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Summary High-intensity renal replacement therapy protocols in intensive care patients with acute kidney injury have failed to translate to improved patient outcomes when compared with lower-intensity protocols. This retrospective study explored the clinical and economic impacts of switching from a 30–35 ml.kg−1.h−1 (high-volume) to a 20 ml.kg−1.h−1 (low-volume) protocol. Patients (n = 366) admitted 12 months before (n = 187) and after (n = 179) the switch were included in the study. There was no difference in in-hospital mortality (77/187 (41%) vs 75/179 (42%), respectively, p = 0.92), intensive care unit mortality (55/187 (29%) vs 61/179 (34%), respectively, p = 0.40), duration of organ support or extent of renal recovery between the high- and low-volume cohorts. A 25% reduction in daily replacement fluid usage was observed, equating to a cost saving of over £27 000 per annum. In conclusion, a switch from high- to low-volume continuous haemodiafiltration had minimal effects on clinical outcomes and resulted in marked cost savings.

Paleopathologists have identified osteoporosis in ancient skeletons and modern physicians and scientists have identified risk factors for osteoporosis today, but they are not clearly linked, making it more difficult to clarify the causes of osteoporosis in the past. The evidence for osteoporosis in the remote past, its causes, and the management of this disease is reviewed in the light of evolving and improving diagnostic modalities, more precise definitions, and the recent rapid expansion of therapeutic options. While the specific effects of parity and lactation on the development of osteoporosis are still not entirely clear, duration of reproductive span and age at first pregnancy appear to be significant predisposing factors.

Distal ulcerative colitis can be treated with oral or rectal mesalazine, or both. A foam enema preparation has been developed and its efficacy investigated. The aim of this study was to evaluate the efficacy and safety of mesalazine foam enemas compared with prednisolone foam enemas in the treatment of patients with acute distal ulcerative colitis. Patients aged over 18 years presenting with a relapse of distal ulcerative colitis were randomly allocated treatment with mesalazine foam enema (n = 149 evaluable patients) and prednisolone foam enema (n = 146 evaluable patients) for four weeks. A randomised multicentre investigator blind parallel group trial was conducted. It was found that after four weeks of treatment, clinical remission was achieved by 52% of mesalazine treated patients and 31% of patients treated with prednisolone (p < 0.001). There was a trend in favour of more patients in the mesalazine group achieving sigmoidoscopic remission (40% v 31%, p = 0.10). Histological remission was achieved by 27% and 21% of patients receiving mesalazine and prednisolone respectively. Symptoms improved in both treatment groups. Significantly more mesalazine patients had no blood in their stools after four weeks of treatment (67% v 40%, p < 0.001). Prednisolone treated patients had significantly fewer days with liquid stools than mesalazine patients, with a median of 0 and 1 days respectively by week 4 (p = 0.001). In this study mesalazine foam enema was superior to prednisolone foam enema with regards to clinical remission, this was supported by favourable trends in sigmoidoscopic and histological remission rates. Both treatments were well tolerated.

Introduction Rings are required to be removed from a finger in many clinical situations. Rings that are difficult to remove is a problem encountered frequently. Many techniques have been reported for this problem. This study looks at the effectiveness of a single technique for removing difficult rings from fingers. Methods A two rubber band technique was used in this study of 69 difficult to remove rings. Success of the technique and time to removal were recorded. Results Difficult rings were removed in 92.5% of cases, in a mean time of 10.7 seconds. No fingers or rings suffered damage during the study. Conclusions This two rubber band technique is a rapid, safe and effective method for removing rings that cannot be removed easily.

The Inca Empire (AD 1438–1532) made common practice of relocating individuals, households and entire communities throughout their expansive realm for different reasons depending on subjects' assigned social class. Reconstructing patterns of immigration at Inca-period sites could therefore permit some estimation of the social class(es) among their constituents, and thereby provide insights into the functional dynamics of Inca political economy. However, this is a difficult endeavor using only archaeological lines of evidence. This study presents oxygen, strontium and lead isotopic results from the well-preserved, well-contextualized skeletal population ( N = 74) from the Inca site of Machu Picchu, Peru. Isotopic data are used to reconstruct patterns of immigration at the site, which are in turn used to directly estimate the social class of the population. The resulting isotopic data are widely distributed with no apparent modality, matching the expected distribution of a particular class of nonelite retainers. A novel application of multivariate statistics coupled with geological and faunal isotopic reference data also permits tentative estimation of individuals' regions of origin. This study provides empirical and analytical frameworks for future research in reconstructing residential movement and class dynamics in the late prehistoric Andes.

Three-hundred and twenty-five patients with endoscopically verified oesophagitis entered a double-blind, randomized multicentre study that compared 300 mg nizatidine b.d., 300 mg nocte and placebo. The 6- and 12-week treatment responses were studied. Healing was defined as complete epithelialization of all oesophageal lesions. The healing rates were 40% in the 300 mg nizatidine b.d. group, 30% in the 300 mg nocte group and 26% in the placebo group at 6 weeks. The corresponding figures after 12 weeks of treatment were 50%, 44% and 34%, respectively. The healing rates were significantly different (P less than 0.05) between the high-dose nizatidine group and placebo only, both at 6 and 12 weeks. Despite a trend at both 6 and 12 weeks in favour of 300 mg nizatidine nocte compared to placebo, this was not significantly different. The most important factor for the outcome, apart from the treatment group, was the pre-entry severity of oesophagitis. The differences observed between treatment groups in healing rates, symptomatic relief, and antacid consumption appear to result mainly from the patients with moderate and severe oesophagitis upon entry. Nizatidine (300 mg) b.d. appeared to be safe and effective in the treatment of reflux oesophagitis.

Introduction Appetite loss is commonly reported by patients following major surgery, including total joint arthroplasty (TJA). A number of studies have examined related problems, particularly in relation to physiological responses to surgery. However, no published paper has looked specifically at the duration of appetite loss in total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients. Methods A simple, established appetite screening tool was administered preoperatively and at 2-week intervals postoperatively in 50 TJA patients until appetite levels returned to preoperative levels. The results were examined for various descriptive parameters and compared using the chi-squared test. Results Thirty-three patients underwent TKA and 17 THA. There were 27 female and 23 male patients. No patients were lost to follow-up. The median time for return of appetite in both male and female patients was 4 weeks (interquartile range [IQR]: male, 2–4; female, 4–6). The median time for return of appetite was 4 weeks both in TKA patients (IQR 4–6) and in those undergoing THA (IQR 4–4). The time to return of appetite was not significantly associated with either the gender of the patients (p=0.13) or the type of joint replacement (p=0.49). Conclusions The study provides a clear time frame for return of appetite in uncomplicated primary joint replacements. This is a commonly noted patient problem that has not previously been specifically reviewed.

BACKGROUND: Previous reports have indicated that 5-13 per cent of colorectal cancer is hereditary. However, the proportion of cases arising as a result of mutations in the hereditary non-polyposis colorectal cancer (HNPCC) genes remains to be determined. METHODS: This study is a part prospective, part retrospective review of all cases of colorectal cancer from a district hospital over 14 years. Some 1137 consecutive patients with colorectal cancer were questioned about their family history of cancer and details were logged on a database. For the past 4 years each case has been re-evaluated where possible. RESULTS: Some 118 patients indicated initially that they had a first-degree relative with colorectal cancer, but on re-evaluation there were significant discrepancies. Only three cases (0.3 per cent) occurred in families which strictly fulfilled the criteria for HNPCC and there were no cases of familial adenomatous polyposis. A total of 16 patients (1.4 per cent) fulfilled looser criteria for HNPCC. CONCLUSION: This population-based study has shown a lower frequency of familial bowel cancer than previous studies and may reflect a lower incidence of inherited mutations in the HNPCC DNA mismatch repair genes than is currently accepted.

For nearly 500 years, scholars have argued about the origin and antiquity of syphilis. Did Columbus bring the disease from the New World to the Old World? Or did syphilis exist in the Old World before 1493? Here, we evaluate all 54 published reports of pre- Columbian, Old World treponemal disease using a stand- ardized, systematic approach. The certainty of diagnosis and dating of each case is considered, and novel informa- tion pertinent to the dating of these cases, including radiocarbon dates, is presented. Among the reports, we did not find a single case of Old World treponemal dis- ease that has both a certain diagnosis and a secure pre- Columbian date. We also demonstrate that many of the reports use nonspecific indicators to diagnose treponemal disease, do not provide adequate information about the methods used to date specimens, and do not include high-quality photographs of the lesions of interest. Thus, despite an increasing number of published reports of pre-Columbian treponemal infection, it appears that solid evidence supporting an Old World origin for the disease remains absent. Yrbk Phys Anthropol 54:99

Cannula tubing (1·6 mm external, 1 mm internal diameter) was fabricated from medical grade polyurethane containing 2% 2,4,4′-trichloro-2′-hydroxydiphenyl ether (‘Irgasan', Ciba-Geigy). When shaken with 10ml of phosphate-buffered saline an equilibrium was set up with only traces of ‘Irgasan' in the aqueous phase. When phosphate-buffered saline flowed through the tubing, 0·26 mg of ‘Irgasan' per g of tubing per day was eluted, and this was not detectably increased by buffers of pH 3 or pH 8·5. However, a 20% lipid emulsion eluted 6 mg per g of tubing per day with a flow rate of 250 ml per day and 11 mg with a flow rate of 11 per day. These results scaled up show that a 7·11 g Hickman catheter would lose 78 mg of Irgasan in the first day with Intralipid, compared to 1·8 mg with PBS. If elution by tissue fluids (including blood) does not exceed that by Intralipid then comparison with available toxicological data suggests an adequate margin of safety for adults, but not for premature babies.

Since Darwin situated humans in an evolutionary framework, much discussion has focused on environmental factors that may have shaped or influenced the course of human evolution. Developing adaptive or causal perspectives on the morphological and behavioral variability documented in the human fossil record requires establishing a comprehensive paleoenvironmental context. Reconstructing environments in the past, however, is a complex undertaking, requiring assimilation of diverse datasets of varying quality, scale, and relevance. In response to these difficulties, human evolution has traditionally been interpreted in a somewhat generalized framework, characterized primarily by increasing aridity and seasonality periodically punctuated by pulses or intervals of environmental change, inferred largely from global climatic records. Although these broad paradigms provide useful heuristic approaches for interpreting human evolution, the spatiotemporal resolution remains far too coarse to develop unambiguous causal links. This challenge has become more acute as the emerging paleoenvironmental evidence from equatorial Africa is revealing a complex pattern of habitat heterogeneity and persistent ecological flux throughout the interval of human evolution. In addition, recent discoveries have revealed significant taxonomic diversity and substantially increased the geographic and temporal range of early hominids. These findings raise further questions regarding the role of the environment in mediating or directing the course of human evolution. As a consequence, it is imperative to critically assess the environmental criteria on which many theories and hypotheses of human evolution hinge. The goals here are to 1) compile, review, and evaluate relevant paleoecological datasets from equatorial Africa spanning the last 10 Ma, 2) develop a hierarchical perspective for developing and evaluating hypotheses linking paleoecology to patterns and processes in early hominid evolution, and 3) suggest a conceptual framework for modeling and interpreting environmental data relevant to human evolution in equatorial Africa.

Substantial barriers to prenatal mental health screening exist. The primary objective of this randomized controlled trial is to evaluate the acceptability of computer tablet-based prenatal screening compared to paper-based screening. Secondary objectives are to compare the two screening modes on: (1) detection of depression/anxiety symptoms; (2) disclosure of symptoms; (3) factors associated with acceptability, and disclosure; (4) psychometric properties of the e-version of the tools; and (5) cost-effectiveness. Pregnant women were recruited from maternity clinics in an urban Canadian city, and were eligible if they were: 1) able to speak/read English; 2) willing to have a diagnostic interview within 1 week. Allocation was by computer-generated randomization. Women in the intervention group completed screening on a computer tablet and those in the control group completed the same assessment in paper-based form. Intention-to-treat analyses compared groups on primary and secondary outcomes. Multivariable logistic regression will identify predictors of intervention acceptability and disclosure. Preliminary Results – Recruitment was completed on December 8, 2014 (n=587). Mean age of women was 28.7 years (SD 4.7) with 96% partnered and 77% completing at least some post-secondary education. One-third (32.3%) had been treated previously for a mental health problem. Over 90% of women in the intervention and control groups indicated they found/would find computer-based screening acceptable and could fully disclose their concerns. No significant differences in mean depression or anxiety scores were found between groups. Additional results to be generated for presentation Implications Clinical and cost data will inform approaches to routine prenatal mental health screening.

Of 905 patients with colorectal cancer admitted to a single district general hospital, 272 (30 per cent) were admitted as emergencies. Emergency patients had more advanced tumours (Dukes stage B and C 96 per cent versus 88 per cent of those admitted electively, P < 0·006), a shorter history (median 3 versus 11 weeks, P < 0·001), were less likely to be fully ambulatory (44 versus 80 per cent, P < 0·0001) and more likely to have abdominal pain (74 versus 51 per cent, P < 0·001) and vomiting (40 versus 10 per cent, P

In this database study of 882 patients with colorectal cancer, elderly patients are of poor physical status on admission and are more likely to be either completely inoperable or require urgent surgery. The operative mortality rate is higher and hospital stay is likely to be longer. However, if the elderly patient is fit for surgery, survives for more than 30 days and a curative resection performed, the 5-year survival and post-operative complication rates are as good as those patients in the younger age groups.

Local recurrence has been studied in a selected group of 379 patients, 39% of whom underwent simple mastectomy and 61% lumpectomy. The axilla was sampled in 52%, cleared in 8% and untreated in 40%. Axillary recurrence occurred in 16% of patients with a median follow-up of 54 months. Ninety-one per cent of these patients with lymph node recurrence had no surgery or sampling to the axilla, and a third received radiotherapy. Local recurrence was satisfactorily controlled by various modalities of treatment in all but 29 patients. Death related to distant metastasis in all but six of these 29 patients. Analysis suggests that patients with locally uncontrolled disease had aggressive tumours at diagnosis which were larger than average, most often grade 3 histologically and more frequently required mastectomy. Our results support previous studies indicating that survival would not be influenced by more radical surgery but that sampling followed by radiotherapy would have prevented the majority of our lymph node recurrences.

A prospective controlled randomised trial to evaluate the effectiveness and safety of razoxane is reported. Some 603 patients with colo-rectal cancer having curative surgery entered the study, and all have been followed up for a minimum of five years. Statistical analysis showed that razoxane treatment had no effect either beneficial or adverse on the rates of recurrence or on five year survival of patients with colo-rectal cancer. It is possible that a more prolonged course of razoxane might have significantly influenced survival. The incidence of severe adverse reaction was low but it is of concern that one patient developed leukaemia. Should razoxane be considered for future use it is recommended that continuous low dose therapy be given for no longer than 12 months. No renal, hepatic, pulmonary or cardiac toxicity was noted.

Analysis of data from a randomised trial of adjuvant razoxane involving 603 patients with colo-rectal cancer having curative surgery is reported. The results show that razoxane was ineffective but peri-operative subcutaneous heparin treatment apparently conferred a statistically significant improvement in survival at 5 years, or equivalently a reduction in the risk of death. This beneficial effect is apparent in both razoxane treated and control patients and is not explained by demonstrable differences between heparin and non-heparin treated patients in the distribution of known prognostic factors. Adjustment for these factors slightly increased the apparent magnitude of the beneficial effect.

Cannula tubing (1·6 mm external, 1 mm internal diameter) manufactured from medical grade polyurethane containing 2% 2,4,4′-trichloro-2′-hydroxydiphenylether (‘Irgasan', Ciba-Geigy) was found to have no effect other than that seen with control (‘Irgasan'-free) tubing in the following test systems: (i) haemolysis, (ii) endothelial cell cultures, (iii) paravertebral muscle of rabbits, (iv) jugular vein of rabbits, (v) cannulation of baboons and (vi) clotting times of human platelet-rich plasma. However, the results from (iv) showed a significant amount of damage from both impregnated and control cannulae and (v) showed that all detectable ‘Irgasan' had been eluted from the portions of tubing retained within the animal before the end of the experiment, more rapidly than predicted from in-vitro studies. The rate of elution of ‘Irgasan' in vivo needs to be further investigated, and consideration should be given to developing a plastic-disinfectant combination with a slower rate of loss of disinfectant.

We have reviewed spreading infections of the dermis, with special reference to the importance of synergy in their causation. Evidence for this is accumulating from both clinical studies and from studies in laboratory animals. Necrotizing fasciitis (rapid spread over 24 h) can be caused by β-haemolytic streptococci, sometimes with Staphylococcus aureus, or by mixed infections of aerobes and anaerobes, often of gut origin. Animal studies provide good evidence that S. aureus can potentiate the β-haemolytic streptococcal infection in necrotizing fasciitis. There is also evidence that mixtures of aerobes and anaerobes can act synergistically, but animal models for necrotizing fasciitis have not been developed. Anaerobic cellulitis (variable rate of spread from hours to days) can be caused by mixed aerobes and anaerobes or by mixed clostridia. Animal studies provide good evidence for synergy in the former. Meleney's synergistic postoperative gangrene (slow spread over weeks) may be cutaneous amoebiasis: the animal model of Brewer and Meleney relates to the more rapid infections of anaerobic cellulitis.

OBJECTIVE--To establish whether a single preoperative dose of cefotaxime plus metronidazole was as effective as a standard three dose regimen of cefuroxime plus metronidazole in preventing wound infection after colorectal surgery. DESIGN--Prospective randomised allocation to one of two prophylactic antibiotic regimens in a parallel group trial. Group sequential analyses of each 250 patients were performed. SETTING--14 District general and teaching hospitals. PATIENTS--1018 Adults having colorectal operations were randomised, of whom 943 were evaluated. Demographic features, conditions requiring surgery, and operative procedures were similar in the two groups. Most patients had surgery for carcinoma of the colon or rectum. INTERVENTIONS--Group 1 received cefotaxime 1 g intravenously plus metronidazole 500 mg intravenously preoperatively. Group 2 received cefuroxime 1.5 g intravenously plus metronidazole 500 mg intravenously preoperatively, followed by cefuroxime 750 mg intravenously plus metronidazole 500 mg intravenously eight hours and 16 hours postoperatively. MAIN OUTCOME MEASURES--Development of surgical wound infection (as evidenced by the presence of pus), death, or discharge from hospital. RESULTS--Wound condition was scored on a five point scale on alternate days until discharge or for up to 20 days postoperatively. Wound infection rates were: group 1, 32/453 (7.1%; 95% confidence interval 4.7% to 9.4%); group 2, 33/454 (7.3%; 95% confidence interval 4.9% to 9.6%). Death rates (group 1: 26/470 (5.5%); group 2: 31/471 (6.6%], the incidence of postoperative complications, the median duration of hospital stay (12 days), and antibiotic tolerance were all similar in the two groups. Pooled data from groups 1 and 2 showed that wound infections were more frequent when minor faecal contamination had occurred at operation and when the duration of operation exceeded 90 minutes (greater than 90 min 11.2% of cases; less than 90 min 4.8%) and were associated with an extended hospital stay. CONCLUSIONS--A single preoperative dose of cefotaxime plus metronidazole is an efficacious as a three dose regimen of cefuroxime plus metronidazole in preventing wound infection after colorectal surgery and has practical advantages in eliminating the need for postoperative antibiotics.

A review of patients following a partial gastrectomy for benign peptic ulceration reveals very satisfactory symptomatic results. Minimal haematological and biochemical disturbances have been produced and all the patients with gastric ulcers were cured. The gastric resection has been limited to two-thirds in all the cases. One hundred and ninety patients were included in the review, and of these, 99 underwent detailed haematological and biochemical investigation. Ninety per cent of the patients were graded as Visick I or II. There was a low incidence of severe vomiting (1.5 per cent), diarrhoea (1.5 per cent) and dumping (1.9 per cent) Anaemia was manifest only in males (18 per cent). Iron deficiency was present in both sexes and increased in severity with time. The deficiency has been readily corrected with oral iron. There was no macrocytic anaemia, 10 per cent of patients having subnormal serum vitamin B12 levels. There was no folate deficiency. No biochemical abnormality was noted. Eight patients treated for duodenal ulcers developed recurrent ulcers but 6 of these followed Billroth I gastrectomy. Recurrence following a Poly a gastrectomy was 2 per cent. No gastric ulcer recurred. These findings justify treatment of both duodenal and gastric ulcers by partial gastrectomy. A modification of the Billroth I operation was used to overcome technical problems. Operation details are given and it is suggested that this operation is ideal for gastric ulcer.

Twenty-one children aged between 2 and 54 months, 14 with eczema and 7 with allergies in first-degree relatives, were referred for diagnostic jejunal mucosal biopsy for a variety of symptoms. A partial villous atrophy was found in 19 of the 21 biopsies obtained; the other 2 were normal. We report a highly significant (P less than 0.0001) lower IgA cell count in biopsies with partial villous atrophy compared with the results of our previous study of IgA and IgM plasma cells in the mucosal biopsies in children without eczema or a history of atopy matched for age and histological appearances. The IgM cell count was also lower.

Bacteriological studies on the communion cup have shown that there is a low level of contamination with mouth organisms on the rim. The death rate of bacteria on the cup surface would not be significant, but the wine had a bactericidal effect on most but not all organisms tested. However droplets of saliva did not readily mix with the wine. In considering the spread of AIDS, extensive studies of people infected with human immunodeficiency virus (HIV) in hospital or at home have shown that the established routes of spread are the injection of blood or blood products, sexual intercourse or at birth. There are only very rare examples of spread by other means. The virus is rarely isolated from the saliva and a study of homosexuals indulging in oral sexual intercourse suggests that it is very poorly infectious when taken into the mouth or swallowed. It is concluded that the risk of transmission of HIV by the common communion cup can be neglected under ordinary circumstances. Suggestions are made for improving the hygiene of the communion service which may be useful under special circumstances: there is no evidence that disease is spread in this way under normal conditions.

Serial CEA levels were measured in 157 patients with advanced inoperable gastric carcinoma entered in a controlled trial of cytotoxic therapy. In 49 (31%) of cases initial levels were greater than 50 ng/ml. However, serial measurements were only possible in 57 (36%) cases and results were prognostically valuable in only 15 (9.5%) of cases.

Forty-one patients presented to our hospital between 1959 and 1983 with periampullary carcinoma. Twenty-six (63 per cent) underwent radical surgery, eight (20 per cent) local excision of the tumour, six (15 per cent) had bypass procedures and one was treated by endoscopic sphincterotomy (2 per cent). Potentially curative resection was performed in 83 per cent of the 41 patients. The operative mortalities for radical, local and bypass surgery were 7.7 per cent, 25 per cent and 16.6 per cent respectively. The degree of tumour differentiation significantly affected survival while local spread did not significantly affect survival in patients treated radically. The 5 year survival rates (calculated actuarially) for radical, local and bypass surgery were 34, 44 and 0 per cent respectively.

Nineteen diagnostic peroral biopsy specimens from 18 children without diarrhoea, vomiting, or abdominal pain ('control' children) were compared with those taken from 23 children with diarrhoea of varying aetiology to establish the morphometric characteristics of jejunal mucosa in childhood. Comparison was also made with normal jejunal mucosa from adults. Statistical analysis of each characteristic individually showed no significant difference between the 'control' children and those with diarrhoea, but there were significant differences between the mucosae of 'control' children and those of adults; the villi tended to be shorter and the crypts longer in children. Thirty-seven per cent of specimens from the 'control' children showed a partial villous atrophy, that is, they were abnormal by adult criteria. Discriminant analysis of the features measured showed effective separation of the following groups: normal histology from partial villous atrophy in children, healthy adults from 'control' children, and normal histology in adults from normal histology in children.

Summary The incidence of patients with gastric carcinoma having had a previously diagnosed or suspected peptic ulcer was noted in two studies. These studies were the West Midlands Gastric Chemotherapy Trial (1974–6) and a retrospective study of patients presenting to the United Birmingham Hospitals with gastric carcinoma during the years 1958–62 and 1968–72. The incidence of patients found to have had a previous operation for duodenal ulcer or to have post-mortem evidence of one was 6.5 per cent and 5.7 per cent respectively. A radiologically proved duodenal ulcer had been identified in 5.5 per cent and 2.1 per cent respectively and the incidence of previous symptoms suggestive of a duodenal ulcer was 4.0 per cent and 5.2 per cent. These figures indicate the total incidence could be 12.97 – 16.0 per cent, which is much higher than previously reported. The mean time interval between operation for duodenal ulcer and the development of gastric carcinoma was much longer in patients having had a partial gastrectomy than in patients having had a vagotomy and drainage procedure. The incidence of previous benign gastric ulcers was 2.5 per cent and 0.9 per cent. Fifty-three per cent of patients having had a previous operation for duodenal ulceration were found to have an unresectable carcinoma, compared with the overall unresectable rate of 35 per cent.

The incidence of flatulent dyspepsia and its relationship to gallbladder function has been studied in 100 consecutive patients with gallstones undergoing cholecystectomy. Thirty-three per cent of patients suffered significant flatulent dyspepsia of whom 80 per cent were cured or improved by operation. In 15 patients gastric function was studied pre- and postoperatively and it was noted that there was no difference in gastric emptying times between patients with flatulent dyspepsia who were cured by operation and those who remained symptomatic. Bacteriological studies on gallbladder bile from 39 patients suggested that infection within the gallbladder may be a factor in the causation of flatulent dyspepsia.

Bile bacteriology, wound sepsis and the effect of prophylactic antibiotics have been studied in a controlled prospective double blind randomized trial on 375 patients undergoing elective cholecystectomy at a district general hospital. We have examined the overall prevalence of bacteria in bile and have identified several factors associated with an increased incidence. The identity of organisms isolated from a total of 21 patients with infected wound swabs was compared with isolates from the bile at operation, and in only two instances was there a correlation. Cephazolin, given either pre-operatively, or into the wound, reduced wound infection rates compared with a control group (from 11·8 to 2·4 per cent, P < 0.005). We conclude that the majority of wound infections in this series were caused by organisms from the patients' skin or exogenous sources, rather than by bacteria from the biliary system.

Experience in treating tumours of the ampulla of Vater in the North West region of the UK is reviewed. The results of local resection, radical resection and palliative bypass in 61 cases have been compared. Local resection in this series offers a better survival than radical procedures at one, two, three and five years. The operative mortality for radical procedures was 30 per cent. There were no operative deaths in those patients having a local resection. No patient having palliative bypass surgery survived more than 18 months.