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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.

Here we describe a complete skull and partial skeleton of a large cercopithecoid monkey (KNM-TH 46700) discovered in the Chemeron Formation of the Tugen Hills at BPRP Site #152 (2.63 Ma). Associated with the skeleton was a mandible of an infant cercopithecoid (KNM-TH 48364), also described here. KNM-TH 46700 represents an aged adult female of Theropithecus brumpti, a successful Pliocene papionin taxon better known from the Omo Shungura Formation in Ethiopia and sites east and west of Lake Turkana, Kenya. While the morphology of male T. brumpti is well-documented, including a partial skeleton with both cranial and postcranial material, the female T. brumpti morphotype is not well-known. This skeleton represents some of the first associated evidence of cranial and postcranial female T. brumpti remains. In addition to the complete skull, postcranial material includes elements of the axial skeleton and lower limb. While aspects of the skeleton conform to those of specimens previously assigned to T. brumpti, other features on the femur and tibia appear to differ from those previously described for this species. It is unclear whether these differences represent general variation within the T. brumpti population, variation between the sexes in T. brumpti, or the incorrect assignment of previous isolated hindlimb specimens. In total, the observable morphological features of the hindlimb suggest that KNM-TH 46700 was a terrestrial quadruped similar to modern savannah baboons (Papio). From the available evidence, it is difficult to assess whether or not KNM-TH 46700 frequently engaged in the specialized squatting and shuffling behavior observed in extant geladas (Theropithecus gelada).

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.

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

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.

A prospective study of 618 patients undergoing elective colorectal surgery performed in a district general hospital over a 10-year period is reported. Multivariate analysis has been used in an attempt to identify risk factors. The risk of wound infection was increased if septicaemia, respiratory sepsis or faecal contamination was present, if the surgeon was a consultant and if increased risk of serious complications if the patient was male and of poor physical status. Operative mortality was significantly associated with poor physical status, respiratory sepsis and intra-abdominal abscess. Only three risk factors could be identified preoperatively: patient gender, physical status and seniority of surgeon. However, procedures low in the pelvis are more difficult and in this study group are also associated with a higher risk of wound infection. The majority of these procedures are performed by consultants. In addition, this study group has proportionally more female patients of poor physical status who are selectively being operated on by the consultant, seemingly indicating the 'consultant' as a risk factor.

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 study of 825 consecutive patients with colorectal cancer presenting to three general surgeons in a district general hospital over a 10-year period are reported. In all, 735 patients had an operation and are grouped according to whether their operation was within 24 h of admission (n = 63), more than 24 h after admission (n = 151), or elective (n = 521). Operative mortalities for these groups were 15.9%, 15.2% and 6.5%, respectively, significantly higher in both the emergency groups. Delayed surgery to allow complete resuscitation did not improve the operative mortality when compared with those patients having urgent surgery. Both groups of emergency patients, delayed (27%) urgent (19%), showed poorer 5-year survival than the electively treated patients (36%), many dying of non-cancer causes. Patients who undergo emergency surgery for colorectal carcinoma are more likely to be in poorer physical condition than patients undergoing elective surgery for the same condition. It appears that the physical status is the principal determinant of outcome after emergency colorectal surgery rather than any other factor.

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.

The effect of perioperative blood transfusion on cancer progression remains controversial because retrospective clinical studies have produced conflicting results. We have collected data prospectively on 379 patients undergoing curative surgery for colorectal adenocarcinoma and assessed the effect of variables, including blood transfusion, on survival. Univariate and multivariate survival analysis has been carried out. When the end-point for analysis used was death due to recurrent colorectal carcinoma and non-cancer deaths were censored, there was no difference in cancer-specific survival between transfused and non-transfused patients. Survival analysis was also carried out without censoring the non-cancer deaths and clearly demonstrated how the statistical analysis and data interpretation could be distorted by age-related non-cancer deaths. The incidence of recurrence of colorectal carcinoma was not greater in the transfused group than in the non-transfused group. We conclude that blood transfusion should not be withheld in colorectal surgery for fear of worsening the prognosis.

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.

A study of 578 patients treated for colorectal cancer in the North-west region comparing survival after surgery in teaching and non-teaching hospitals was performed. All patients had a minimum of 5 years follow-up. A greater proportion of elderly and emergency patients were treated in the non-teaching hospitals. The number of operative mortalities and 5-year survival figures for all causes of death and for colorectal deaths alone were similar in teaching and non-teaching hospital patients.

Oral razoxane 125 mg daily brought active Crohn's disease into remission when used alone and mainly on an out-patient basis in all nine patients studied. Remissions took several months to achieve, but no relapses have occurred on treatment and no surgery has been necessary in any of the patients. In the two patients with active non-specific proctitis, oral razoxane 125 mg daily rapidly controlled the condition. Apart from mild bone marrow toxicity in one patient, no other acute toxicity has occurred and no long-term side-effects have been observed.

Summary: A direct immunofluorescent technique with fluorescein-labeled antigens was used to examine the jejunal mucosa for specific antibody production in 23 children aged 2–25 months referred for diagnostic biopsy. Plasma cells containing antibodies to β-lactoglobulin (βLG) or bovine serum albumin (BSA) were present in 11 of 16 biopsies from patients with cow's milk protein intolerance (CMPI) but only one of eight controls, all on a diet containing cow's milk. Antibody-containing cells (ACC) constituted approximately 0.5–5% of the total (IgA + IgM) plasma cell population. Their presence did not correlate with either histologic abnormality or IgA plasma cell count. Double immunofluorescence with rhodamine-labeled antigens and fluorescein-labeled class-specific anti-human immunoglobulin sera showed the ACC to be approximately 70% IgA cells and 30% IgE cells.

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.

Time to diagnosis from first symptoms has been assessed in 332 patients with colorectal cancer treated by the three general surgeons in Trafford Health Authority. When compared with other series, delay to diagnosis has been shortened, particular general practitioner and hospital delay. Fewer patients presented as emergencies and a greater proportion of patients had early-stage disease. There was no significant difference in delay times between Dukes' stage B and C patients but there was a significant difference in survival at 2 years between these two stages. Delay times for patients with risk factors, family histories or diverticular disease were not significantly different from times in patients without these factors.

Two hundred and twenty-nine patients were entered into a study to compare the effectiveness and safety of two single-shot antibiotic regimes in patients undergoing elective colorectal surgery in two district general hospitals. A single shot of intravenous (IV) latamoxef disodium was as effective as an IV combination of cefuroxime and metronidazole in control of wound infection following elective large bowel surgery when given as a bolus at the time of anaesthetic induction. The incidence of major wound infection was 6% and was evenly distributed in the two treatment groups. Half the major wound infections were associated with faecal fistulae. A single shot of IV antibiotic at the time of anaesthetic induction was safe, simple and an effective prophylaxis against major wound infection. There was a low incidence (1.3%) of serious postoperative bleeding and no serious adverse reactions were noted. The overall mortality was 9%. Death was significantly related to elderly patients, a poor performance status, operative contamination and wound infections.

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.

Serum JD from a 14-year old girl with Sydenhams chorea contained antibodies which gave immunofluorescent staining of the limiting membrane of the brain, ependymal tissue and fibrous astrocytes. These antibodies could be completely absorbed by Str. pyogenes type 24 (NCTC 8305) but only partially if at all by type 6 matt (NCTC 8302) or type 6 glossy (NCTC 8709). In contrast, staining by the same serum of the choroid plexus, the periphery of hepatocytes, the periphery of the cells of the gastric mucosa, and tubules in the kidney could be absorbed out by the type 6 matt and type 24 strains (but not by the type 6 glossy or Staph. aureus NCTC 6571). A rabbit anti-streptococcal serum (3/74) raised against disintegrated washed cells of Str. pyogenes type 24 stained and the same structures in the brain to high titre, but not the choroid plexus and not the other structures stained by serum JD. These staining reactions of 3/74 could be absorbed out by Str. pyogenes type 24 but not by Str. pyogenes type 6 matt or type 6 glossy. None of these staining patterns given by serum JD or by 3/74 could be absorbed by human uterine smooth muscle. Serum 3/74 stained heart muscle but this reaction could be absorbed without affecting the brain staining reactions. Sera from 4 other patients with Sydenham's chorea were found to give staining of the ependyma and the limiting membrane, 2 only very weakly.

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.

A small prospective trial was conducted to evaluate the effectiveness and safety of a single antibiotic regimen, Augmentin, compared with a combination regimen of cefuroxime and metronidazole in the treatment of serious post-operative sepsis. Both regimens used were effective against Bacteroides and other anaerobes, with a similar satisfactory cure rate and no serious side effects. Intravenous Augmentin was easy to use and the change to oral therapy was significantly quicker than in the cefuroxime-metronidazole treatment arm. No significant resistance or serious adverse reaction was noted. The majority of patients had more than one site of infection, making selective antibiotic treatment difficult.

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.