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Biosystems Engineering and Control Group 20

8044640

The prevention and mitigation of famine: policy lessons from Botswana and Sudan.

Botswana and Sudan experienced consecutive years of drought in the 1980s. Sudan faced a large decline in food entitlement and nutritional deterioration, which translated into famine in 1984/85. Botswana, on the other hand, nearly compensated income losses and averted nutritional deterioration and famine-related deaths. There are important lessons to learn from the famine prevention experience of Botswana. Its strategy for dealing with drought and famine combines policies of steady economic growth with supplementary poverty alleviation and drought relief programs. To provide continuity and stabilization of market operations in times of distress, the country channels sufficient food through market chains, provides price support to preempt market collapse and augments the income of consumers through public income transfer programs to prevent demand failure. In addition, it maintains a responsive and accountable political system and a decentralized participatory administrative structure. While Sudan should develop policies that are compatible with its own environment, it is crucial that it recognizes the critical role of public action in promoting growth, alleviating poverty, and providing timely relief responses in times of anticipated growth failure.

8044639

Northern Sudan in 1991: food crisis and the international relief response.

By the end of 1991, less than half the amount of relief food requested for North Sudan at the beginning of the year had been delivered. Despite ample evidence of social and economic stress and high rates of child malnutrition, many donors felt that relief needs had been exaggerated, and were unwilling to accept that relief assistance was urgently needed. The feeble response of the main food aid donors is explained initially by the politics of relief in 1990/91, which seriously delayed the launch of the relief operation. These problems were compounded by an oversimplified understanding of famine among some sections of the relief community, and by the orientation of the international relief system to crisis indicators. Toward the end of 1991, donors argued that despite the shortfall in relief assistance there had been no deaths from starvation, and therefore local people had 'coped' better than expected. This paper challenges that view by arguing that excess deaths did occur, but went unnoticed and unremarked. Local people's 'coping strategies', which supposedly 'saved the day', actually had very negative and sometimes fatal consequences.

8044638

Volcanic disaster mitigation in the Philippines: experience from Mt. Pinatubo.

Considerable progress has been made in volcanic disaster mitigation in the Philippines during the last four decades, since the devastating Hibok-Hibok eruption in 1951 and the establishment of the Commission on Volcanology (COMVOL), the forerunner of the Philippine Institute of Volcanology and Seismology (PHIVOLCS) in 1952. The management of the Pinatubo Volcano eruption crisis of 1991-92 marks the highest point in the development of volcanic disaster mitigation in the country. State-of-the-art volcano monitoring techniques and instruments were applied; the eruption was accurately predicted; hazards zonation maps were prepared and disseminated a month before the violent explosions; an alert and warning system was designed and implemented; and the disaster response machinery was mobilized on time. The unprecedented magnitude and lingering nature of the hazards, however, and their widespread, long-term impacts have sorely tested the capability of the country's volcanic disaster mitigation systems. In particular, the lahar threat has triggered controversies and put decision makers in a dilemma of choosing between adaptive versus confrontational/control approaches. At least three strategies have been articulated and adopted in varying degrees and forms: (1) the establishment of a lahar monitoring-warning-evacuation system to deal with the lahar problem on an emergency basis; (2) relocation of settlements from the hazard zones; and (3) installation of engineering countermeasures to control/divert the lahar flows and protect settlements. A combination of the three appears to be the best, but the most effective and least costly mix remains to be determined.

8044637

Environmental monitoring of bleached kraft pulp mill chlorophenolic compounds in a northern Canadian river system.

The environmental transport of pulp mill effluent compounds and the exposure of two fish species has been monitored by parallel analyses of effluent, water column and suspended sediment samples, and fish bile and muscle. Compounds analyzed included over 20 chlorophenolic compounds and 12 fatty and resin acids. The concentration of chlorophenols varied with seasonal river flows and mill process changes such as the substitution of chlorine dioxide (ClO2) for chlorine gas (Cl2) in the bleach plant. At 100% (ClO2) substitution, the effluent and the water column concentrations of most chlorophenolics approached the analytical detection limits of 0.1-1 parts per billion. Chlorophenolic and fatty/resin acid compounds were detected in the bile of both mountain whitefish (Prosopium williamsoni) and longnose sucker (Catostomus catostomus), but were rarely detected in fillets. Fish bile concentrations were observed in an apparent spatial gradient as far as 230 km downstream of the mill. A depuration experiment with fish held in uncontaminated water for eight days indicated a rapid decrease in chlorophenol levels. These observations corroborate previous investigations that chlorophenolic compounds are rapidly excreted and can be used as sensitive markers for recent exposure to mill effluents.

8044636

Utilization of 2-phosphonobutane-1,2,4-tricarboxylic acid as source of phosphorus by environmental bacterial isolates.

Six bacterial strains able to degrade aerobically 2-phosphonobutane-1,2,4-tricarboxylic acid (PBTC) were isolated. The bacteria used PBTC as sole source of phosphorus in the presence of an alternative source of carbon. The microorganisms were taken from various ecosystems, e.g. river water, river sediment and activated sludge. PBTC up to a concentration of 1 mM (270 mg/l) was completely degraded by a defined mixed culture.

8044635

Changes in concentrations of selenium and mercury in largemouth bass following elimination of fly ash discharge to a quarry.

Elimination of slurried fly ash discharges to a water-filled quarry was followed by a steady increase in concentrations of mercury in the axial muscle of resident largemouth bass (Micropterus salmoides). Average mercury concentrations in bass (adjusted for covariance with fish weight) increased from 0.02 micrograms/g to 0.17 micrograms/g in three years. Aqueous selenium concentrations in the quarry decreased from 25 micrograms/L to < 2 micrograms/L after elimination of fly ash discharges, but selenium concentrations in bass remained about three times background levels. Previous studies have shown selenium addition to be a viable means of ameliorating mercury contamination in fish in low alkalinity, low pH waters of northern Europe and Canada. These results suggest that selenium may also be effective at blocking the accumulation of methylmercury in harder, more alkaline waters.

8044634

Toxicity identification evaluations for the investigation of fish kills: a case study.

A large fish-kill was observed in the river Tajo during the Spring-Summer of 1991. The mortality was first detected between Aranjuez and Toledo, affecting several fish species. Then it was slowly going downstream, affecting only carp (Cyprinus carpio), reaching the Spanish-Portuguese border several months later. Short-term toxicity tests on Daphnia magna and in vitro cytotoxicity tests on RTG-2 cells were used as toxicity monitoring systems in water samples and different water fractions. The fish kill was associated to the outbreak of infectious diseases, spring viremia of carp and saprolegniosis, related to an increase in the fish's susceptibility due to the presence of a toxic chemical. Bioassay-directed sample fractionations allowed to detect a toxic chemical. HPLC-MS identified the compound as dehydroabietic acid, a resin acid previously described immunotoxic.

8044633

Volatile organic compounds from household waste.

Ninety volatile organic compounds were identified in the headspace of biodegradable and mixed household waste by GC/MS. Most of them could be attributed to biological waste, microbiological growth in biological waste or packaging materials. Although none of the compounds were present at concentrations exceeding their threshold limit values, it is possible that in closed garbage cans or containers organic sulfur compounds could contribute to the reported gastrointestinal problems of collection personnel.

8044632

An attempt to control the polychlorocatechol pigment production during 3-chlorobenzoate aerobic co-metabolism in growing-cell batch culture.

A strain of Pseudomonas fluorescens, designed CP30, was capable of co-metabolizing 3-chlorobenzoic acid via chlorocatechols, thus producing a polychlorocatechol black pigment. The pigment production was found to be enzyme-mediated in P. fluorescens cultures; however, the results of the autoxidation studies suggested that a large amount of pigment could derive from the simple autoxidation of the chlorocatechols accumulated in the CP30 culture during the 3-chlorobenzoate degradation. The polymerization of chlorocatechols should reduce the toxicity of the culture and generally resulted in a large production of a water-insoluble (i.e. a easily removable) pigment with the release a large amount of chloride ions. Both 3-chlorobenzoate degradation and pigment production were stimulated and inhibited in the same way by high and low pH values, respectively, in CP30 cultures; the culture conditions which permitted an extensive 3-chlorobenzoate degradation with the lowest pigment production were not identified. However, on the basis of the detoxification property of the pigment production process, high pH and dissolved oxygen concentrations appears to be the most suitable culture conditions for an enhanced detoxicant treatment of 3-clorobenzoate-contaminated waste water.

8044631

Uniform system for the evaluation of substances. I. Principles and structure.

In April 1994, the first version of the Uniform System for the Evaluation of Substances (USES 1.0) was launched to comply with an action point of the Netherlands National Environmental Policy Plan. USES is a tool for the rapid, quantitative assessment of the hazards and risks of chemical substances, including new substances, existing substances, agricultural pesticides and biocides. It was developed to be applied as a decision-support system by the central government, by industry and institutes in the private sector and by international fora. Since hazard and risk assessment must be transparent to all users and easy to perform, USES 1.0 is well documented and available as a computer program. An overview of this system will be presented including its objectives, the national and international framework, the general principles involved, as well as the structure and the content of the models used.

8044630

Prediction of chemical residues in aquatic organisms for a field discharge situation.

A field study was performed which compared predicted and measured concentrations of chemicals in receiving water organisms from three sampling locations on Five Mile Creek, Birmingham, Al. Two point source discharges, both from coke manufacturing facilities, were included in the field site and five chemicals were studied, i.e., biphenyl, phenanthrene, anthracene, fluoranthene, and pyrene. Composite samples of effluent, receiving water organisms, crayfish (Decapoda) and sunfish (Lepomis sp.), and stream and discharge flow data were collected in March and April 1990. For the crayfish and sunfish, the measured residues were within a factor of 5 for 80% (12 of 15) and 53% (8 of 15) of the residues predicted using EPA's draft procedure (US-EPA 199 lb), respectively, and were within a factor of 5 for 60% (9 of 15) and 40% (6 of 15) of the residues predicted using EPA's procedure with a BCF set equal to the chemical's Kow (after adjustment for lipid content of the organism), respectively. The predicted residues tended to be larger than the measured residues and with increasing Kow, greater disagreement between the predicted and measured values was observed.

8044629

Polychlorinated biphenyls in mother milk and adapted cow's milk.

In the present study, 50 samples of mother milk and 20 samples of adapted cow's milk produced for bottle feeding supplied from the lactarium of the Pediatric Hospital were examined for presence of 6 indicator congeners of polychlorinated biphenyls (IUPAC No. 28, 52, 101, 138, 153, and 180). Congeners No. 138, 153, and 180 were predominant in all samples, the highest mean as well as the maximum level was found for No. 138 for both type of samples. The average daily intake based on the sum of indicator congeners was found to be 2.56 micrograms. (kgb.w..day)-1 for mother milk, and 0.85 microgram.(kgb.w..day)-1 for adapted cow's milk.

8044628

Screening for planar chlorobiphenyl congeners in tissues of marine biota by high-performance liquid chromatography with photodiode array detection.

A rapid method has been developed to screen for planar chlorobiphenyl (CB) congeners, as well as certain other CBs and DDTs, in tissue samples from marine biota. The analytes were extracted from tissue matrices with 1:1 hexane/pentane (v/v) and interfering compounds were separated from the CBs on a gravity-flow column packed with acidic, basic and neutral silica gel eluted with 1:1 hexane/methylene chloride (v/v). Subsequently, the planar CB congeners were resolved from the DDTs and other CBs by HPLC on Cosmosil PYE analytical columns cooled to 9 degrees C and were measured by an ultraviolet (UV) photodiode array (PDA) detector. Two important advantages of PDA over conventional UV detection were the ability to identify individual analytes by comparing their UV spectra to those of reference standards and the ability to establish the spectral homogeneity (purity) of the analytes by comparing spectra within a peak to the apex spectrum. The HPLC/PDA method was tested with tissue samples from fish, shellfish and marine mammals; concentrations of certain CBs and DDTs in samples determined by screening compared favorably with those in the same samples analyzed by a comprehensive method (e.g., gas chromatography/high resolution mass spectrometry). However, the HPLC/PDA method was about an order of magnitude less sensitive than determinations by comprehensive methods.

8044627

Heavy metal pollution in water, sediment and fish from the Tigris river in Turkey.

Some heavy metals (Co, Cu, Mo, Ni, Pb, V and Zn) were determined in water, sediments and some fish species (Cyprinion macrostomus and Garra rufa) from the Tigris River. Mo and V were not detected in water and Co, Cu, Ni, Pb, Zn were found low values. Co, Cu, Ni, Pb, V and Zn were found very high levels in the sediments. All the fish samples contain high concentrations of Cu, Ni and Zn, while Co, Mo, Pb and V were not detected. The high concentrations of heavy metals may be directly related to the contamination of the Tigris River by Ergani Copper Plant and the geochemical structure of this region.

8044621

Intra-abdominal sepsis and survival after surgery for colorectal cancer.

Of 361 patients who survived curative left colonic or sphincter-saving rectal resection for cancer, 44 developed significant postoperative intra-abdominal sepsis and 317 did not. The two groups were well matched for age, sex, site of tumour, Dukes stage, tumour differentiation and timing of operation. There was no significant difference in the 5-year overall actuarial survival rate (P = 0.25) or in the 5-year disease-free survival rate (P = 0.23). Stepwise regression analysis of prognostic variables including age, sex, site of tumour, Dukes stage, tumour differentiation, timing of operation, grade of surgeon and postoperative intra-abdominal sepsis identified Dukes stage, age at operation and tumour differentiation as predictors of survival. These results suggest that postoperative intra-abdominal sepsis is not a prognostic factor for long-term survival in colorectal cancer as has been previously reported.

8044620

Magnetic resonance imaging of rectal carcinoma: a prospective study.

Accurate preoperative staging of rectal cancer is necessary to identify patients who might benefit from adjuvant therapy. Magnetic resonance imaging (MRI) was evaluated in 20 consecutive patients with rectal cancer undergoing 'curative' surgery. Detailed histopathological examination of the resected lesion was correlated with findings of MRI. MRI staging concurred with histological staging in 18 of 20 patients using the Dukes or tumour node metastasis classification but in only 14 using the modified Astler-Coller system. MRI diagnosed transmural invasion in all but one patient with microscopic mural invasion (positive predictive value, 100 per cent; negative predictive value, 80 per cent; overall accuracy, 95 per cent). MRI correctly diagnosed tumour deposits or involved lymph nodes in 12 patients. MRI overstaged one patient, in whom nodes that were enlarged on imaging studies were negative at histological examination (positive predictive value, 92 per cent; negative predictive value, 100 per cent; overall accuracy, 95 per cent). MRI has a role in selected cases for the preoperative assessment of rectal carcinoma.

8044619

Requirement for bowel preparation in colorectal surgery.

To determine whether mechanical bowel preparation influences the incidence of anastomotic dehiscence following colorectal surgery, 186 patients undergoing elective left colonic or rectal resection were randomized before surgery to bowel preparation (n = 89) or no bowel preparation (n = 97). Surgical technique was standardized and no patient had a defunctioning colostomy. Seventeen patients were excluded (seven with preparation, ten without). Indications for surgery in the remaining 169 patients were carcinoma (133 patients), diverticular disease (26), inflammatory bowel disease (six) and miscellaneous conditions (four). Operations performed were left colonic resection or reversal of Hartmann's procedure (26 with preparation, 28 without) and anterior resection (56 versus 59). The overall morbidity rate (18 per cent) was similar in the two groups. All seven clinical anastomotic leaks occurred after low anterior resection, in three of the 39 patients who had undergone bowel preparation and four of the 36 who had not (P > 0.9). Two deaths occurred, both of patients who had received bowel preparation, one being secondary to anastomotic leakage. Bowel preparation does not influence outcome after elective colorectal surgery.

8044618

Prospective randomized trial of Ivalon sponge versus sutured rectopexy for full-thickness rectal prolapse.

Ivalon sponge rectopexy is a safe reliable procedure in the management of rectal prolapse. Sutured rectopexy is simpler and avoids the use of foreign material. Sutured rectopexy is mandatory if synchronous resection is to be considered. Sixty-three patients (62 women) with full-thickness rectal prolapse were entered into a prospective randomized trial of Ivalon sponge rectopexy (31 patients) versus sutured rectopexy (32). Twenty patients (32 per cent) had coexistent incontinence (ten in each group). The operation was performed in the standard manner with a sutured rectangle of sponge or sutures alone placed along the length of the sacrum. Postoperative morbidity occurred in nine patients (14 per cent) of whom three underwent a sutured procedure and six Ivalon rectopexy: wound infection in three, chest infection in two, urinary tract infection in two and thromboembolism in two. There were no deaths within 30 days. At a median follow-up of 47 months prolapse had recurred in two patients (3 per cent), one in each group, 14 (22 per cent) suffered from incontinence (of whom five had undergone a sutured procedure), while 25 (40 per cent) had developed constipation (of whom 15 had received Ivalon rectopexy). The medium-term results of rectopexy by suture alone are equivalent to those obtained following the conventional Ivalon procedure. These data suggest that Ivalon rectopexy could now be abandoned.

8044617

Histological assessment of the distal 'doughnut' in patients undergoing stapled restorative proctocolectomy with high or low anal transection.

A non-randomized prospective study of 38 patients, 32 with ulcerative colitis and six with familial adenomatous polyposis (FAP), who underwent high or low anal transection during stapled restorative proctocolectomy was undertaken. The median (range) height of the staple line 6 months after operation was 5.2 (3.2-6.0) cm after high transection compared with 2.9 (1.8-3.6) cm after low transection. Nineteen of 20 patients after high anal transection had columnar epithelium in the distal 'doughnut' versus 16 of 18 after low transection. Active colitis was present in 12 of 19 'doughnuts' in patients with high anal transection and columnar mucosa and in seven of 16 after low transection. Nine patients (high transection two, low transection seven; P < 0.05) had striated muscle in the stapled distal 'doughnut'. Dysplasia was found in the resected colon in one patient with ulcerative colitis and adenocarcinoma in two colectomy specimens (ulcerative colitis, one; FAP, one). No dysplasia or carcinoma was seen in any of the 'doughnuts' from patients with ulcerative colitis. Four patients with FAP (high transection, two; low transection, two) had microadenoma in the distal 'doughnut'. Despite attempts to place a stapled pouch-anal anastomosis below the anal transition zone, it was not possible to remove columnar mucosa completely from the remaining anal canal in most patients (16 of 18). High anal transection and pouch-anal anastomosis should be the preferred option in restorative proctocolectomy, as a dentate-line anastomosis may not fully eliminate columnar epithelium and may involve resection of some of the external sphincter.

8044616

Comparison of three methods to obtain percutaneous needle core biopsies of a renal allograft.

During 280 renal transplant biopsy procedures, 440 biopsy cores were obtained using three techniques: blind vertical pass, ultrasonographic guidance and ultrasonographic guidance with immediate specimen examination by stereoscopic microscopy. The success rates per procedure in obtaining renal cortex by blind vertical pass, ultrasonographic guidance and ultrasonographic guidance with microscopy were 75, 91 and 100 per cent respectively. Ultrasonographic guidance improves the success rate of percutaneous renal allograft biopsy. The additional use of immediate examination by stereoscopic microscopy yields a 100 per cent success rate for individual biopsy procedures.

8044614

Acute scrotal pain complicating familial Mediterranean fever in children.

Twenty-nine children with familial Mediterranean fever presented with 39 attacks of acute scrotal pain. Of these, 25 patients had an acute scrotum complicating familial Mediterranean fever and only four had testicular torsion. Scrotal pain was the only manifestation of a familial Mediterranean fever crisis in 36 episodes and in 15 boys scrotal involvement was the first manifestation of the condition. Fourteen patients were treated medically. Of 15 patients who underwent scrotal exploration there were no definite diagnostic findings in 11 and four had testicular torsion. Three cardinal features strongly suggest the diagnosis of acute scrotum in familial Mediterranean fever in a boy of Mediterranean origin with a relevant family history: recurrent scrotal pain or swelling; body temperature above 37.5 degrees C; and gradual onset of pain, usually of more than 12 h duration. Conservative management can safely be undertaken in these boys without fear of losing a salvageable testis.

8044613

Multicentre audit of death from acute pancreatitis.

A prospective audit of acute pancreatitis involving nine hospitals in the North-West Thames Region recruited 631 patients over 54 months. There were 57 deaths (9 per cent); a diagnosis had been reached in 50 patients (88 per cent) before death and in seven (12 per cent) at autopsy. Eighteen patients (32 per cent) died within the first week, usually as a result of multisystem organ failure (15 patients). Thirty-nine patients (68 per cent) died after the first week from complications related to infection (26 patients) co-morbid conditions (nine) or non-infective complications (four). Twenty-one patients (42 per cent) had been inadequately evaluated by Ranson's criteria, and only 22 (44 per cent) of 50 with a premortem diagnosis of pancreatitis had undergone computed tomography (CT). Fifteen of 26 patients who died from infection-related complications had CT and only nine underwent necrosectomy or surgical drainage. These data suggest that improved diagnosis, investigation and management of patients with acute pancreatitis is possible, and may result in improved clinical outcome.

8044612

Antimicrobial treatment of pancreatic infection in cats.

An investigation examined the efficacy of antibiotics in a novel feline model of pancreatic infection in acute pancreatitis. Acute pancreatitis was induced in cats using an established technique. In control animals (no pancreatitis) and cats with pancreatitis, Escherichia coli (10(4) in 0.1 ml) was placed in the pancreatic duct. Reoperation was performed after 24 h in six controls and six cats with pancreatitis. E. coli was cultured from the pancreas in five control animals and five cats with pancreatitis. Reoperation was performed after 1 week in ten controls, in 11 cats with pancreatitis and in nine with pancreatitis that were treated with cefotaxime (50 mg/kg intramuscularly three times daily) started 12 h after the induction of pancreatitis and administration of E. coli. Pancreatic infection developed in eight cats with pancreatitis compared with none of the cefotaxime-treated animals and none of the controls (P < 0.05). Cefotaxime reached bactericidal levels in pancreatic tissue and juice. In conclusion, ductal administration of E. coli caused pancreatic infection only in cats with acute pancreatitis. Early administration of an appropriate antibiotic was effective in treating pancreatic infection in acute pancreatitis.

8044610

Chemotherapy prolongs survival in inoperable pancreatic carcinoma.

Forty-three patients with irresectable advanced pancreatic cancer were randomized to receive chemotherapy using a combination of 5-fluorouracil, Adriamycin and mitomycin or no chemotherapy. Groups were well matched with regard to age, extent of disease and performance status on entry. Chemotherapy was well tolerated and, although common, side-effects were usually mild. Psychological measurements based on the Hospital Anxiety and Depression score were made in 31 patients. These showed significantly less depression but not anxiety in the treated group immediately after randomization and following 2 months of chemotherapy. Median survival in the treated group was 33 (range 9-80) weeks compared with 15 (range 1-62) weeks in the untreated group (P < 0.002). Chemotherapy should be considered in all patients presenting with advanced inoperable pancreatic cancer.

8044609

Endoscopic drainage of traumatic pancreatic pseudocyst.

Pancreatic pseudocyst following trauma is usually caused by a major duct injury and may present late. The outcome of endoscopic treatment in five patients with post-traumatic pseudocyst is described. Diagnosis was made from 3 weeks to 1 year after injury by ultrasonography and computed tomography. A distinct bulge was visible in the stomach or duodenum using endoscopic retrograde cholangio-pancreatography, and a cyst enterostomy was established with a knife or standard papillotome. Successful drainage was achieved without complications. One patient developed a recurrence, which was redrained endoscopically, but surgical intervention was required for persistent pain. Early results suggest that endoscopic drainage for selected pancreatic pseudocysts is feasible and safe.

8044608

Chromosome allele loss in colorectal liver metastases and its association with clinical features.

Molecular genetic changes are better characterized in colorectal carcinoma than in other common adult tumours. Consistent allele losses, or loss of heterozygosity (LOH), on chromosomes 5q, 17p and 18q have been well established. These changes are associated with the prognosis of the disease. Little is known of such changes in liver metastases of colorectal origin. The extent of allelic loss and its association with clinical features were investigated in 19 patients with colorectal liver metastases by using 24 probes to detect restriction fragment length polymorphism. A high frequency of LOH on chromosomes 5q, 17p and 18q was found in these secondary tumours. No consistent loss has so far been shown in any other chromosome. The frequency of allele loss correlated significantly with prognostic features such as the number and size of liver secondaries (P < 0.005), metastasis to the lymph nodes (P < 0.01) and curative or palliative operation (P < 0.02).

8044607

Conservative initial treatment for liver abscesses in children.

A total of 124 children aged less than 14 years with a liver abscess were seen in a 16-year period (1974-1990) and treated by non-operative initial management. Of the abscesses 98 occurred in the right liver and 26 in the left. The abscesses were solitary in 93 patients. Overall, 77 of the solitary and 21 of the multiple abscesses were confined to the right liver. In 78 of the right-sided and 20 of the left-sided abscesses the infection was primarily pyogenic in nature with Staphylococcus aureus being the usual organism cultured. The remainder were of amoebic origin. Clinical features were similar in patients with amoebic and pyogenic abscesses. Clinical and ultrasonographic follow-up demonstrated successful non-operative management and healing in 37 per cent of all patients submitted to an initial protocol of medical supportive care and antibiotic therapy. Of the multiple abscesses 60 per cent responded to non-operative management. Fourteen of the 16 solitary left-sided liver abscesses required drainage and three left-sided abscesses ruptured before drainage. Patients with a solitary left-sided abscess warrant early operative intervention.

8044606

Randomized trial of adrenaline injection and laser photocoagulation in the control of haemorrhage from peptic ulcer.

Forty-nine consecutive patients with bleeding from peptic ulcers that would conventionally have required surgical intervention were randomized to receive endoscopic injection of adrenaline (1:10,000) or laser photocoagulation. Patients were included only if they had a visible vessel at endoscopic examination. Five patients proceeded directly to surgery and, of the remaining 44, 21 received laser photocoagulation and 23 injection therapy. Haemostasis was achieved initially in all patients. There was one rebleed in the group of patients who received laser treatment and four in those treated by injection. All five patients underwent further endoscopic haemostasis according to the initial randomization. Haemostasis was again achieved in all cases, but the patient who had undergone laser treatment suffered recurrent haemorrhage after a further 48 h and subsequently died. Overall, one of the 21 patients receiving laser treatment died compared with none of the 23 injected with adrenaline. Injection of adrenaline achieves similar results to laser photocoagulation for bleeding peptic ulcer.

8044605

Effect of intraoperative manipulation and anaesthesia on lower oesophageal sphincter function during fundoplication.

The variables influencing the intraoperative measurement of lower oesophageal sphincter (LOS) pressure and a new method of assessing the effect of a fundal wrap on LOS function were investigated in 13 patients undergoing fundoplication. All patients had a 360 degrees wrap fashioned around a 50-Fr bougie; four also underwent highly selective vagotomy. The effect of the fundal wrap, independent of LOS pressure, was assessed by inducing LOS relaxation with balloon distension. Preoperative mean(s.e.m.) LOS pressure (14.1(2.6) mmHg) did not correlate with that at the start of operation (11.5(1.5) mmHg). After mobilization of the oesophagus mean(s.e.m.) LOS pressure increased significantly (to 19.8(2.0) mmHg; P < 0.0005) and oesophageal distension elicited LOS relaxation on 16 of 33 occasions. After completion of the wrap there was no further increase in LOS pressure, but LOS relaxation occurred after only five of 33 distensions (P < 0.01). These findings indicate that anaesthesia and intraoperative manipulation during fundoplication have significant effects on LOS function that detract from the validity of intraoperative assessment. They question the rationale of current approaches to intraoperative manometry for the assessment of antireflux surgery.

8044604

Surgical management of intrathoracic oesophageal rupture.

Intrathoracic oesophageal rupture is a life-threatening condition that requires early diagnosis and effective treatment if death or serious prolonged illness is to be avoided. Six consecutive patients with intrathoracic oesophageal rupture were treated by debridement and irrigation of the mediastinum and primary suture closure with reinforcement of the suture line by pedicled omentum. The cause of the rupture was Boerhaave's syndrome in five patients and compressed air injury to the oesophagus in one. All but one patient presented more than 24 h after onset of symptoms, with a mean of 38 (range 12-72) h. All the patients recovered well with no postoperative oesophageal leakage. The mean hospital stay was 11.5 (range 9-15) days. Irrespective of the duration of the oesophageal rupture, aggressive resuscitation and prompt primary suture closure with reinforcement of the suture line with a well vascularized pedicled tissue flap is required for optimal results.

8044603

Prediction of pulmonary complications after transthoracic oesophagectomy.

Postoperative pulmonary complications are often fatal in patients with oesophageal cancer. The influence of various preoperative and perioperative risk factors in the prediction of such complications was analysed. Some 170 oesophageal resections performed through a thoracotomy between January 1977 and December 1991 were reviewed. Twenty-two parameters generated from various medical risk categories were studied. Six variables were significant (P < 0.05) on univariate analysis: vital capacity, serum albumin level, partial pressure of carbon dioxide in arterial blood, presence of liver cirrhosis, presence of chronic obstructive airway disease and clinical stage of the tumour. Multivariate discriminant analysis of these six factors identified three as significant, namely vital capacity (P < 0.0001), liver cirrhosis (P = 0.01) and tumour stage (P = 0.01), yielding an equation for assessment of the risk of postoperative pulmonary complications. Calculation of the risk score showed that 42 of 53 patients with pulmonary complications had scores of 0 or more and that 74 of 102 without had scores below 0. The mean risk score was 0.34 for patients with complications and -0.26 for those without. The equation predicted pulmonary complications after transthoracic oesophagectomy with 74.8 per cent accuracy, 79.2 per cent sensitivity and 72.5 per cent specificity. It is concluded that the risk of postoperative pulmonary complications can be accurately assessed in individual patients by calculation of a risk score based on vital capacity, liver cirrhosis and tumour stage.

8044602

Perioperative and postoperative tranexamic acid reduces the local wound complication rate after surgery for breast cancer.

A randomized double-blind trial has shown that, in 160 women with breast cancer undergoing lumpectomy or mastectomy with axillary clearance, perioperative and postoperative administration of tranexamic acid 1 g three times daily resulted in a significant reduction in the mean postoperative drainage volume compared with patients given placebo (283 versus 432 ml, P < 0.001). The frequency of postoperative seroma formation was also decreased by tranexamic acid administration (27 versus 37 per cent, P = 0.2). Haematoma formation was infrequent in both groups and was not altered by administration of tranexamic acid. No infectious complications occurred. Age over 60 years was a significant risk factor for overall wound complications but tumour size and regional lymph node metastases were not. Tranexamic acid may be used to reduce the frequency of postoperative wound complications following surgery for breast cancer.

8044601

Comparison of radioligand assay and immunostaining for epidermal growth factor receptor in human breast cancer.

Epidermal growth factor (EGF) receptor status is a useful prognostic indicator in women with breast cancer. Lack of standardization and correlation of methodology for the detection of EGF receptor has hampered its further evaluation. EGF receptor status was ascertained by immunohistochemistry and radioligand assay in 120 breast cancers. Of 52 tumours negative for EGF receptor on radioligand assay, 47 were negative on immunohistochemistry and, of 68 tumours positive for the receptor on assay, 52 were positive on immunohistochemistry. If the more widely evaluated radioligand assay is assumed to be the 'gold standard', immunohistochemistry has a sensitivity of 81 per cent and a specificity of 91 per cent.

8044600

Increased gut permeability after multiple trauma.

Gut permeability was studied in multiply injured patients with respect to the development of multiple organ failure (MOF). Two groups were defined according to MOF score (threshold 10 points) as to whether MOF developed (group 1; n = 11, four deaths) or did not (group 2; n = 21, no death). Gut permeability was determined from the ratio of urinary excretion of enterally administered lactulose and mannitol. Serum elastase concentrations were also determined. Mean(s.e.m.) gut permeability was abnormal during the entire study (day 1: group 1--5.1(2.1) versus group 2--10.6(4.1) (P not significant; P < 0.001 versus normal volunteers, 0.56(0.24)). An increase on days 3 and 5 correlated with serum elastase levels only in patients in group 1 (rs = 0.71, P < 0.01). Severe injury leads to increased intestinal permeability, which is related to a systemic inflammatory response.

8044599

Venous function and clinical outcome following deep vein thrombosis.

The severity of post-thrombotic symptoms in 111 limbs (107 patients) with previous phlebographically proven deep vein thrombosis (DVT) was correlated with superficial and deep venous function as determined by foot volumetry (n = 90) and duplex ultrasonography (n = 62). The median delay between DVT and assessment was 8 (range 1-34) years. Symptoms were mild (group 1) in 31 limbs (28 per cent), moderate (group 2) in 41 (37 per cent) and severe (group 3) in 39 (35 per cent). There was no significant relationship between the site of DVT, or the time since DVT, and the severity of symptoms. Without tourniquet occlusion of superficial veins, limbs in group 3 had a significantly shorter half-refilling time than those in groups 1 and 2 (P = 0.01). Although a similar trend was observed after tourniquet occlusion of superficial veins, this was not statistically significant. There was no significant difference in the expelled volumes between the three clinical groups. On duplex scanning, deep and superficial venous reflux was detected in just over half of the limbs in each group. Eight patients had entirely normal scans and none of them had severe symptoms (P = 0.04). This study identifies a strong association between severe postphlebitic syndrome and venous reflux, such that it may be considered that venous reflux is necessary for the development of severe post-thrombotic symptoms. However, many patients with severe reflux have only mild symptoms and additional factors must therefore contribute to the development of severe postphlebitic syndrome.

8044597

Influence of compression stockings on lower-limb venous haemodynamics during laparoscopic cholecystectomy.

Lower-limb venous haemodynamics were studied prospectively in 40 patients (24 women, 16 men of median age 52 years) undergoing laparoscopic cholecystectomy. Patients were randomized to wear compression stockings during surgery or no stockings. All received subcutaneous heparin prophylaxis. Venous capacitance and outflow were measured non-invasively before, during and after pneumoperitoneum. In the group without compression stockings (20 patients) venous capacitance and outflow decreased during pneumoperitoneum in most patients. In the group wearing stockings (20 patients) the changes were less pronounced or abolished. There was a significant difference between the groups in venous capacitance and outflow ratios at mid-operation: median (interquartile range) 0.89 (0.56-1.16) and 0.89 (0.56-1.15) respectively in the group without stockings versus 1.48 (1.09-2.19) and 1.71 (1.20-2.19) respectively in that with stockings (P < 0.001). Pneumoperitoneum creates a significant resistance to venous return. Compression stockings counteract the changes observed.

8044595

Outcome in patients who require renal support after surgery for ruptured abdominal aortic aneurysm.

Over a 3-year period haemofiltration and dialysis was provided for 18 patients who developed renal failure after operation for ruptured abdominal aortic aneurysm (AAA). Four of the patients underwent operation elsewhere and were transferred when renal failure was diagnosed. The median duration of renal support in the 11 survivors was 24 days, while the seven patients who died received support for a median of 11 days. By 3 months after operation eight of the 11 survivors were independent of dialysis. Renal support was life saving in eight of 91 patients operated on in Oxford for ruptured AAA and reduced the 30-day operative mortality rate from a potential 47 per cent to an actual 38 per cent. Haemofiltration and haemodialysis for acute renal failure after surgery for ruptured aortic aneurysm is clinically justified and results in the long-term survival of most patients.

8044594

Trends in vascular surgery since the introduction of percutaneous transluminal angioplasty.

Lower-limb percutaneous transluminal angioplasty (PTA) has been used increasingly over the past decade, either alone or in conjunction with arterial reconstructive surgery. However, its impact on operation rates has not been evaluated properly. Rates of vascular operations and PTAs performed per referral for peripheral arterial disease to the regional vascular service at The Royal Infirmary, Edinburgh, were calculated for the years 1986-1992. The overall rate of PTA for peripheral arterial disease increased ninefold over this period; that for critical ischaemia increased fivefold. Rates of aortic and femoral reconstruction for all peripheral arterial disease increased by 40 and 100 per cent respectively, but rates for critical ischaemia remained static. The major amputation rate rose by 47 per cent between 1986 and 1990, and thereafter reached a plateau. Increased use of PTA was not associated with a reduction in the number of vascular operations.

8044593

Carotid endarterectomy in Great Britain and Ireland: practice between 1984 and 1992.

Of 356 questionnaires on carotid endarterectomy sent to all vascular surgeons in Great Britain and Ireland likely to undertake this procedure, 326 (92 per cent) were returned. Of those who replied 131 (40 per cent) performed at least one carotid endarterectomy in 1992; 57 (44 per cent) of these carried out ten or fewer operations and 74 (56 per cent) more than ten. The 131 surgeons were collectively responsible for 2628 operations in 1992, twice as many as were undertaken in either 1984 or 1989, years for which similar survey data are available. This sharp rise in the number of operations was accounted for by increased activity on the part of experienced operators, rather than any rise in the number of 'occasional' carotid surgeons. In 1992, although the neurologist remained a major source of patient referral, general practitioners (and others) were also referring patients in large numbers direct to the vascular surgeon; this represents a change in practice compared with previous years. Many of the technical aspects surrounding carotid endarterectomy remained unchanged over the years surveyed (1984, 1989, 1992) but by 1992 duplex scanning, intra-arterial (but not intravenous) digital subtraction angiography and transcranial Doppler ultrasonography had become established as clinically useful techniques.

8044591

Influence of Losartan, an angiotensin receptor antagonist, on neointimal proliferation in cultured human saphenous vein.

An organ culture of human saphenous vein was used as a model of vein graft intimal hyperplasia and the potential of Losartan, an angiotensin II receptor antagonist, to inhibit neointimal proliferation was investigated. Median (range) neointimal thickness was reduced from 17 (16-19) to 11 (8-18) microns in veins cultured with Losartan (median difference 5 (95 per cent confidence interval 2-8) microns). A similar decrease in the median neointimal proliferation index was seen from 21 (range 14-47) to 15 (range 5-31) per cent (median difference 8 per cent (95 per cent confidence interval 5-11 per cent)). These results demonstrate that angiotensin II receptor antagonists may be of therapeutic value for the modulation of vein graft intimal hyperplasia.

8044590

Platelet activation during hand vibration.

The level of beta-thromboglobulin, the circulating platelet aggregate ratio and platelet sensitivity to aggregation with adenosine 5'-diphosphate (ADP) and collagen were assessed in 12 control subjects, 16 patients with vibration white finger (VWF) and 15 patients with primary Raynaud's disease; this was done before and after a 1-min exposure to hand vibration. The beta-thromboglobulin level increased significantly in controls, from a median (interquartile range) of 35.5 (22-47) to 47.5 (27-52) ng/ml, and in the VWF group from 44.0 (39-60) to 47.5 (42-109) ng/ml (P < 0.005). Vibration had no effect on circulating platelet aggregate ratio in any group. The platelets of normal subjects tended to be more sensitive to aggregation with low-dose ADP (1 mmol/l) than those of patients with VWF or primary Raynaud's disease. Significant change occurred in the lag phase of the aggregation response to vibration in the control group at an ADP concentration of 2 and 5 mmol/l. These results indicate that intravascular platelet aggregation occurs as a result of exposure to vibration. Platelet sensitivity to aggregation with ADP may be decreased in patients with VWF or established Raynaud's disease.

8044589

Hypercoagulable states in patients with leg ischaemia.

Hypercoagulable states are found in up to 10 per cent of patients with a history of unexplained venous thrombosis. To investigate the prevalence in arterial thrombosis, thrombophilia screening was performed on 124 patients who had previously undergone lower-limb revascularization, 45 claudicants and 27 controls. Of the patients who had undergone revascularization 40 per cent had a hypercoagulation abnormality (low levels of protein C, protein S and antithrombin III or presence of the lupus anticoagulant) in comparison with 27 per cent of claudicants and 11 per cent of controls (P < 0.01). Furthermore, patients who had suffered reocclusion after revascularization were significantly more likely to have a hypercoagulation abnormality than those who had not (P < 0.05), even if the occlusion had occurred more than 6 months previously. Lupus anticoagulant was the abnormality most frequently detected and, like low protein C levels, was found only in patients with peripheral vascular disease. It appears that hypercoagulable states are common in patients with arterial disease and may predispose to failure of revascularization.

8044588

Management of bile duct stones in the era of laparoscopic cholecystectomy.

The introduction of laparoscopic cholecystectomy has resulted in increased options for the management of bile duct stones and has stimulated a fundamental reappraisal of the situation before the laparoscopic era. This article reviews the natural history of bile duct stones and details the different ways in which they may now be treated. New areas of controversy are highlighted and the need for further studies is emphasized.

8044587

Neutrophils may contribute to the morbidity and mortality of claudicants.

Peripheral arterial occlusive disease is a common cause of morbidity in middle-aged men; 5 per cent of those aged over 50 years suffer from intermittent claudication. While claudication itself is not fatal, claudicants have a mortality rate approximately three times that of non-claudicating men of the same age, mainly from cardiovascular disease. This review examines the evidence for involvement of the neutrophil in this increased mortality and describes the possible pathogenesis. It also discusses how treatment of claudication may modify neutrophil behaviour, reducing subsequent mortality and morbidity rates.

8044569

Rectoanal inhibition and incontinence in patients with rectal prolapse.

Thirty-five patients with complete rectal prolapse, 32 with neurogenic faecal incontinence and 33 controls underwent ambulatory recording using a computerized anal electromyographic and anorectal manometry system. Median resting anal pressures were 34 cmH2O in patients with prolapse, 51 cmH2O in those with neurogenic faecal incontinence and 94 cmH2O in controls. Median basal rectal pressures were 18, 21 and 21 cmH2O respectively. High-pressure rectal waves of median amplitude 71 cmH2O lasting 30-150 s and associated with inhibition of the electromyographic activity of the internal and sphincter and a fall in anal pressures were seen in all patients with prolapse but not in controls or those with neurogenic incontinence. These waves were abolished following successful resection rectopexy. Recovery of continence occurs by abolition of high-pressure rectal waves, which produce maximal inhibition of sphincter activity before operation.

8044568

Unconjugated faecal bile acids in familial adenomatous polyposis analysed by gas-liquid chromatography and mass spectrometry.

Previous studies have suggested reduced formation of secondary bile acids in patients with familial adenomatous polyposis (FAP). Developments in the collection, extraction and analysis of faecal bile acids as well as in the accurate diagnosis of FAP by DNA markers prompted reinvestigation of this hypothesis. The median (interquartile range (i.q.r.)) faecal bile acid concentration (3.69 (1.66-5.36) mumol per g dry weight) and daily excretion rate (60.5 (29-149) mumol per g per 24 h) in ten patients with FAP were similar to those of nine control subjects (3.31 (0.65-8.38) mumol per g dry weight and 30.1 (7.9-228) mumol per g per 24 h). Although the median (i.q.r.) concentration of only one bile acid (12-oxo-lithocholic acid) was significantly different between patients with FAP and controls (49 (34-70) versus 0 (0-20) nmol per g dry weight, P = 0.006), the derivatives of chenodeoxycholic acid (3.35 (1.76-5.32) versus 0.51 (0.13-2.37) mumol per g dry weight, P = 0.02) and cholic acid (1.63 (0.42-2.34) versus 0.80 (0.13-3.57) mumol per g dry weight, P = 0.006) were increased in those with polyposis. These results show increased bacterial biotransformation of faecal bile acids in patients with FAP.

8044567

Prognosis of elderly patients with large bowel cancer.

The effect of age on the presentation, diagnosis, management and survival of patients with colorectal cancer was studied prospectively in 512 patients admitted to a single institution. In all, 225 patients were aged 70 years or more and 287 less than 70 years. Older patients had a significant excess of emergency presentations (18 versus 11 per cent). Methods of diagnosis, proportion of curative operations performed, stage and histological grade were similar in the two age groups. The postoperative mortality rate was 6 per cent in the elderly group and 3 per cent in younger patients. The postoperative mortality rate rose to 15 and 12 per cent respectively in those undergoing emergency surgery. The relative 5-year survival rate standardized for age and sex was 52 per cent for older patients and 45 per cent for younger patients; for those undergoing curative surgery it was 68 and 59 per cent respectively. The behaviour of colorectal carcinoma changes little with age and, allowing for population mortality, age has no effect on the long-term survival of elderly patients with large bowel cancer.

8044566

The 5-year natural history of complicated diverticular disease.

The natural history of complicated diverticular disease based on details of 300 patients entered into a national audit between 1985 and 1988 is reported. Questionnaires were sent to the general practitioners of 176 patients with this condition 5 years after hospital admission; 120 responded. Of these 120 patients, ten died from recurrent complicated diverticular disease, 29 died from other disorders and 81 remain alive. Forty of 110 patients (excluding those who died from recurrence) are still symptomatic or were so at the time of unrelated death. Thirty-nine patients developed a severe complication after the index admission, 14 of whom had the same complication initially. Of the 77 patients who had initially been managed by sigmoid resection, only two developed recurrent complications compared with 37 of 43 managed conservatively. Of the ten patients who died from recurrent diverticular disease, nine had not undergone sigmoid colectomy at or after the original admission. These data argue for interval sigmoid colectomy in most patients who initially present to hospital with complicated diverticular disease to prevent later development of potentially lethal complications.

8044565

National audit of complicated diverticular disease: analysis of index cases.

Details of 300 patients with complicated diverticular disease from 30 hospitals between 1985 and 1988 were entered into a national audit organized by the Surgical Research Society. Complications present on admission included acute phlegmon (n = 104), pericolic abscess (n = 34), purulent peritonitis (n = 40), large bowel obstruction (n = 31), faecal peritonitis (n = 23), pericolic abscess complicated by fistula (n = 28) and lower gastrointestinal bleeding (n = 40). The overall mortality rate was 11.3 per cent (acute phlegmon, 4 per cent; purulent peritonitis, 27 per cent; pericolic abscess, 12 per cent; faecal peritonitis, 48 per cent; large bowel obstruction, 6 per cent; bleeding, 2 per cent; fistula, 4 per cent). Acute phlegmon was treated without operation in 78 patients (75.0 per cent) and by resection in 24 (23.1 per cent). Management of purulent peritonitis generally involved Hartmann's procedure (62 per cent) or resection and primary anastomosis (15 per cent). Similarly, patients with pericolic abscess usually underwent Hartmann's procedure (38 per cent) or resection and primary anastomosis (35 per cent). The principal operation for faecal peritonitis was Hartmann's resection (83 per cent). Large bowel obstruction was managed conservatively in four patients (13 per cent), by Hartmann's procedure in nine (29 per cent), and by resection and primary anastomosis with or without a proximal stoma in 13 (42 per cent). Most patients (82 per cent) with fistula associated with an abscess were managed by resection and primary anastomosis; 90 per cent with acute gastrointestinal bleeding were treated without operation.

8044564

Life-table analysis of stomal complications following ileostomy.

Stomal complications of ileostomy may occur many years after construction. An actuarial analysis of complications of 150 permanent end ileostomies constructed over a 10-year period is reported. By 20 years the incidence of stomal complications approached 76 per cent in patients operated on for ulcerative colitis and 59 per cent in those with Crohn's disease (P < 0.05). Revisional surgery rates were higher in patients with ulcerative colitis than in those with Crohn's disease (28 versus 16 per cent), albeit not significantly. The four commonest complications were skin problems (cumulative probability 34 per cent), intestinal obstruction (23 per cent), retraction (17 per cent) and parastomal herniation (16 per cent). Closure of the lateral space did not reduce the probability of developing intestinal obstruction (18 per cent at 20 years in those with closure versus 3 per cent in those without, P > 0.1). Fixation of the mesentery did not reduce the probability of developing prolapse of the ileostomy (11 per cent in those with fixation versus none in those without, P < 0.1). The incidence of parastomal herniation was not reduced by sitting through the rectus abdominis (21 per cent in those sited through the body of the rectus abdominis versus 7 per cent in those sited through the oblique muscles, P < 0.1). Some of the surgical dogmas relating to ileostomy construction are not supported by the results of this study.

8044563

Influence of total colectomy on serum antineutrophil cytoplasmic antibodies in inflammatory bowel disease.

Perinuclear antineutrophil cytoplasmic antibodies (pANCAs) have previously been demonstrated in patients with various forms of vasculitis and more recently in those with inflammatory bowel disease (IBD) by an indirect immunofluorescence technique. Sera from 194 patients were tested for pANCAs: 101 with ulcerative colitis (43 with varying grades of disease severity, 19 after subtotal colectomy, 39 following restorative proctocolectomy), 40 with Crohn's disease, five with indeterminate colitis, 24 patients without IBD and 24 healthy volunteers (controls). The overall prevalence of pANCAs in patients with ulcerative colitis was 70.3 per cent (71 of 101). These antibodies were still present in 29 of 39 patients after restorative proctocolectomy, in whom the median follow-up after surgery was 2 years. All five patients who had pouchitis after restorative proctocolectomy were pANCA positive. By contrast, only ten of 40 patients with Crohn's disease had pANCAs, nine of whom had Crohn's colitis. No pANCAs were detected in controls. These results show that pANCAs are more prevalent in colonic IBD, especially ulcerative colitis. The persistence of pANCAs in the sera for 2 years after restorative proctocolectomy suggests that the antigens are not fully eradicated and, therefore, that it is not just the colon that is targeted immunologically in ulcerative colitis.

8044561

Laparoscopic cholecystectomy for biliary pancreatitis.

A prospective study was undertaken to assess the technical difficulty of early laparoscopic cholecystectomy for acute biliary pancreatitis. Patients underwent early endoscopic retrograde cholangiography (ERC) and laparoscopic cholecystectomy was performed after signs of clinical improvement. Five steps were assessed during surgery using a visual analogue score. These patients were compared with a control group undergoing elective surgery for chronic symptomatic gallstones. Of 24 patients aged 28-83 (median 60) years, eight had three or more positive signs according to Ranson's criteria. Twenty-three patients underwent successful ERC; seven had choledocholithiasis and were managed endoscopically. Laparoscopic cholecystectomy performed 3-24 (median 7) days after admission was successful in 21 of the 24 patients. The mean(s.d.) operative difficulty score was significantly increased in patients with acute biliary pancreatitis compared with that in the 40 controls (5.4(1.8) versus 3.6(1.4), P < 0.002), particularly for dissection of Calot's triangle (6.5(1.5) versus 3.0(1.6), P < 0.001). A dilated cystic duct was present in over 50 per cent of patients and in seven could not be safely closed with a clip; this finding was not predicted by ERC. Biliary pancreatitis is a further indication for laparoscopic cholecystectomy. Early surgery is safe but technical difficulty is increased. Cystic duct dilatation must be anticipated; an externally tied ligature in continuity is recommended.

8044558

Splenic autotransplantation after splenectomy: tuftsin activity correlates with residual splenic function.

This study set out to determine the relationship between splenic function (as assessed by the percentage of pitted red cells) and tuftsin activity, and to confirm the return of effective splenic function after splenectomy for trauma. Twenty-three patients (13 men) took part. Ten of mean age 48.5 (range 30-74) years had had the spleen removed for traumatic rupture and 13 of mean age 49.7 (range 23-66) years had undergone elective splenectomy. At the time of the study all patients had had the spleen removed a minimum of 1 year previously (mean 6.1 (range 1-15) years). Fifty healthy volunteers matched for sex and age were also studied. In each subject, residual splenic function was evaluated by counting the percentage of pitted red cells. Tuftsin activity was also determined. A highly significant negative correlation was found between pitted red cell percentage and tuftsin activity (rs = -0.80, P < 0.001). Compared with healthy controls (mean 21.6 (range 13-37) per cent), tuftsin activity was significantly reduced both in patients who had undergone splenectomy for trauma (mean 4.4 (range 0-9) per cent; P < 0.0001) and in those who had had elective splenectomy (mean 0; P < 0.0001). Tuftsin activity was significantly (P < 0.001) more depressed after elective than traumatic splenectomy. These data confirm a decrease in tuftsin activity following splenectomy and show that this deficit is significantly greater after elective than emergency removal. These observations confirm that residual splenic function is often present after traumatic splenectomy.

8044556

Thoracoscopic evaluation of the diaphragm in patients with knife wounds of the left lower chest.

The role of thoracoscopy in assessing the status of the diaphragm in penetrating knife wounds of the left lower chest was studied prospectively in 55 patients. Those with positive thoracoscopic findings (n = 22) proceeded to exploratory laparotomy and those with an uninvolved diaphragm (n = 32) were observed. Thoracoscopy was inconclusive in one patient and two were lost to follow-up. With operative findings or 30-month follow-up data as evaluation endpoints, thoracoscopy in 52 patients was 100 per cent sensitive, 90 per cent specific and 94 per cent accurate. A projected negative laparotomy rate of 63 per cent would have occurred with a policy of mandatory laparotomy; using thoracoscopy the actual rate was 6 per cent. Thoracoscopy is a safe and reliable method of evaluating the diaphragm in patients with left lower thoracic stab wounds.

8044555

Screening for abdominal aortic aneurysm in Northumberland.

A study was carried out to examine the feasibility of setting up a community-based screening programme for abdominal aortic aneurysm (AAA) in men aged 65-79 years served by a district general hospital. A pilot project was run in two general practices from which 800 men were invited to undergo ultrasonography of the abdominal aorta. Of these, 628 (78.5 per cent) attended; 42 (6.7 per cent) were found to have an aneurysm (aortic diameter greater than 29 mm), ten (1.6 per cent) had a large aneurysm (diameter above 49 mm) and seven (1.1 per cent) received aortic grafts. On the basis of these findings it was felt that to screen all men aged 65-79 years (n = 12,800) or aged 65-74 years (n = 10,300) would lead to more operations than local facilities could handle. A more practical option would be to target annually men aged 65 years, with rescreening at intervals of 5 years until age 75 years, but even this would eventually lead to an unmanageable number of operations.

8044554

Mortality rates associated with operative treatment of infrarenal abdominal aortic aneurysm in The Netherlands.

Information on surgery for non-ruptured and ruptured infrarenal abdominal aortic aneurysm (AAA) in all hospitals in The Netherlands in 1990 was obtained from the Dutch National Medical Registration Foundation. The operation rate in the population over the age of 50 years was 30.3 per 100,000 for non-ruptured AAA and 16.8 per 100,000 for ruptured aneurysm. The hospital operative mortality rate for non-ruptured AAA surgery was 6.8 per cent in 1289 patients and for ruptured aneurysm 43.6 per cent in 709. For non-ruptured AAA the mortality rate almost doubled per age group of 10 years, whereas the influence of age was less significant for ruptured lesions. The operative mortality rate for non-ruptured aneurysm in university hospitals exceeded that in other hospitals, but no difference was found for emergency surgery on ruptured AAA. Nationwide results give a more representative picture of the true mortality rate associated with operation for aortic aneurysm. Such data are important for planning future treatment strategy and for evaluating the efficacy of screening.

8044552

Long-term human vein graft contractility and morphology: a functional and histopathological study of retrieved coronary vein grafts.

Vasoreactivity of 11 coronary artery vein bypass grafts and 13 human saphenous veins was examined. Isometric tension studies were performed in response to potassium chloride (110 mmol/l), noradrenaline (10(-9)-10(-4) mol/l), serotonin (10(-9)-10(-4) mol/l) and histamine (10(-8)-10(-2) mol/l). After precontraction with noradrenaline (10(-5) mol/l), the response to acetylcholine (10(-8)-10(-4) mol/l) and the calcium ionophore A23187 (10(-8)-10(-4) mol/l) was also assessed. Results are given as mean(s.e.m.). Compared with saphenous veins, vein grafts showed decreased sensitivity to noradrenaline (1.7(0.5) versus 0.4(0.1) mumol/l, P = 0.01), no change in sensitivity to serotonin (55(18) versus 37(15) mumol/l, P > 0.05) and supersensitivity to histamine (3.2(0.9) versus 30.1(13.2) mumol/l, P = 0.01). Vein grafts had a decreased maximal contraction to potassium chloride (1.1(0.3) versus 5.5(0.8) g, P = 0.0001), noradrenaline (1.2(0.3) versus 4.1(0.8) g, P = 0.005), histamine (1.2(0.3) versus 4.5(0.8) g, P = 0.003) and serotonin (0.7(0.2) versus 5.7(0.6) g, P = 0.0002) compared with saphenous vein. Precontracted vein grafts did not relax in response to acetylcholine; in contrast, saphenous vein relaxed in a dose-dependent manner to a maximal relaxation of 22(3) per cent. Both saphenous vein and vein graft relaxed in response to A23187. Vein graft intimal thickness was approximately fourfold greater than that of saphenous vein (540(110) versus 136(30) microns). Scanning electron microscopy of vein and vein graft revealed an intact endothelium. Coronary artery vein grafts are capable of responding to various contractile agonists; these response are notably different from those of saphenous vein and there is a loss of endothelium-dependent relaxation. Even at a late stage vein grafts are not inert but are functional conduits with an abnormally responsive endothelium and a less potent, but significantly altered, smooth muscle contractile profile.

8044550

Inappropriate neutrophil activation in venous disease.

Neutrophil oxygen radical production was studied in 18 limbs with class 2 or 3 venous disease and compared with that of nine normal limbs. Neutrophils were isolated from arm and leg venous samples. Free radical production was determined using chemiluminescence after stimulation with the chemotactic peptide formyl-methionyl-leucyl-phenylalanine (FMLP) or the ester phorbol myristate acetate (PMA). The ratio of leg to arm luminescence was greater after FMLP stimulation in patients with venous disease (median 1.52 (95 per cent confidence interval (c.i.) 1.27-2.60)) than in controls (median 0.97 (95 per cent c.i. 0.70-1.12); P < 0.01). These changes were not observed with PMA (venous disease 1.16 (95 per cent c.i. 1.05-1.40); controls 0.95 (95 per cent c.i. 0.78-1.24)). There were fewer FMLP receptors on activated leg neutrophils (median 20.19 (95 per cent c.i. 3.58-51.42) fluorescence units) than arm neutrophils (median 36.03 (95 per cent c.i. 13.00-65.28) fluorescence units; P < 0.05), indicating an amplification of signal transduction. Intracellular calcium imaging demonstrated a larger release of calcium after stimulation of leg neutrophils (median 25.0 per cent (95 per cent c.i. 15.7-43.9 per cent)) compared with neutrophils from the arm (median 8.0 per cent (95 per cent c.i. 5.6-16.1 per cent); P = 0.04), demonstrating calcium-dependent activation. Neutrophils in patients with chronic venous disease inappropriately produce more oxygen free radical as a result of amplification of a calcium-dependent signal pathway.

8044549

Endoluminal ultrasonography in the follow-up of patients with rectal cancer.

One principal aim in follow-up after curative surgery for colorectal cancer is to identify recurrent disease at an early and possibly treatable stage. The major problem for patients with rectal carcinoma is local recurrence, which occurs in 3-30 per cent of cases and carries a 5-year survival rate of less than 5 per cent. Since 1989, in addition to digital and sigmoidoscopic examination, endorectal ultrasonography has routinely been used in the follow-up of patients with rectal cancer. Sixty-six patients (40 men) who had undergone attempted radical surgery for mid- and lower-third rectal cancer were included in the study. The mean age was 68 (range 43-87) years. A total of 190 scans were performed, with a mean of 3 (range 1-9) for each patient. Thirteen (20 per cent) of the 66 patients developed local recurrence; in all cases this was suggested by rectal ultrasonography. Digital examination and rigid sigmoidoscopy failed to detect recurrence in three patients. Four detected recurrences were treated radically; the remaining patients received radiotherapy, palliative transanal resection or laser management because of advanced age or refusal to undergo surgery. Six patients were alive a mean of 21 (range 4-50) months after recurrence. Of these six patients, four were free from disease (three had undergone salvage surgery and one radiotherapy). Postoperative rectal ultrasonography can detect some local recurrences at an early treatable stage. The method is more accurate than digital examination and sigmoidoscopy, and should be used as part of a regular follow-up programme.

8044548

Colorectal cancer surveillance in patients with ulcerative colitis.

In a prospective study carried out between 1977 and 1991, 131 patients with ulcerative colitis from an area of 65,000 inhabitants were followed by clinical visits and regular colonoscopy with biopsy. At the end of the study 58 patients had had total colitis for more than 10 years, 38 had left the programme (16 after radical operations, nine because of death--one from colitis, one from carcinoma--and 13 for other reasons) and 632 colonoscopies had been performed. Colorectal carcinoma was diagnosed in four patients, of whom two were included in the programme with a diagnosis of cancer. Dysplasia was diagnosed in 24 patients, other than those with malignancy; in four this was of high grade. Carcinoma and dysplasia occurred mainly in the left colon and in patients with total colitis. The surveillance programme was resource consuming and the cost-benefit must be questioned.

8044547

Prognostic factors and survival of patients aged less than 45 years with colorectal cancer.

Colorectal cancers in 92 patients aged 45 years and under presenting over a 20-year period (1970-1990) were studied. A delay of more than 4 months in presentation was seen in 27 per cent of patients. All underwent surgery, 14 per cent emergency and 86 per cent elective, and follow-up was available for 91 patients. Overall, 14 per cent of patients had Dukes A tumours, 32 per cent Dukes B, 36 per cent Dukes C and 18 per cent Dukes 'D'. Local recurrence occurred in eight (9 per cent) of the 92 patients and overall 5- and 10-year survival rates were 61 and 59 per cent. Multivariate analysis identified independent risk factors for local recurrence to be mucinous carcinoma (relative effect 4.9) and the presence of intramural vascular invasion by tumour (relative effect 9.4). For overall survival, independent risk factors were involvement of the regional lymph nodes by tumour (relative effect 2.0), extramural invasion by tumour cells (relative effect 3.0), tumour size (relative effect 1.8) and the presence of metastatic disease at initial diagnosis (relative effect 3.7).

8044545

Practical score to aid decision making in doubtful cases of appendicitis.

During recent years different procedures have been used to assist in diagnosis of questionable cases of appendicitis. Among these methods, there are few scoring systems that have been shown to be effective. The aim of this study was to create a scoring system and to test its accuracy in the preoperative diagnosis of acute appendicitis. Clinical data from 360 patients who had undergone appendicectomy were collected to identify attributes that distinguished patients having a negative laparotomy from those with appendicitis. Seven independent criteria were identified. Using Bayesian methodology a weight was given to each criterion and an overall score calculated. A cut-off point was identified to separate patients for surgery and those for observation. The scoring system was applied prospectively to 166 consecutive patients; 134 had appendicitis and 32 a normal appendix (19.3 per cent error diagnosis). For the 166 patients the method suggested surgery in 113, 107 (94.7 per cent) of whom were found to have appendicitis. The system suggested observation in hospital in 38 cases. For the whole group the scoring system showed a sensitivity of 80 per cent and specificity of 81 per cent. Scoring systems from a local database could become the ideal complementary method in the diagnosis of suspected acute appendicitis.

8044544

Repeated reconstruction for recurrent benign bile duct stricture.

Since 1965, 101 operations for benign bile duct stricture have been performed, including 51 Roux-en-Y end-to-side hepaticojejunostomies. Complete follow-up to a mean of 12.5 years has been achieved. Nine patients required reoperation for stricture; the total cumulative late patency rate was 90 per cent, including successful repair. Seven of the nine patients who underwent a second operation had a favourable outcome. Early hepaticojejunostomy is a satisfactory treatment for recurrent biliary stricture.

8044542

Surgical treatment of insulinoma.

The role of preoperative and intraoperative procedures for the localization of insulinoma has been extensively debated. Transhepatic portal vein sampling before surgery has been recommended when other tests fail to localize the tumour. To determine the role of different investigations, 53 patients with insulinoma, four with hyperplasia or nesidioblastosis and one with insulin autoimmune syndrome were studied. Patients were operated on in three consecutive periods during each of which a different localization procedure was considered to represent the 'gold standard'. During the first period, of 16 patients (including one with hyperplasia) investigated by arteriography, 13 underwent successful resection. Tumours in the other three patients with insulinoma were resected at a second operation, one during the first period and one each during the second and third periods. During the second period, 28 patients underwent exploration after transhepatic portal sampling: the tumour was found in all 26 patients with insulinoma operated on in this hospital, one patient with hyperplasia is receiving medical treatment and one patient had unsuccessful surgical exploration elsewhere despite positive findings on arteriography and transhepatic portal sampling performed in this department. During the third period 13 procedures were performed. All were successful using intraoperative ultrasonography without transhepatic portal sampling. In three further patients intraoperative localization failed because of non-adenomatous beta cell disease. Left-sided resection successfully cured symptoms in two patients with hyperplasia and prompted the diagnosis of insulin autoimmune syndrome. High success rates for surgical treatment of insulinoma can be achieved with transhepatic portal vein sampling or intraoperative ultrasonography. Transhepatic portal sampling is therefore unnecessary before a first operation on the pancreas for insulinoma. In the rare failures of intraoperative localization of an insulinoma, a small left pancreatic resection can help to distinguish insulinoma from hyperplasia without precluding further segmental resection.

8044541

Intestinal anastomosis with a skin stapler: a safe and efficient method in humans.

A method of intestinal anastomosis with a skin stapler has been used successfully in 39 patients to form 40 anastomoses. The method has been employed in elective and emergency surgery, in small and large intestine, for a variety of pathological conditions and in the presence of obstruction, sepsis and soiling. Bowel anastomosis with a skin stapler is safe, simple and efficient in time and materials.

8044539

Intravenous digital subtraction angiography versus computed tomography in the assessment of abdominal aortic aneurysm.

Results of preoperative investigation of 127 patients who underwent elective aortic aneurysm repair during a 3-year period were examined and compared with findings at operation. The accuracy of preoperative computed tomography (CT) and intravenous digital subtraction angiography (DSA) in assessing proximal and distal aneurysm extent was compared. From a total of 118 CT scans, ten of 12 suprarenal aneurysms were correctly predicted, with 11 false positives (positive predictive value 48 per cent, sensitivity 83 per cent, specificity 90 per cent). After 103 DSA investigations, six of ten suprarenal aneurysms were correctly predicted with one false positive (positive predictive value 86 per cent, sensitivity 60 per cent, specificity 99 per cent). Using CT, 30 of 54 aneurysmal iliac arteries were correctly diagnosed with 20 false positives (positive predictive value 60 per cent, sensitivity 56 per cent, specificity 88 per cent). Thirty-six of 48 aneurysmal iliac arteries were diagnosed correctly using DSA, with 32 false positives (positive predictive value 53 per cent, sensitivity 75 per cent, specificity 79 per cent). Intravenous DSA also provided useful information about renal and peripheral occlusive disease. Both investigations have their own specific limitations; clinicians should be aware of these when ordering and interpreting them.

8044538

Variation in outcome of surgical procedures.

Evidence regarding the relationship between outcome and the number (volume) of patients treated at individual hospitals or by individual surgeons is reviewed and the interplay of other factors such as hospital characteristics, population profiles and referral preferences examined. An inverse relationship between mortality rate and hospital volume has repeatedly been found and, while there have been similar findings for surgeon volume, these results have been less consistent. What is certain is that wide variation in outcome does occur. What is less clear is whether the relationship to volume is a causal one or whether it is due to other factors such as those mentioned above. Despite there being a great deal that we do not understand about these relationships, considerable action has been taken as a result of the studies reported here, in the USA in particular. This has taken the form of rationalization of services, publication of hospital mortality rates and the setting of minimum numbers of specific procedures that should be performed each year by individual surgeons. Understanding of this area should be much greater before rationalization is considered in the name of higher quality and before mortality rates according to hospital or surgeon are published.

8044537

Abdominal wall metastases following laparoscopy.

Only 18 cases of recurrence at the sites of cannula insertion after laparoscopy have been reported in the literature, ten of them in the past year. The period between laparoscopic surgery and presentation of wound metastasis varies widely, from 7 days to 10 months; the lesions are typically hard, craggy and painful. The most likely mechanism is direct implantation of viable exfoliated tumour cells but three aspects specific to laparoscopy may also be important. First, there may be increased exfoliation of tumour cells following manipulation by laparoscopic instruments of an unsuspected malignancy. Second, there may be repeated close contact between tumour-laden instruments and the port. Third, the passage of resected tissue through a small incision may coat the wound with potentially malignant cells.

8044536

Ischaemia-reperfusion injury.

Ischaemia-reperfusion injury is a complex phenomenon often encountered in surgical practice. The consequences of such injury are local and remote tissue destruction, and sometimes death. Several different processes have been implicated. This review discusses the pathology of such injury, the mechanisms of free radical production, and the role of neutrophils and endothelial factors in ischaemia-reperfusion. Finally, several mechanisms that limit ischaemia-reperfusion injury are discussed and a number of novel therapies presented.

8044533

Reasons for patient drop-out from an intracavernous auto-injection programme for erectile dysfunction.

To identify factors that contribute to patient drop-out rates from an intracavernous auto-injection programme for erectile dysfunction. Forty-seven patients who had been successfully treated with intracavernous vasoactive agents but who subsequently failed to attend follow-up appointments were included in the study. Each patient completed a self-administered questionnaire. Thirty (64%) completed questionnaires were returned. The reasons for withdrawal from treatment are outlined. The majority of patients who discontinued intracavernous therapy did so for reasons unrelated to treatment associated problems.

8044532

Ultrasound in the evaluation of urethral stricture disease: a prospective study in 175 patients.

To investigate the characteristic ultrasonic appearance of urethral stricture disease in men. Between 1990 and 1992 a prospective study in 175 men with the suspicion of urethral stricture was performed using urethral ultrasound as the first diagnostic procedure, followed by retrograde urethrography, voiding cystourethrography or urethroscopy. The sensitivity and specificity in detecting urethral strictures were 98% and 96% respectively. Ultrasound offers a three-dimensional study in the evaluation of the urethra without exposing the gonads to ionizing radiation. The exact length and depth of the stricture, the severity of the strictured segment as well as the anatomy of the periurethral scars were diagnosed accurately. Ultrasound is a simple, inexpensive and rapid investigation of the urethra which requires no exposure of the patient to ionizing radiation and should be the preferred diagnostic procedure in the evaluation of strictures in the anterior urethra in men.

8044531

The effect of pharmacological stimulation and blockade of autonomic receptors and of pudendal blockade on urethral stress relaxation in healthy women.

To examine the influence of autonomic receptor stimulation and blockade (noradrenaline, prazosin, terbutaline, propranolol, carbachol and atropine), and of pudendal nerve blockade on urethral stress relaxation. Forty healthy women were evaluated. The stress relaxation parameter was defined as the relative rate of pressure decrease during a fixed period of time following a rapid dilatation of the urethra. The dilatation was performed by water-infusion into a small rubber cylinder placed in the urethra. The drugs did not affect stress relaxation significantly, whereas the pudendal blockade produced a significant change along the length of the urethra characterized by a faster pressure decay following dilatation. In women, stress relaxation in the urethra relies significantly on the pudendal nerve-innervated striated muscles.

8044530

Altered saccharide sequences in two groups of patients with metastatic prostatic carcinoma.

To investigate the hypothesis that primary prostatic carcinomas with metastases to different sites (lymph nodes or bone) show varying expression of cell surface and cytoplasmic glycoconjugates. A group of 14 patients with primary prostatic carcinoma with lymph node metastases but no bone metastases has previously been shown to have an increased survival time. This group was compared with a control group of 14 patients with lymph node-negative, bone metastasis-positive primary prostatic carcinoma using a panel of biotinylated lectins revealed by the avidin-biotin peroxidase complex method. The results were analysed semi-quantitatively and differences in binding patterns between the two groups were sought. No significant differences were seen using the LCA, LTA, UEA-1, WFA, VVA or SBA lectins. The group with bone metastases but no lymph node involvement showed significantly increased binding for the ECA and AHA lectins, both before and after neuraminidase pre-treatment, compared with the lymph node-positive group. These results suggest that tumours lacking or having a reduced affinity for binding sites for both Gal beta 1-3GalNac (Type I oligosaccharide structures--AHA) and Gal beta 1-4GlcNac (Type II oligosaccharide structures--ECA) sequences are more likely to develop lymph node metastases and less likely to develop bone metastases and thereby increasing the patient's chances of survival. This is further evidence that the metastatic potential of tumours per se and the ultimate site of distal metastases from such tumours is affected in part by the glycoconjugates expressed on their cell surfaces and indicates that metastatic phenotypes for prostatic carcinoma exists.

8044529

Rapid tumour recurrence following cessation of long-term treatment with intravesical thiotepa.

To report tumour recurrence related to cessation of long-term therapy with thiotepa. A group of 12 patients with low grade (I-II), low stage (TA-T1) transitional cell carcinoma of the bladder were included in the study. All patients had been treated with intravesical thiotepa for a period ranging from 24 to 71 months and none had had a recurrence for a period of between 15 and 51 months. After referral to this department all the patients were withdrawn from thiotepa therapy. All the patients developed bladder tumours within 6 months of cessation of therapy. The recurrent tumours were grade II in 10 patients and grade III in two patients. Eight patients had stage TA and four had stage T1. All responded to bacille Calmette-Guérin therapy and none had tumour recurrence on follow up at 24 months. Meticulous follow-up of patients is indicated soon after the cessation of long-term therapy with thiotepa.

8044528

Destruction of the vesicoureteric plexus for the treatment of hypersensitive bladder disorders.

To determine whether bilateral vesicoureteric ganglion excision is effective in the treatment of women with hypersensitive bladder disorders. Utilizing neuroconductive studies, 175 women with hypersensitive bladder complaints of burning and frequency were selected by the presence of abnormal pudendal nerve sensory latency studies. Cystoscopy under anaesthesia revealed petechial haemorrhaging peritrigonally with bladder neck involvement, consistent with interstitial cystitis. Laser obliteration of the vesicoureteric plexus bilaterally resulted in complete relief of pelvic pain in 112 patients and partial relief in 58. Forty-five patients with complete relief were followed for 2 years with no recurrence of symptoms. Complications included one case of periureteric fibrosis secondary to cauterization. Bilateral vesicoureteric ganglion excision offers a new approach to treating hypersensitive bladder disorders such as interstitial cystitis.

8044527

The invaginated sleeve technique for a continent cystostomy--five years' clinical experience.

To evaluate the invaginated sleeve technique for continent cystostomy in humans. Over the past 5 years six patients have undergone this operative procedure. An essential principle utilized in the technique is the property of partial thickness bladder grafts to stretch longitudinally, so that each tubularized pedicle graft could be directed transmurally and extended extravesically to reach the skin of the lower abdominal wall. As a consequence a urothelial-lined tract, both extravesically and through the bladder wall, was provided for intermittent self-catheterization. Apart from one woman, whose cystostomy tract was disrupted by inappropriate catheterization in the immediate post-operative period to attempt to stop leakage through exposed fenestrations in the suprapubic stent, this procedure provided robust, continent catheterizing routes for all patients for periods of 63, 52, 12, 7 and 1.5 months respectively. Two patients developed discrete stenoses at their mucocutaneous junctions at 3 and 5 months which were corrected easily. This simple, minimally morbid technique, which avoids the use of non-urinary tract epithelial structures and maintains bladder capacity, is strongly recommended for patients who need to practise clean intermittent self-catheterization and for whom the urethral route is impracticable.

8044526

The radionuclide assessment of pre-natally diagnosed hydronephrosis.

To determine if a pre-operative non-invasive radionuclide study can predict the results of surgery in infants with pre-natally diagnosed hydronephrosis. Eight male infants with prenatally diagnosed hydronephrosis were treated by pyeloplasty within the first 4 months of life. All infants underwent a pre-operative diuresis renogram and a dimercapto-succinic acid (DMSA) scan, followed by a further renogram 6 months after surgery to assess renal function and drainage. There was a significant difference between the results of the relative renal function estimates obtained by the pre-operative renogram and the pre-operative DMSA scan (P = 0.001). In all patients the recovery in renal function following surgery was accurately predicted by the pre-operative DMSA scan. The results of this preliminary study suggest that a pre-operative DMSA scan could replace the use of invasive nephrostomy drainage to assess the potential for recovery in the poorly functioning neonatal kidney and give an indication of those kidneys most likely to benefit from reconstructive surgery.

8044525

Chronic hydronephrosis: renographic drainage patterns and renal morphology in an animal model.

To develop an animal model of chronic progressive hydronephrosis; to establish patterns of diuretic renography during development of the condition; and to relate renographic abnormality to morphological change in the renal parenchyma. The cellophane sclerosis technique was used to produce a hydronephrosis in the left kidney of six rabbits. Post-operatively MAG3 diuretic renography was performed at weekly intervals. When a steady renographic trend was noted the rabbits were killed and the kidneys examined histologically. Four rabbits had persistent type II renographic curves on the left for 12 weeks. The measured split renal function fell steadily to < 20% in this time. Morphologically there was hydronephrosis with marked structural changes in the parenchyma seen on histological examination. Two rabbits had stable type IIIa renographic drainage patterns on the left with preserved renal function. Morphologically there was hydronephrosis but histologically the kidneys were normal. There were no renographic or structural changes in a control rabbit after a sham laparotomy. The cellophane sclerosis technique can be used to create a reproducible chronic progressive hydronephrosis. In this animal model hydronephrosis and a persistent type II curve are associated with renographic evidence of deteriorating renal function and disruption of renal architecture histologically. Hydronephrosis and a type IIIa curve are associated with preservation of normal renal function and histological structure.

8044524

The influence of banana stem extract on urinary risk factors for stones in normal and hyperoxaluric rats.

To study the effect of banana stem (Family Musaceae) extract on urinary risk factors in an animal model of hyperoxaluria. Thirty male rats were divided into five groups of six rats each. The rats in Group I acted as the control, in Group II rats hyperoxaluria was induced using sodium glycollate, Group III were given aqueous banana stem extract alone, Group IV were given both sodium glycollate and aqueous banana stem extract and Group V were given sodium glycollate alone followed by aqueous banana stem extract. Urine analysis (24 h) was carried out to determine the levels of calcium, phosphorous, oxalate, glycollic acid and glyoxylic acid in each of the five groups. In the rats treated with aqueous banana stem extract, urinary oxalate excretion was significantly reduced when compared with the controls. The extract reduced urinary oxalate, glycollic and glyoxylic acid and phosphorus excretion in the hyperoxaluric rats. The extract appeared to have no effect on urinary calcium excretion. Banana stem extract from the Musaceae family may be a useful agent in the treatment of patients with hyperoxaluric urolithiasis.

8044522

Immunological parameters in peripheral blood of patients with renal cell carcinoma before and after nephrectomy.

To determine the effects of nephrectomy on the immune response of patients with renal cell carcinoma (RCC). Five patients with RCC were monitored before and over a period of up to 3 months after nephrectomy. The aspects measured were the phenotypic expression of markers on circulating lymphocytes, circulating concentrations of cytokines, markers of inflammatory and immune responses, and natural killer (NK) cell and lymphokine-activated killer (LAK) cell activity in peripheral blood mononuclear cells (PBMC). The suppressive activity of patients' plasma on NK activity and ability to generate interleukin-2 (IL-2) induced LAK cells in PBMC of normal volunteers was also investigated. The results indicated that high CD4/8 ratios were present pre-nephrectomy with evidence of inflammatory responses and immune activation in some patients, particularly those with metastatic disease. The effect of nephrectomy was to decrease the inflammatory response and increase immune activation. Various defects in NK cell activity and LAK cell generation were demonstrated pre-surgery which slowly improved once the primary tumour had been removed and it is suggested that such defects could have contributed to tumour growth and development due to an ineffective immune response.

8044506

Laparoscopic procedure for varicocelectomy.

To report the results of laparoscopic varicocelectomy, a new surgical technique which presents minimal risks and provides an effective management of clinical varicoceles. Between July 1991 and November 1992, 45 laparoscopic varicocelectomies were performed in 44 patients whose ages ranged from 11 to 41 years. Endoscopic ligation, carried out according to the technique described by Palomo, was performed in 14 patients. In the remaining 30 patients ligation of 31 spermatic veins was performed according to Bernardi's procedure. On post-operative follow-up symptoms disappeared in all the patients treated. Two of the patients showed persistent venous reflux on colour Doppler ultrasound examination. The excellent identification of the anatomical structures, the minimal surgical trauma, the decrease in post-operative morbidity and the quick convalescence of the patients have made this new technique a viable alternative to routine open high ligation.

8044505

Interferon as adjunctive treatment for non-metastatic renal cell carcinoma.

To investigate the effect of recombinant alpha 2b-interferon therapy on natural killer (NK) activity and antibody-dependent cell-mediated cytotoxicity (ADCC) in the peripheral blood in patients with renal cell carcinoma who had undergone radical nephrectomy. Between January 1988 and June 1989, 20 patients (14 men and six women, mean age 59 years, range 43-80) received interferon (IFN) therapy following radical nephrectomy for renal cell carcinoma. Thirteen patients had stage I disease, one had stage II and six had stage III; none had metastases. There was a significant increase in NK activity at 5 and 7 months after starting IFN therapy but there was no increase in ADCC. Low doses of IFN administered long-term increased NK activity in patients with renal cell carcinoma. This finding should be helpful in designating protocols for randomized studies of post-operative IFN administration as adjuvant therapy.

8044504

Vacuum constriction devices in erectile dysfunction: acceptance and effectiveness in patients with impotence of organic or mixed aetiology.

To investigate the value of vacuum constriction devices in the treatment of erectile dysfunction. A total of 67 patients were treated with vacuum constriction devices. The impotence was of organic origin in 36 men (54%) while in the remaining 31 (46%) it was of mixed aetiology (organic and psychological factors). Forty-seven patients continued to use the device at home for the duration of the practice period. All 67 patients underwent a vacuum test which resulted in nearly half of them achieving an erection sufficient for intercourse. Adequate erections were achieved in 34 of 47 (72%) patients who used the device at home during the practice period. In the group of patients with organic impotence (venous leakage), rigidity was better and the frequency of intercourse higher than in patients with diabetes and in those with neurogenic disorders. These findings support further the role for vacuum devices for the treatment of erectile dysfunction in carefully selected patients.

8044503

Sex differences in aggression: social representation and social roles.

Previous research suggests that men hold an instrumental social representation of aggression in which aggression is viewed as a functional interpersonal act aimed at imposing control over other people while women view aggression in expressive terms as a breakdown of self-control over anger. The present study examines the relative contribution of gendered personality differences (communality-agency) and occupational role in accounting for these differences. Men and women in the armed forces and nursing profession completed the Personal Attributes Questionnaire (PAQ: Spence & Helmreich, 1976) together with a psychometric measure of their tendency to view aggression as expressive rather than instrumental (Expagg: Campbell, Muncer & Coyle, 1992). The results indicate that occupational role and sex are both important correlates of individuals' representations of aggression. Though agency showed a significant negative zero-order correlation with expressive aggression, the impact of gendered personality traits was diminished when occupation and sex were taken into account. The data strongly support social role theory's emphasis upon contemporaneous occupational factors in explaining sex differences in the understanding of aggression but are less supportive of the role of masculine and feminine personality traits.

8044502

The development of gender differentiation in young children.

A sample of 128 boys and girls in four age groups (three, five, seven, nine years) undertook tasks designed to assess their ability to categorize by gender, gender constancy, evaluations of gender groups, and gender discrimination in the allocation of prizes in a task performance setting. Results indicated that all children could categorize accurately by gender although nine-year-olds tended to adopt more complex criteria. Gender constancy increased with age, although not monotonically--seven-year-olds displayed less constancy than five-year-olds. Gender differentiation in attitudes was very marked from five years upwards, and even earlier in girls (both groups viewed their own gender more favourably). This greater own gender favouritism among girls was even clearer in the discrimination task: girls awarded girls' groups more desirable toys even when they had ostensibly performed less well than the boys' group. The boys attended more to performance information. Girls also made more negative comments about boys than vice versa.

8044501

Estimation of body composition in Chinese and British men by ultrasonographic assessment of segmental adipose tissue volume.

It has been shown that ultrasonographic measurements can be used to predict body composition in adults. The purpose of this study was to assess the relationship between ultrasonograph and caliper (SKF) measurements of subcutaneous adipose tissue thickness in athletic Caucasian (English, E) and Asian (Chinese, C) men against estimates of body composition determined from hydrodensitometry (HYD). The usefulness of a proposed ultrasonographic method of estimating lean and fat proportions in the upper and lower limbs was also evaluated as a potential method of predicting body composition. Ultrasonography (US) was used to measure adipose and skin thickness at the following sites: biceps, triceps, subscapular, suprailiac, abdominal, pectoral, thigh and calf. Caliper measurements were also made at the above sites. Subcutaneous fat thickness and segmental radius were measured directly from the display screen of the ultrasonic scanner (Aloka 500 SD). By applying the geometry of a cone, the proximal and distal radii of the upper arm and upper leg were used to calculate the proportionate volumes of adipose tissue. The best correlations for US and SKF were obtained at the quadriceps, subscapular and pectoral sites for E (r = 0.96, 0.93 and 0.90, respectively) and at the quadriceps, calf and abdominal sites for C (r = 0.90, 0.81 and 0.75, respectively). The best ultrasonographic predictor of the percentage fat in both groups was the percentage adipose tissue volume in the upper leg (r = 0.83 and 0.79 for C and E, respectively). Stepwise multiple regression analysis indicated that the prediction of percentage fat was improved by the addition of the ultrasonographic abdomen measurement in both groups: Chinese sample: %fat = %fat(leg) (0.491) + US abdomen (0.337) + 0.95 ( R = 0.89, s.e.e. = 1.9%); English sample: %fat = %fat(leg) (0.435) + US abdomen (0.230) - 0.765 ( R = 0.80, s.e.e. = 3.6%). It is concluded that ultrasonographic measurements of subcutaneous adipose tissue and volumetric assessment of percentage adipose tissue in the thigh are useful estimates of body composition in athletic English and Chinese males.

8044497

Bungee running--a new sport but old injuries.

Bungee running, a new sport related to bungee jumping, is fast becoming more common. This report of two cases of injury associated with it shows the need for safety precautions during the game.

8044496

Single photon emission computed tomography (SPECT) scanning for adolescent back pain. A sine qua non?

Nine cases of adolescent back pain show that a diagnosis of spondylolysis cannot be made on physical examination alone and that single photon emission computed tomography (SPECT) scanning revealed pars interarticularis stress lesions undiagnosable on planar technetium-99 bone scan. As management of spondylolysis differs from other lumbar dysfunctional problems SPECT scanning of children should be a sine qua non in extension related back pain with a normal radiograph and planar bone scintigraphy.

8044494

Precompetition anxiety in women volleyball players: a test of ZOF theory in a team sport.

Consistency in psychological factors is widely regarded to be important for successful performance in team sports, but the Zone of Optimal Function (ZOF) theory contends that athletes should exhibit considerable variability in the level of anxiety that will optimize performance. In an attempt to determine if tenets of ZOF theory held for athletes in a team sport, anxiety was measured using Spielberger's state-trait anxiety inventory (STAI) at the baseline and before easy and difficult competitions in nine members of a collegiate women's volleyball team. The ability to predict precompetition anxiety was assessed by having the athletes complete the STAI both 3 weeks and 2 days before each match according to how they thought they would feel 1 h before competition. Each athlete also completed the STAI on the basis of how she recalled feeling before her best competition. Four anxiety units were added and subtracted from this value to establish the ZOF of each player. Actual precompetition anxiety was assessed 1 h before each match. In accordance with ZOF theory, considerable variability was found in the range of optimal anxiety, and 55.5% of the team members reported performing best at either low or high levels of anxiety. The prediction of precompetition anxiety made 2 days before competition was significantly correlated to actual anxiety for the difficult match (r = 0.69, P < 0.05) but not the easy match (r = 0.21, P > 0.05). Predictions made 3 weeks before competition were not significant (P > 0.05). More (P < 0.05) of the player possessed anxiety levels within the ZOF for the difficult match compared with the easy match (77.7% versus 22.2%). In summary, athletes in the team sport of volleyball exhibit considerable variation in optimal precompetition anxiety in accordance with ZOF theory. As posited by ZOF theory, the athletes were able to predict anxiety before a difficult match accurately and were more likely to have anxiety levels with ZOF.

8044493

Oxygen consumption, heart rate and oxygen pulse associated with selected exercise-to-muscle class elements.

The purpose of the investigation was to determine the relative oxygen consumption (VO2), heart rate and oxygen pulse associated with the constituent elements of an exercise-to-music class. Six women exercise-to-music leaders with a mean(s.d.) age, weight and height of 33.2(5.2) years, 51.0(2.8) kg and 157.9(5.6) cm respectively, completed five distinct exercise-to-music movement elements. The movement elements were of a locomoter (circuit, jump and low impact) and callisthenic (prone and side/supine) nature. The movement elements were distinguishable from one another in terms of their movement patterns, posture and tempo. Relative VO2 values were greatest for the circuit element (40.6 ml kg-1 min-1) and least for the side/supine element (20.0 ml kg-1 min-1). The differences in VO2 between the locomotrr and callisthenic elements were significant (circuit approximately jump approximately low impact > prone approximately side/supine). However, effect size data suggested that the differences between the low impact and jump elements and the prone and side/supine elements were of practical significance (circuit approximately jump > low impact > prone > side/supine). With a single exception similar parametric statistics and effect size trends were identified for absolute heart rate. Specifically, the heart rate associated with the low impact element was not significantly greater than the prone element. The oxygen pulse associated with the locomotor elements was significantly greater than the callisthenic elements (circuit approximately jump approximately low impact > prone > side/supine). This suggested that heart rate may be an inappropriate index for making comparisons between exercise-to-music elements. Reasons for differences in oxygen uptake values between movement elements are discussed.

8044492

Effects of rider position on continuous wave Doppler responses to maximal cycle ergometry.

Using 10 well-trained (VO2peak = 60.6 ml kg-1min-1) college age cyclists and continuous wave Doppler echocardiography, peak acceleration (PkA) and velocity (PkV) of blood flow in the ascending aorta, and the stroke velocity integral (SVI) were assessed to determine if rider position influenced the central haemodynamic responses to graded maximal cycle ergometry. Cyclist position was determined by hand placement on the uprights (UPRI) or drops (DROP) of conventional handlebars or using aerodynamic handlebars (AHB). All subjects consistently achieved a peak workload of 300 W. The Doppler variables did not differ significantly between rider positions at each stage of the maximal exercise tests but did change in response to increasing workloads. PkA was significantly (P < 0.05) greater at workloads > or = 240 W versus < or = 120 W. PkV increased significantly (P < 0.05) up to 180 W and then reached a plateau. SVI increased to a workload of 120 W and then progressively declined, becoming significantly (P < 0.05) less at 300 W. For each stage, neither submaximal VO2, VI nor heart rate (HR) differed significantly between each trial. These results suggest that rider position does not affect the physiological response to maximal bicycle ergometry as responses to each position are similar.

8044490

Extra-articular tenodesis for anterior cruciate ligament rupture in amateur skiers.

Thirty one amateur skiers with 33 knees which had had a symptomatic chronic rupture of the anterior cruciate ligament (ACL) treated with the Lemaire operation were reviewed retrospectively at an average of 4.5 years. Of the patients 23 were women. The operation failed to control symptoms in 17 out of the 33 knees. However the operation did control symptoms in 13 out of 19 knees in patients over 35 years old, compared with only three out of 14 knees in patients under 35 years old. Clinical and objective testing however showed that most knees were still unstable. Despite this 21 patients continued skiing. One patient with a successful result switched to playing tennis. Five patients gave up all sports. Four further patients, all under 35 years old, returned to skiing after an additional intra-articular reconstruction of the anterior cruciate ligament. An isolated extra-articular procedure in amateur skiers under 35 years old with symptomatic chronic ACL rupture is not recommended. They need at least an intra-articular reconstruction to control their symptoms and to stabilize the knee.

8044491

Hearing loss in Grand Prix motorcyclists: occupational hazard or sports injury?

The prevalence of noise-induced hearing loss (NIHL) in current motorcycle grand prix racers was investigated. A total of 44 riders was randomly recruited and underwent interview, otological examination and pure tone audiometry. The median age was 28 (range 18-37) years and median racing experience was 10 (range 2-21) years. Twenty riders (45%) had hearing losses greater than expected for age matched controls. Not surprisingly this hearing deficit tended to increase with racing experience (r = 0.5, t = 2.51, 19 d.f., P < 0.05). Only 17 riders (39%) were regular users of earplugs and only nine had used them for most of their racing careers. There is a need to raise awareness to this problem and increase the use of earplugs to avoid NIHL in grand prix motorcyclists.

8044488

Isokinetic profile of dorsiflexors and plantar flexors of the ankle--a comparative study of élite versus untrained subjects.

A comparative study was made of the isokinetic characteristics of the ankle (plantar-flexion and dorsiflexion) in young men. Six cyclists, seven gymnasts, 10 soccer players and 25 non-athletic young men were tested on the Cybex II+ dynamometer. Peak torque, torque acceleration energy (TAE), total work and average power were measured. Cyclists had slightly higher (5%) mean plantar flexion than the others, but this was not significant. The situation was reversed for dorsiflexion. Moreover, the average dorsiflexion per unit of plantar flexion was significantly higher in the gymnasts than it was in the cyclists for both torque and work. This suggests that at a specific level of plantar flexion, the gymnasts had stronger dorsiflexion compared with the cyclists and that in sports involving jumping and running, increased attention should be given to strengthening the antagonist muscle groups (dorsiflexors) in order to achieve greater agonist-to-antagonist muscle balance thus preventing injury. The non-athletic subjects had substantially lower endurance capability in both flexors as measured by the endurance ratio. This implies that identifiable specialization in particular muscles results from training or participating in specialized sports.

8044487

Should an athlete eat straight after training?--A study of intestinal transit time and its relationship to prior exercise.

The mouth-to-caecum transit time of food was measured using the rise in breath hydrogen after a standard breakfast of baked beans on two occasions in seven healthy volunteers. The first occasion was after resting and the second after moderate exercise on a bicycle ergometer. There was no significant difference between the transit times with or without prior exercise. It is concluded that moderate exercise taken before food does not interfere with transit time and therefore should not in that way interfere with nutrition.

8044486

Comparison of effects of two interval-training programmes on lactate and ventilatory thresholds.

Twenty-one women subjects were matched in terms of their Vo2max and assigned to one of two groups: (1) training at 30 s; or (2) 2 min with a 1:1 work: relief ratio (1:1 WR) before participating in a 7-week training programme which began at an intensity of 85% Vo2max and increased 5% every two weeks (90% and 95% Vo2max). The subjects trained to exhaustion four times per week. Maximal oxygen consumption (Vo2max), lactate threshold (Tlac) and ventilatory threshold (Tvent) were determined before and after the training programme. After training, there were significant increases (P < 0.05) in Vo2max (5% and 6%), Tlac (19.4% and 22.4%), and Tvent (19.5% and 18.5%). There were no significant group differences on any dependent measure but this research adds support to previous training studies in that a strong correlation (P < 0.05) between Tlac and Tvent is maintained from before to after the test. It was concluded that both formats of high intensity aerobic interval-training produce similar changes in Vo2max, Tlac and Tvent and that these changes appear to be independent of the length of the work interval.

8044485

Paralympics--Barcelona 1992.

The British Team at the 9th Paralympic Games in September 1992 in Barcelona comprised 151 men and 54 women athletes in a total of 15 sports. They were supported by a staff of 86 including a 12-strong medical team. The athletes were selected from the National Championships of the five disability organizations: British Wheelchair Sports Federation; British Blind Sport; Cerebral Palsy Sport; British Amputee Sports Association; and the British Les Autres Sports Association. This article outlines the organization and experience of the medical support team. The injury/illness profile was similar to those in able bodied sport. The team went on to achieve 40 gold, 47 silver and 41 bronze medals, maintaining third place on the medal table as achieved in Seoul in 1988.

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Cost containment through reducing pressure ulcers.

The cost of pressure ulcer prevention is significantly less than treatment. The Agency for Health Care Policy and Research was formed recently to develop clinical practice guidelines for healthcare professionals. This article discusses methods in which nurse managers can implement the guideline: "Pressure Ulcers in Adults: Prediction and Prevention".

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Databook: monitoring a critical care unit.

DataBook is a computer application developed to assist the nurse manager in collecting, assessing and monitoring unit data on a day-to-day and summary basis. Once captured, this information can then be presented to create "information snapshots" of unit characteristics. Utilizing a PC-based spreadsheet program, the application is designed to be used by individuals with a modest degree of computer literacy.

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Improving communication ..."over the sink".

Conventional communication techniques--hospital newsletters, meetings and inservices--are not always the most successful methods. To accommodate the hectic schedules of OR personnel, short, one-page information briefs are placed at convenient locations--the scrub sinks. Within five minutes, pertinent information is communicated effectively, reinforcing inservices and staff meetings.