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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.

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.

Distinctive characteristics of modern humans, including language, tool manufacture and use, culture, and behavioral plasticity, are linked to changes in the organization and size of the brain during hominin evolution. As brain tissue is metabolically and nutritionally costly to develop and maintain, early hominin encephalization has been linked to a release of energetic and nutritional constraints. One such nutrient-based approach has focused on the n-3 long-chained polyunsaturated fatty acid docosahexaenoic acid (DHA), which is a primary constituent of membrane phospholipids within the synaptic networks of the brain essential for optimal cognitive functioning. As biosynthesis of DHA from n-3 dietary precursors (alpha-linolenic acid, LNA) is relatively inefficient, it has been suggested that preformed DHA must have been an integral dietary constituent during evolution of the genus Homo to facilitate the growth and development of an encephalizing brain. Furthermore, preformed DHA has only been identified to an appreciable extent within aquatic resources (marine and freshwater), leading to speculation that hominin encephalization is linked specifically to access and consumption of aquatic resources. The key premise of this perspective is that biosynthesis of DHA from LNA is not only inefficient but also insufficient for the growth and maturation demands of an encephalized brain. However, this assumption is not well-supported, and much evidence instead suggests that consumption of LNA, available in a wider variety of sources within a number of terrestrial ecosystems, is sufficient for normal brain development and maintenance in modern humans and presumably our ancestors.

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.

The early evolutionary history of the cercopithecoids is poorly understood, primarily due to a lack of fossil material from between 15 and about 9 Ma. Cercopithecoid primate specimens from a fossil site in the Ngorora Formation of the Tugen Hills, Kenya, belong to the genus Victoriapithecus, possibly a new species. These fossils are associated with a hominoid specimen that resembles Proconsul, and another tooth of a catarrhine, also probably hominoid. The locality is BPRP#38, in the Kabasero type section of the Ngorora Formation, and well dated at 12·5 Ma. If the hominoid specimen is confirmed as Proconsul, it would be one of the most recent recorded. The relatively diverse mammal fauna from the site in some ways resembles that of Fort Ternan. The site is underlain, and not far removed in time, from one of the best fossil macro-floras in Africa, which indicates lowland rainforest conditions in this portion of the Rift Valley at 12·6 Ma.

Fossils from a large-bodied hominoid from early Miocene sediments of Uganda, along with material recovered in the 1960s, show features of the shoulder and vertebral column that are significantly similar to those of living apes and humans. The large-bodied hominoid from Uganda dates to at least 20.6 million years ago and thus represents the oldest known hominoid sharing these derived characters with living apes and humans.

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

BACKGROUND: Major biological and cultural innovations in late Pliocene hominin evolution are frequently linked to the spread or fluctuating presence of C(4) grass in African ecosystems. Whereas the deep sea record of global climatic change provides indirect evidence for an increase in C(4) vegetation with a shift towards a cooler, drier and more variable global climatic regime beginning approximately 3 million years ago (Ma), evidence for grassland-dominated ecosystems in continental Africa and hominin activities within such ecosystems have been lacking. METHODOLOGY/PRINCIPAL FINDINGS: We report stable isotopic analyses of pedogenic carbonates and ungulate enamel, as well as faunal data from approximately 2.0 Ma archeological occurrences at Kanjera South, Kenya. These document repeated hominin activities within a grassland-dominated ecosystem. CONCLUSIONS/SIGNIFICANCE: These data demonstrate what hitherto had been speculated based on indirect evidence: that grassland-dominated ecosystems did in fact exist during the Plio-Pleistocene, and that early Homo was active in open settings. Comparison with other Oldowan occurrences indicates that by 2.0 Ma hominins, almost certainly of the genus Homo, used a broad spectrum of habitats in East Africa, from open grassland to riparian forest. This strongly contrasts with the habitat usage of Australopithecus, and may signal an important shift in hominin landscape usage.

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.

Global climate change, linked to astronomical forcing factors, has been implicated in faunal evolutionary change in equatorial Africa, including the origin and diversification of hominin lineages. Empirical terrestrial data demonstrating that orbital forcing has a significant effect, or is detectable, at early hominin sites in equatorial continental interiors during the Pliocene, however, remain limited. Sedimentation patterns in the Baringo Basin within the Central Kenyan Rift Valley between ca. 2.7 and 2.55 Ma, controlled by climatic factors, provide a detailed paleoenvironmental record spanning 35 fossil vertebrate localities, including three hominin sites. The succession includes a sequence of diatomites that record rhythmic cycling of major freshwater lake systems consistent with approximately 23-kyr Milankovitch precessional periodicity. The temporal framework of shifting precipitation patterns, relative to Pliocene insolation curves, implicate African monsoonal climatic control and indicate that climatic fluctuations in Rift Valley ecosystems were paced by global climatic change documented in marine cores. These data provide direct evidence of orbitally mediated environmental change at Pliocene Rift Valley hominin fossil localities, providing a unique opportunity to assess the evolutionary effect of short-term climatic flux on late Pliocene East African terrestrial communities.

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

Interpretations of faunal assemblages from the late Miocene Mpesida Beds in the Tugen Hills of the Central Kenyan Rift Valley have figured prominently in discussions of faunal turnover and establishment of the modern East African communities. These faunal changes have important implications for the divergence of the human lineage from the African apes ca. 8–5 Ma. While fossil material recovered from the Mpesida Beds has traditionally been analyzed collectively, accumulating evidence indicates that Mpesida facies span the 7–6 Ma interval and are scattered more than 25 km along the eastern flanks of the Tugen Hills. Stratigraphic distinctions between Mpesida facies and younger sediments in the sequence, such as the Lukeino Formation, are not yet fully resolved, further complicating temporal assessments and stratigraphic context of Mpesida facies. These issues are discussed with specific reference to exposures of Mpesida facies at Rurmoch, where large fossil tree fragments were swept up in an ancient ash flow. Preserved anatomical features of the fossil wood as well as estimated tree heights suggest a wet, lowland rainforest in this portion of the rift valley. Stable isotopic analyses of fossil enamel and paleosol components indicate the presence of more open habitats locally. Overlying air-fall tuffs and epiclastic debris, possibly associated with the ash flow, have yielded an assemblage of vertebrate fossils including two teeth belonging to one of the earliest colombines of typical body size known from Africa, after the rather small Microcolobus. Single-crystal, laser-fusion,40Ar/39Ar dates from a capping trachyte flow as well as tuffs just below the lava contact indicate an age of greater than 6·37 Ma for the fossil material.

The Muruyur Beds are a substantial sedimentary deposit within a middle Miocene sequence of mafic volcanic flows associated with early stages of rifting in the central Kenyan Rift Valley. They are best represented in the Muruyur region, near Bartabwa, north of Kipsaramon, where dates range from 16·0 to 13·4 Ma. At Kipsaramon, located about 10 km south of Muruyur along the crest of the Tugen Hills, the upper Muruyur Beds are absent and the lower part can be divided into three members. Important fossil sites within Member 1 are dated between 15·8 and 15·6 Ma, and within Member 3 between 15·6 and 15·4 Ma. BPRP#89, in Member 1, is a bonebed at least 2500 m 2 in areal extent and up to 30 cm thick, which constitutes one of the richest concentrations of in situ fossil vertebrate bones in eastern Africa. BPRP#91, at approximately the same level at BPRP#89, is the source of a hominoid talus and other mammal and bird fossils. In Member 3, BPRP#122 has produced specimens of at least five individuals of the hominoid Equatorius , including a partial skeleton. The Muyuyur Beds were deposited near the western margin of a lake that was formed during the early stages of faulting and volcanism in the African Rift system. The bonebed in Member 1 appears to represent the influx of fluvially transported vertebrate and plant remains into a shallow portion of the lake. Elements of the fauna as well as stable isotopes that indicate both forest and more open environments occurred in proximity to the lake during the time of deposition of Member 1.

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.

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.

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.

The use of blood transfusion was examined in 476 patients who underwent curative surgery for large bowel cancer. Of these patients, 128 were not transfused while 348 received a total of 1174 units of blood. A patient was considered over-transfused if the predischarge haemoglobin was more than 12 g/dl. Using this criteria and accepting that single unit transfusions should be avoided, transfusion could have been avoided in 30% of the patients and a total of 377 units were given unnecessarily. Major under-transfusion did not occur; no patient being discharged with a haemoglobin of less than 9 g/dl. This study shows that blood transfusion is overused and the reasons for its use rarely recorded. In view of the morbidity related to transfusion, it is suggested that surgeons and anaesthetists reappraise their transfusion policy and the first step in this must be to record the reason for transfusion.

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.

Ten human jejunal biopsy specimens were examined by both immunofluorescence (IF) and immunoperoxidase (IP) methods to compare both plasma cell counts and the distribution of extracellular immunoglobulins. Each specimen was cut into at least two portions, one fixed in 5% formaldehyde in phosphate-buffered saline before being snap-frozen and sectioned on a cryostat for IF, the other being fixed in half-strength Zenker and embedded in paraffin wax by standard methods for IP. Plasma cell counts were comparable in the eight biopsy specimens for which they could be estimated, geometric mean values being IgA 22.9 (IF), 19.3 (IP) and IgM 9.5 (IF), 10.6 (IP). Two specimens showing subtotal villous atrophy had too much extracellular IgA for plasma cell counts to be feasible. For these the IF methods had the advantage that the extracellular immunoglobulin was more readily distinguishable from background staining.

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.

Past research indicates weaknesses in typical approaches to the utilization of faculty evaluation information to improve faculty teaching effectiveness. This paper describes an alternative faculty development method relying on workshop formats and tested training techniques to facilitate the development of specific teaching skills. An empirical study of student evaluation of teaching data obtained prior and subsequent to faculty development interventions demonstrates that significant impact on faculty performance as teachers can be produced by this approach.

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.

Delay to diagnosis from first symptom has been assessed in 332 patients with colorectal cancer treated by the three general surgeons in Trafford Health Authority. Delay was divided into three parts; that due to (a) the patient, (b) the general practitioner and (c) the hospital. There was no significant difference in delay between Dukes stage B and C patients but there was a significant difference in survival at two years between these two stages. Delay for patients with risk factors as family histories or diverticular disease was not significantly different to patients without these factors. When compared to other series delay has been shortened, particularly general practitioner and hospital delay. Fewer patients presented as emergencies and a greater proportion of patients had disease at an earlier stage. However, these favourable aspects are not reflected in an improved survival at 2 years.

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.

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.

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.

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.

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.

Summary: Jejunal biopsies obtained from 45 children referred for a variety of clinical conditions were examined histologically and by standard immunofluorescence methods. The number of plasma cells was recorded per “mucosal tissue unit.” The results showed that most of the immunoglobulin A (IgA) counts in infants under 3 yr with normal mucosa were low and that there was a rise in the number of IgA plasma cells starting after this age. Despite this, under pathologic conditions (partial villous atrophy with increased inflammatory cell infiltration - PVA) a significant rise in IgA plasma cells occurred in all age groups. Patients with coeliac disease tended to show the highest IgA as well as IgM plasma cell counts. In all other patients, IgM counts did not change significantly with age or histologic abnormalities.

Five sera raised in rabbits against three strains of Streptococcus pyogenes (grown in semi-synthetic media) were shown by immunofluorescence to have antibodies reacting with both myocardial and conducting fibres. The pattern of staining on the conducting fibres was different to that on myocardial fibres and suggested the presence of larger amounts of cross-reacting antigen. Most work was done on ox heart, but the results were confirmed on human heart and rabbit heart. Absorption studies, carried out with three sera on ox heart only, showed that absorption with the homologous organism abolished in parallel the staining of both types of fibre. Absorption with heterologous organisms was less effective indicating the existence of more than one cardiac cross-reacting antigen. Absorption with myocardium, suggested that the conducting fibres contained streptococcal cross-reacting antigens additional to those found in the contractile fibres.

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.