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Major changes in health care delivery and the increased number of clerkship sites used for teaching by many medical schools has resulted in significant implications for medical education. Methods have become necessary to achieve and maintain a comparable clinical experience and a uniform assessment process at each teaching site. Following a review of existing practices, a new core curriculum, a problem-based approach and the Objective Structured Clinical Examination (OSCE) were introduced into this department. Over 1200 students have passed through this revised surgical clerkship over the past 8 years. The introduction of the OSCE has helped to direct student learning, provide an objective assessment to complement the ward grade, and enabled an audit of teaching and learning to be carried out. In one group of 103 students no significant correlation was found between the OSCE and ward grades. Performance at different hospitals was similar and those carrying out their clerkship later in the academic year benefited from their previous other attachments. The OSCE has enabled immediate feedback to be given to learners as well as providing teachers with an opportunity to see for themselves the outcome of their tuition. A clinical performance record card has now been introduced to improve the monitoring of students' clinical experience.

Ten cases of acute acalculous cholecystitis, presenting to one university affiliated institution, are described. These patients were predominantly older males with either overt vascular disease or a predisposition to vascular disease and were without the usual precipitating factors described for acalculous cholecystitis. Ultrasonography was helpful in making the diagnosis and early laparotomy revealed gangrenous cholecystitis in all patients, three of whom had perforated gall-bladders. Although there was no mortality, morbidity was high, and patients stayed in hospital a mean of 10.5 days. A vascular aetiology seems likely and early surgery is recommended to avoid the high mortality reported in the literature. It seems that this form of acalculous cholecystitis is different to that seen in other clinical settings.

One hundred consecutive colocolic and colorectal anastomoses are reviewed. The operative mortality was 5%, wound infection rate 27%, and faecal fistula rate 15%. These complications are shown to double the hospital bed stay. Factors affecting their occurence are examined, and recommendations are made with a view to lower this morbidity.

A phase II trial of sequential oral medroxyprogesterone acetate (MPA) and epirubicin was performed in 12 postmenopausal women with advanced breast cancer. Patients received MPA at a dose of 500 mg twice daily by mouth for 25 days. Following a 3-day washout, epirubicin was administered in a dose of 75 mg/m2. After a 3-week hiatus, the cycle was recommenced with MPA. Responses were evaluated at the end of the first 25-day period of MPA and following the end of the first cycle. Partial responses were obtained in two patients (17%)--one after the first 25 days of MPA and the other at the end of the first cycle. One of the patients had chest wall disease and the other had hepatic involvement with ascites. Minimal toxicity was experienced from this regimen and the response durations were 2 and 7 months. The response rate reported here does not warrant the further development of sequential therapy. The dose intensity of both MPA and epirubicin are compromised and may be the cause of this low response rate.

The high gastric reduction operation has been performed on one hundred and nine obese patients over a sixteen-month period. Patient selection, preoperative care, operative technique and postoperative care are described. Our early results show that a satisfactory initial and continuing weight loss can be sustained for a twelve-month period with a low morbidity and mortality. Further follow-up of these patients is required before the ultimate place of this procedure is established.

Para-ileostomy hernia is an uncommon cause of bowel obstruction following ileostomy. Two cases are reported that demonstrate the difficulty in diagnosis and the high morbidity associated with this condition. Early recognition and repair of the uncomplicated and strangulated hernia are recommended.