point of contact with the health service provider with the intention of improving the quality of care of these patients. The syndromic approach to STI management depends on patient symptoms and the signs presented at the clinical examination. The four main syndrome management protocols are for urethral discharge and swollen testes, genital ulcers, vaginal discharge and lower abdominal pain in women. After identification of a syndrome, combined therapy is utilised to treat the common causes of the infection. A diagnosis can be made quite rapidly without the need for expensive equipment and tests or special skills. Health care providers make use of flow charts or algorithms for diagnosis and treatment. Algorithms or flowcharts should be adapted to local conditions taking into consideration aetiology, local antimicrobial susceptibility patterns and drug availability. These protocols will help with the prevention and treatment STIs in South Africa.

Laparoscopy for the management of acute lower abdominal pain in women of childbearing age.

This is an updated version of the original review, published in Issue 1, 2011, of The Cochrane Library. Acute lower abdominal pain is common, and making a diagnosis is particularly challenging in premenopausal women, as ovulation and menstruation symptoms overlap with symptoms of appendicitis, early pregnancy complications and pelvic infection. A management strategy involving early laparoscopy could potentially provide a more accurate diagnosis, earlier treatment and reduced risk of complications. To evaluate the effectiveness and harms of laparoscopy for the management of acute lower abdominal pain in women of childbearing age. TheMenstrual Disorders and Subfertility Group (MDSG) Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, PsycINFO, LILACS and CINAHL were searched (October 2013). The International Clinical Trials Registry Platform (ICTRP) was also searched. No new studies were included in this updated version. Randomised controlled trials (RCTs) that included women of childbearing age who presented with acute lower abdominal pain, non-specific lower abdominal pain or suspected appendicitis were included. Trials were included if they evaluated laparoscopy with open appendicectomy, or laparoscopy with a wait and see strategy. Study selection was carried out by two review authors independently. Data from studies that met the inclusion criteria were independently extracted by two review authors and the risk of bias assessed. We used standard methodological procedures as expected by The Cochrane Collaboration. A summary of findings table was prepared using GRADE criteria. A total of 12 studies including 1020 participants were incorporated into the review. These studies had low to moderate risk of bias, mainly because allocation concealment or methods of sequence generation were not adequately reported. In addition, it was not clear whether follow-up was similar for the treatment groups. The index test was incorporated as a reference standard in the laparoscopy group, and differential verification or partial verification bias may have occurred in most RCTs. Overall the quality of the evidence was low to moderate for most outcomes, as per the GRADE approach.Laparoscopy was compared with open appendicectomy in eight RCTs. Laparoscopy was associated with an increased rate of specific diagnoses (seven RCTs, 561 participants; odds ratio (OR) 4.10, 95% confidence interval (CI) 2.50 to 6.71; I(2) = 18%), but no evidence was found of reduced rates for any adverse events (eight RCTs, 623 participants; OR 0.46, 95% CI 0.19 to 1.10; I(2) = 0%). A meta-analysis of seven studies found a significant difference favouring the laparoscopic procedure in the rate of removal of normal appendix (seven RCTs, 475 participants; OR 0.13, 95% CI 0.07 to 0.24; I(2) = 0%).Laparoscopic diagnosis versus a 'wait and see' strategy was investigated in four RCTs. A significant difference favoured laparoscopy in terms of rate of specific diagnoses (four RCTs, 395 participants; OR 6.07, 95% CI 1.85 to 29.88; I(2) = 79%), but no evidence suggested a difference in rates of adverse events (OR 0.87, 95% CI 0.45 to 1.67; I(2) = 0%). We found that laparoscopy in women with acute lower abdominal pain, non-specific lower abdominal pain or suspected appendicitis led to a higher rate of specific diagnoses being made and a lower rate of removal of normal appendices compared with open appendicectomy only. Hospital stays were shorter. No evidence showed an increase in adverse events when any of these strategies were used.

Acute right lower abdominal pain in women of reproductive age: Clinical clues

To study possible gynecological organ pathologies in the differential diagnosis of acute right lower abdominal pain in patients of reproductive age. Following Clinical Trials Ethical Committee approval, the retrospective data consisting of physical examination and laboratory findings in 290 patients with sudden onset right lower abdominal pain who used the emergency surgery service between April 2009 and September 2013, and underwent surgery and general anesthesia with a diagnosis of acute appendicitis were collated. Total data on 290 patients were obtained. Two hundred and twenty-four (77.2%) patients had acute appendicitis, whereas 29 (10%) had perforated appendicitis and 37 (12.8%) had gynecological organ pathologies. Of the latter, 21 (7.2%) had ovarian cyst rupture, 12 (4.2%) had corpus hemorrhagicum cyst rupture and 4 (1.4%) had adnexal torsion. Defense, Rovsing's sign, increased body temperature and increased leukocyte count were found to be statistically significant in the differential diagnosis of acute appendicitis and gynecological organ pathologies. Gynecological pathologies in women of reproductive age are misleading in the diagnosis of acute appendicitis.

Validation of the diagnostic score for acute lower abdominal pain in women of reproductive age.

Background. The differential diagnoses of acute appendicitis obstetrics, and gynecological conditions (OB-GYNc) or nonspecific abdominal pain in young adult females with lower abdominal pain are clinically challenging. The present study aimed to validate the recently developed clinical score for the diagnosis of acute lower abdominal pain in female of reproductive age. Method. Medical records of reproductive age women (15–50 years) who were admitted for acute lower abdominal pain were collected. Validation data were obtained from patients admitted during a different period from the development data. Result. There were 302 patients in the validation cohort. For appendicitis, the score had a sensitivity of 91.9%, a specificity of 79.0%, and a positive likelihood ratio of 4.39. The sensitivity, specificity, and positive likelihood ratio in diagnosis of OB-GYNc were 73.0%, 91.6%, and 8.73, respectively. The areas under the receiver operating curves (ROC), the positive likelihood ratios, for appendicitis and OB-GYNc in the validation data were not significantly different from the development data, implying similar performances. Conclusion. The clinical score developed for the diagnosis of acute lower abdominal pain in female of reproductive age may be applied to guide differential diagnoses in these patients.

Persistent abdominal pain over uterine scar during labor as a predictor of delivery complications

ObjectiveTo evaluate the significance of persistent lower abdominal pain in women with previous cesarean delivery. MethodsVarious maternal outcomes were compared between women who underwent repeated cesareans owing to persistent lower abdominal pain (study group) and women who underwent repeated cesareans without persistent abdominal pain (control group). ResultsThe incidence of uterine rupture was significantly higher in the study group than in the control group (8/81 [9.9%] vs 0/119 [0.0%]; P<0.001). While all women with persistent lower abdominal pain and uterine rupture had an additional sign or symptom, only 6/73 (8.2%) women with persistent abdominal pain without uterine rupture had any additional symptoms (P<0.001). There was no difference in incidence of uterine scar dehiscence between the groups. However, the hospitalization period was significantly longer in the study group (4 vs 3.7days; P<0.05). Trial of labor was a contributing factor to uterine rupture. ConclusionIsolated persistent lower abdominal pain in women with previous cesarean is a poor indicator of uterine rupture. However, the positive predictive value for uterine rupture is 57% when an additional sign or symptom is present. Dehiscence of the uterine scar is relatively common and it is not associated with persistent abdominal pain.

Clinical Indicators for Differential Diagnosis of Acute Lower Abdominal Pain in Women of Reproductive Age

Background: Acute lower abdominal pain in women of reproductive age is a challenging condition for clinical diagnosis. Computerized tomography yields high accuracy, but may not be cost-effective in low-middle income countries. Selective diagnostic approach based on clinical findings may be more appropriate. Methods: Medical record review was performed on patients aging between 15 - 50 years who admitted to the surgical department or obstetrics and gynecology (OB-GYN) unit because of acute lower abdominal pain during January to December 2008. Patients were eventually categorized into appendicitis, OB-GYN conditions, or non-specific abdominal pain (NSAP). Clinical indicators were studied for diagnostic values using polytomous logistic regression applied to likelihood ratio for positive test (LR + ) and confidence interval (CI). Results: Anorexia, nausea and vomiting, shifting of abdominal pain decreased the likelihood of OB-GYN conditions. Diarrhea increased the likelihood of NSAP. Right lower quadrant tenderness increased the likelihood of appendicitis but decreased the likelihood of OB-GYN conditions. Left lower quadrant tenderness decreased the likelihood of appendicitis but increased the likelihood of OB-GYN. Guarding or rebound tenderness increased the likelihood of appendicitis but reduced the likelihood of NSAP. Leucocytosis (white blood cell count &gt;= 10,000) increased the likelihood of appendicitis but reduced the likelihood of OB-GYN and NSAP. Neutrophil &gt;= 75% increased the likelihood of OB-GYN but decreased the likelihood of NSAP. Pregnancy reduced the likelihood of appendicitis and increased the likelihood of OB-GYN. Conclusion: Gastrointestinal symptoms, sites of abdominal tenderness, guarding or rebound tenderness, leucocytosis, neutrophil &gt;= 75% and pregnancy are clinical indicators that may help differentiating appendicitis, common OB-GYN conditions, or NSAP in acute lower abdominal pain in women of reproductive age. doi: http://dx.doi.org/10.4021/jcs179w

Torsion of the Fallopian Tube and the Haematosalpinx in Perimenopausal Women- A Case Report

An isolated fallopian tube torsion is a rare, often difficult to diagnose, but significant cause of acute lower abdominal pain in women of the reproductive age group. It is rare in the perimenopausal age group. We are presenting a literature review and the case of a 47 years old woman who presented with a sudden onset of acute lower abdominal pain . Her clinical examination revealed an 8x8 cm, tender, cystic mass in the left lower quadrant, with positive cervical movement tenderness. MRI revealed a gross hydrosalpinx with a small left ovarian cyst. With a diagnosis of left adnexal torsion, an emergency laparotomy was performed, which revealed an isolated left fallopian tube torsion which necessitated a left salpingo-oophorectomy. A tubal torsion should be suspected in females with acute lower abdominal pain, of any age group, especially in those with predisposing factors like pelvic infections, tumours and surgeries which include tubal ligation. Laparoscopy is the preferred modality for the diagnosis and treatment of a tubal torsion.

A Case of Postablation Tubal Sterilization Syndrome

Postablation tubal sterilization syndrome (PATSS) is a cause of severe, cyclic lower abdominal pain in women. There is scant literature available on PATSS for the emergency provider. Most of the evidence that exists on PATSS is presented in case report formats. A patient with PATSS is presented in this article. The purpose of this article is to increase awareness of PATSS as a diagnosis after acute abdominal processes have been excluded and to prevent recurrent emergency department visits. Early diagnosis of PATSS will prompt the emergency department provider to initiate gynecological referral necessary for definitive treatment.

The Effect of Hysterectomy or Levonorgestrel-Releasing Intrauterine, System on Lower Abdominal Pain and Back Pain Among Women Treated for Menorrhagia: A Five-Year Randomized Controlled Trial

Because hysterectomy, the standard treatment option for women of reproductive age with menorrhagia, is associated with serious complications and requires a relatively long-recovery period, the levonorgestrel-releasing intrauterine system (LNG-IUS) has been increasingly used as an alternative option. No randomized trials have compared these two treatment options on lower abdominal pain and back pain. A prior study comparing hysterectomy and LNG-IUS with respect to quality of life outcomes found that the only significant difference was that women with hysterectomy reported less pain after 12 months; this difference, however, disappeared at 5 years. This randomized controlled trial compared the effect of these two treatment procedures on lower abdominal pain and back pain among women of reproductive age treated for menorrhagia. Women aged 35 to 49 years were randomly assigned to treatment by hysterectomy (n = 117) or LNG-IUS (n = 119). Questionnaires were used to assess the frequency and intensity of lower abdominal pain and back pain at baseline and at 6 and 12 month, and 5-year follow-ups. At 6 months, women in both groups had significantly less frequent back pain compared to baseline (P < 0.001) with no difference between the groups. A decrease in lower abdominal pain at 6 months occurred only in the hysterectomy group (P = 0.02); the difference between the 2 groups was not significant (P = 0.5). From 12 months to 5 years, greater reductions were found in the LNG-IUS group in the frequency of lower abdominal pain (P = 0.05) and back pain (P = 0.002) than in the hysterectomy group. With respect to pain scores at 5 years, less lower abdominal pain was experienced among women in both groups compared to the baseline (P = 0.01) for the hysterectomy group and P < 0.001 for the LNG-IUS group). In contrast, the back pain score decreased only among women in the LNG-IUS group and the difference between the two groups was significant (P = 0.02). These findings show that both hysterectomy and LNG-IUS decrease lower abdominal pain in women of reproductive age treated for menorrhagia, but only LNG-IUS appears to have a beneficial effect on back pain.

Clinical Manifestations and Epidemiology of the New Genetic Variant of Chlamydia trachomatis

In 2006, a new genetic variant of Chlamydia trachomatis (nvCT) was discovered in Sweden. Clinical manifestations of this infection were studied in a high-risk population. During 2007, a prospective case-control study on sexual lifestyle and urogenital infections was performed at the Centre for Sexual Health (CSH), affiliated to Malmo University Hospital. A total of 629 C. trachomatis positive cases and 1252 negative controls were included. At Malmo University Hospital, Department of Obstetrics and Gynecology, all cases of pelvic inflammatory disease (PID) were assessed and correlated to the prevalence of nvCT. Patients with nvCT or wild type C. trachomatis (wtCT) infection did not differ regarding their sexual lifestyle. Men with nvCT or wtCT infection did not differ in uro-genital symptoms or clinical findings. Women with nvCT infection reported painful urination (12.2% vs. 25.8%, P = 0.02) and were diagnosed with urethritis (11.1% vs. 40.0%, P = 0.04) less often than women with wtCT infection. The ratio of lower abdominal pain in women with nvCT infection was only half of that in women with wtCT infection (13.4% vs. 27.8%, P = 0.02). PID was detected in 0.8% of women with C. trachomatis infection in Malmo. All these cases were due to wtCT infection. Symptomatic urethral infection and lower abdominal pain was less common in women with nvCT as compared to wtCT. Infection with nvCT was more frequently asymptomatic suggesting a possible difference in virulence between the nvCT strain and the wtCT strain.

Isolated Torsion Of The Fallopion Tube With Hydrosalpinx: A Rare Presentation

Isolated torsion of fallopian tube is a rare event, which generally occurs in the reproductive age group. It is often difficult to diagnose it clinically or on imaging and for diagnosis laparoscopy remains the gold standard. This report describes such a condition in a patient who presented with pain lower abdomen and clinicosonographic evaluation revealed an adnexal mass. Diagnostic laparoscopy revealed dilated tube and diagnosis of hydrosalphinx with torsion of the tube was established. Torsion of fallopian tube is a rare event. It should however be kept in mind in the differential diagnosis of lower abdominal pain in women of all ages.

Adnexal torsion of mature cystic teratoma with hemorrhagic infarction: helpful findings on successive plain abdominal radiographs

Adnexal torsion is a relatively rare cause of lower abdominal pain in women, but in many cases it leads to a serious condition. We present a case of adnexal torsion of a mature cystic teratoma in which hemorrhagic infarction was reflected by progressive enlargement and wall thickening on successive plain abdominal radiographs. There has been no other report describing such changes of adnexal torsion on plain abdominal radiographs.

Painless Ovarian Torsion Mimicking a Uterine Myoma

Uterine myoma is the most common benign solid pelvic tumor seen in women and is easily demonstrated by pelvic ultrasonography. However, a chronic ovarian torsion with entire necrosis may be an exceptional mimicker. We herein present an unusual case of painless ovarian torsion similar to a subserous uterine myoma. A 35-year-old female virgin presented with a palpable midline pelvic mass that had been present for 2 months. Ultrasound revealed a well-defined, heterogeneous solid mass with echogenic rim that resembled a uterine myoma, 10.9 x 9.9 x 7.3 cm in size, just upon the uterus. Surgical exploration disclosed an enlarged stony ovary and swollen tube that were both twisted. The ovary was clogged up with red meat-like necrotic tissue. The pathologic findings were compatible with ovarian torsion, and subsequent infarction and necrosis. Ovarian torsion is a significant cause of acute lower abdominal pain in women and is a gynecologic surgical emergency. Nevertheless, surgical strategies are usually impeded because of ambiguous warning signs. Clinicians may be misled by certain conditions such as silent ovarian torsion. Although there may be no specific indication, the diagnosis of ovarian torsion should be considered on finding a pelvic mass.

Ovarian torsion in a premenarcheal girl: MRI findings

Adnexal torsion is an uncommon cause of severe lower abdominal pain in women and is often difficult to distinguish from other acute abdominal conditions. However, adnexal torsion should be considered in premenarcheal girls admitted with acute abdominal pain and evidence of an ovarian mass. Accurate and early radiological diagnosis is mandatory immediately after onset of clinical symptoms in order to preserve the viability of the ovary. Ultrasound (US) is usually the first line examination performed in an emergency setting, but computed tomography (CT) and magnetic resonance imaging (MRI) can be useful in case of ambiguous US findings, especially in patients with sub-acute symptoms and a suspected adnexal mass. This case report describes the additional value of MRI in a premenarcheal girl with sub-acute right fossa pain.

Computer-aided diagnosis of lower abdominal pain in women

This paper describes the use of a system of computer aided diagnosis in an unselected, prospective survey of 393 women suffering from lower abdominal pain of less than 1 week's duration. An accurate diagnosis was made by clinicians at first patient contact in 68-5 per cent of the group of patients. The computer's diagnostic prediction (based on the same data) matched the final diagnosis in 81-6 per cent of the patients. During this survey a marked improvement in diagnostic accuracy was observed amongst the junior clinicians. It is suggested that this is because of the discipline of data collection imposed and the intermittent feedback received, and also that this educational aspect of computer usage may be of wider benefit.