219 Documentation of Scrotal Examination in Male Children with Abdominal Pain

Background

Abdominal pain is a common presentation in all age groups with 7-10% of emergency department admissions.

Method

This registered audit looks at male children (aged <16), admitted with abdominal pain during this period. Approximately 2,877 children under the age of sixteen were admitted, 1,582 males. This equates to 55% of children admitted within 3 months. Manual note analysis from ED records identified 53 males <16 years of age with abdominal pain for inspection of documentation.

Results

45% of inspected notes had documented genital and scrotal examination, none of which had a documented consent. In addition, 21% had a documented chaperone for the intimate examination. None of the cases had BOTH consent and presence of chaperone documented.

Conclusions

A common presentation in children lacks significant elements of documentation. This is noted in multiple specialties. Potentially overlooked aspects of examination can lead to missed or delayed identification of time sensitive diagnosis namely testicular torsion, with possible substantial legal, professional, and financial consequences.

To improve the quality of documentation, education at junior doctor level has been carried out, with further analysis to take place and with the view to incorporate the three elements of an intimate examination: consent, chaperone, and findings.

Validation of transcutaneous bilirubinometry during phototherapy for detection and monitoring of neonatal jaundice in a low-income setting

Background: Severe neonatal jaundice (SNJ) and the associated long-term health sequelae are a significant problem in low-income countries (LIC) where measurement of total serum bilirubin (TSB) is often unavailable. Transcutaneous bilirubinometry (TcB) provides the opportunity for non-invasive, point-of-care monitoring. Few studies have evaluated its agreement with TSB levels during phototherapy in LIC.Aim: To determine agreement between TcB and TSB during phototherapy in a Haitian newborn population and to establish whether TcB can be safely used to guide treatment during phototherapy when TSB is unavailable.Methods: A single-centre prospective study (February to May 2017) in Cap Haïtien, northern Haiti was undertaken. Newborns <7 days of age with clinically detected jaundice were eligible for inclusion. A TcB device (JM-103) was used to screen for newborn jaundice along with a parallel TSB. A strip of black tape was placed across the sternum during phototherapy and uncovered for subsequent TcB measurements. Decisions about phototherapy treatment were based upon UK National Institute of Clinical Excellence (NICE) threshold criteria. Paired TSB and TcB measurements were compared using Bland-Altman methods.Results: The final analysis included 70 parallel TSB/TcB measurements from 35 infants within the first 5 days of life. Nineteen (54.3%) were male and 12 (34.3%) were <35 weeks. Thirty-two (91.4%) were receiving phototherapy. There was good agreement between TSB and TcB. Compared with TSB, TcB tended to over-estimate bilirubin (mean difference 11.1 µmol/L, 95% CI -10.2-32.5 µmol/L). However, at higher bilirubin levels (>250 µmol/L), TcB tended to under-estimate bilirubin compared with TSB and the difference increased.Conclusion: In an LIC setting in which serum bilirubin testing is not commonly available, TcB demonstrates good agreement with TSB and can be safely used to guide jaundice treatment during phototherapy but can lead to over-treatment at lower bilirubin levels and are more inaccurate at higher levels. For TcB levels >250 µmol, confirmation with serum bilirubin should be performed, if available, to avoid under-estimation.Abbreviations: LIC: low income countries; LMIC: low and middle income countries; TcB: transcutaneous bilirubinometry; TSB: transcutaneous serum biliubin.

Use of pasteurised human donor milk across neonatal networks in England

OBJECTIVES

To describe the use of pasteurised human donor milk (pHDM) in England and the influence of a human milk bank in the network.

DESIGN

Prospective observational study SETTING: All 163 neonatal units (23 networks) in England 2012-2013.

PATIENTS

Preterm infants born at <32 weeks gestational age (GA).

MAIN OUTCOME MEASURES

Proportion of infants and care-days fed pHDM during the first 30 postnatal days by network METHODS: We extracted daily patient-level data from the National Neonatal Research Database (NNRD). We fitted a logistic regression of pHDM exposure on the presence of a pHDM bank within the network, with GA, BW z score and network as covariates. Significance was assessed by the likelihood ratio (chi-squared) test.

RESULTS

Data for 13,463 infants were included in the study. Across the networks, the proportion (95%CI) of infants ranged from 2.0% (1.0, 3.0) to 61.0% (57.4%, 64.6%), and the proportion of care-days in which pHDM was fed from 0.08% (0.04%, 0.10%) to 21.9% (19.9%, 24.0%). In three networks <5%, and in seven networks >30% of infants received any pHDM. Variation in the use of pHDM across networks remained significant after adjustment for presence of a human milk bank within the network and all covariates (p < 0.001).

CONCLUSIONS

Wide variation of pHDM use in England is not fully explained by presence of a pHDM bank or patient characteristics. This suggests clinical uncertainty about the use of pHDM.

A review of biocompatibility in hernia repair; considerations in vitro and in vivo for selecting the most appropriate repair material

PURPOSE

Repair of hernia typically makes use of a prosthetic material; synthetic or biologic in nature. Any material which enters the body is subject to interrogation by the inflammation and immune system in addition to numerous other cell families, the outcome of which ultimately determines the success of the repair. In this review, we discuss the fundamental biology which occurs in situ when a biomaterial associates with a tissue, compare and contrast the techniques available to predict this in vitro, and review how features of hernia repair materials specifically may manipulate tissue interrogation and integration. Finally, we conclude our article by examining how biocompatibility impacts surgical practise and how a better understanding of the manner by which materials and tissues interact could benefit hernia repair.

MATERIALS AND METHODS

A review of the literature was conducted using appropriate scientific search engines in addition to inclusion of findings from the groups' primary research.

RESULTS

Using pre-clinical assays to anticipate the biocompatibility of a medical device is critical; however, to maximise the scientific power of in vitro findings, we must carefully consider the in vivo niche of the cells with which we are working. Excessive in vitro culture or contact to non-self materials can add compounding complexity to studies involving leucocytes for instance; therefore, we must ensure careful and stringent assay design when developing techniques for assaying pre-clinical biocompatibility. Furthermore, many of the features associated with hernia repair material design specifically, included to enhance their mechanical or biodegradation characteristics, are inadvertently instructive to cells, and therefore, throughout the prototype stages of a materials development, regular biocompatibility assessment must be performed.

CONCLUSION

The biocompatibility of a material is rate limiting in its ability to function as a medical device. The future of hernia repair materials will rely on close cohesion between the surgical and scientific communities to ensure the most robust biocompatibility assessment techniques, and models are utilised to predict the efficacy of a given material in a particular surgical application.

The impact of a regional care bundle on maternal breast milk use in preterm infants: outcomes of the East of England quality improvement programme

OBJECTIVE

To evaluate a quality improvement (QI) programme to increase the use of maternal breast milk (MBM) in preterm infants.

DESIGN

Interrupted time series analysis.

SETTING

17 neonatal units in the East of England (EoE) Perinatal Network; 144 in the rest of the UK Neonatal Collaborative (UKNC).

PATIENTS

Infants born ≤32(+6) weeks gestation admitted to neonatal care between 2009 and 2012.

INTERVENTION

A 'care bundle' to promote MBM in the EoE.

OUTCOMES

Percentage of infants receiving exclusive or any MBM at discharge and care days where any MBM was received.

METHODS

Data were extracted from the National Neonatal Research Database; outcomes were compared preintervention and postintervention, and in relation to the rest of the UKNC.

RESULTS

Exclusive and any MBM use at discharge increased from 26% to 33% and 50% to 57% respectively in the EoE, though there was no evidence of a step or trend change following the introduction of the care bundle. Exclusive MBM use at discharge improved significantly faster in EoE than the rest of the UKNC; 0.22% (95% CI 0.11 to 0.34) increase per month versus 0.05% (95% CI 0.01 to 0.09, p=0.007 for difference). The percentage of infants receiving MBM at discharge and care days where any MBM was received was not significantly different between EoE and the rest of the UKNC.

CONCLUSIONS

This QI programme was associated with some improvement in MBM use in preterm infants that would not have been evident without the use of routinely recorded national comparator data.

Fusobacterium necrophorum-induced sepsis: an unusual case of Lemierre's syndrome

Classical Lemierre's syndrome is characterized by severe sepsis with metastatic abscess formation in young, previously fit people from a primary head or neck focus. The causative organisms are the anaerobic fusobacteria, most commonly Fusobacterium necrophorum. We describe the evaluation, therapeutic interventions and management of a patient with Lemierre's syndrome who presented in septic shock with multiple organ dysfunction. The patient required immediate interventions including endotracheal intubation and mechanical ventilation, fluid resuscitation, inotropic support, bilateral thoracostomy tube drainage of empyemata and antimicrobial therapy. The unexpected isolation of Fusobacterium necrophorum from blood cultures and empyema fluid necessitated a change of antibiotic regime to provide anaerobic cover. The patient required 4 weeks of intensive support including prolonged antimicrobial therapy, and after a further 2 weeks was discharged home from hospital. This case highlights the need to raise the awareness of 'the forgotten disease': Lemierre's syndrome. Its diagnosis may, as in this case, be confounded by a lack of symptoms of pharyngitis at the time of presentation, and end-organ dysfunction associated with severe sepsis, possibly suggesting an alternative source of infection. As appropriate antibiotics reduce mortality dramatically, clinicians need to be alert to Lemierre's syndrome and include it in the differential diagnosis in young but otherwise healthy patients presenting with severe sepsis.

Assessing service quality in paediatric audiology and early deaf education

Quality monitoring and assurance is a key aspect of evidence-based service provision in health and education. Part I of the present paper summarizes the results from a survey in which performance of health-based paediatric audiology services in the UK was assessed against existing good practice guidelines (NDCS, 1994, 1996). The results of the survey indicated varied levels of provision, with guidelines commonly not followed. Part II of the paper reports the detailed development of two short questionnaires designed to provide scores (out of 100) reflecting aspects of service quality in paediatric audiology services and in early deaf education services. The results from the use of the two indices (the Paediatric Audiology Service Index (PASI) and the Deaf Education Early Service Index (DEESI)) are presented along with data from some component questions. Although some services are functioning close to guideline levels of service, the overall distribution of scores is such as to raise serious concerns about the variability of quality and the consequent inequity of provision for children with permanent hearing loss and their families in both health and education services.

Association of symptoms of type 2 diabetic patients with severity of disease, obesity, and blood pressure

OBJECTIVE

The symptoms of 430 type 2 diabetic patients were determined by a self-administered questionnaire before entry into the U.K. Prospective Diabetes Study.

RESEARCH DESIGN AND METHODS

Entry into the trial followed 2 months of dietary treatment for newly diagnosed patients with type 2 diabetes. Forty symptoms with five levels of severity were included in the questionnaire. A complaint rate was computed as the sum of symptom scores divided by the number of symptom questions answered.

RESULTS

The complaint rate was independently and positively related to BMI, fasting plasma glucose (FPG), and being a woman. Three symptoms--presence of dry mouth (P < 0.001), thirst (P < 0.01), and stomach pain (P = 0.02)--were related to FPG independent of sex, age, BMI, or blood pressure. Only dry mouth was related to HbA1c (P = 0.05). Complaints of shortness of breath, swollen ankles, headaches, heartburn, sweating, wheezing, nocturia, thirst, and diarrhea increased with BMI independently of other variables. A complaint of cold extremities decreased with BMI. Heartburn, weakness of limbs, and hot flushes were positively related to blood pressure, and unsteadiness was negatively related.

CONCLUSIONS

The symptoms reported by patients with type 2 diabetes increased with FPG and markedly with BMI. The symptoms associated with obesity have been underestimated in the past.

Quality of life in treated hypertension: a case-control community based study

The aim of this case-control community study was to determine whether there was a difference in quality of life between hypertensive subjects and matched normotensive controls. Cases aged 40-79 years were randomly selected from a hypertensive register and matched with controls for age, sex, ethnicity and health centre. Cases had phase V diastolic blood pressure (DBP) > or = 100 mm Hg or systolic blood pressure (SBP) > or = 180 mm Hg, or were on anti-hypertensive medication. Controls had DBP < or = 90 mm Hg and no record of raised BP or anti-hypertensive treatment within the past year. Quality of life was measured by self-administered questionnaire. Data from 90 matched pairs, average age 62 years, with 47% men, were analysed; 80 hypertensive subjects were on anti-hypertensive medication. Hypertensive subjects showed an impairment in well-being compared with controls. They had a lower Health Status Index, had more sickness absence from work, greater symptomatic complaint and impaired psychological well-being. Relatives also reported a poorer quality of life in the hypertensive subjects. This impairment could be a result of the disease, adverse effects of drug treatment or to the effects of labelling.

Establishment of a cell line from a hepatocellular carcinoma from a patient with hemochromatosis

We describe the establishment and characterization of a novel hepatoma cell line. This cell line, designated RBHF-1, was established from a hepatocellular carcinoma of a 67-yr-old man with a history of genetic hemochromatosis. At this writing, the cells have been maintained in RPMI-1640 tissue-culture medium and fetal calf serum without any additional supplements for 30 mo. The cells form colonies on soft agar and are not tumorigenic in nude mice. The cell line is polymorphic and displays characteristics of mature hepatocytes by synthesizing albumin, alpha 2-macroglobulin, fibronectin and alpha-fetoprotein. Cytogenetic analysis shows multiple chromosomal aberrations, with a consistent deletion in the long arm and deletions or rearrangements in the short arm of chromosome 1. There is no evidence for hepatitis B or hepatitis C virus infection of the cell line. The cells contain no detectable intracellular iron after staining with Perls' stain. Unlike other hepatoma cell lines, there is no detectable binding of epidermal growth factor to RBHF-1 cells. This is the first cell line to be established from a patient with hemochromatosis, and it provides a potentially important model for the study of hepatocyte transformation in association with iron overload.

Cognitive function in hypertension: a community based study

Cognitive function was investigated in a random sample of subjects on the general practitioners' registry of hypertensive patients in an inner city area and matched with normotensive controls. The response rate was 66% giving 90 matched pairs, average age 63 yrs, with 47% men. There was no difference in educational background or measures of reading ability between the two groups. Cognitive function tests showed a consistent trend of poorer performance in hypertensives, with significant differences in Verbal Learning (immediate recall and retention). Age was inversely related to cognitive function, but no additional deterioration with increasing age was shown in hypertensives.

Quality of life on antihypertensive therapy: a double-blind trial comparing quality of life on pinacidil and nifedipine in combination with a thiazide diuretic. European Pinacidil Study Group

The quality of life (QL) was evaluated in a 6 month double-blind trial in six European countries. Patients with a sustained supine diastolic blood pressure (SDBP), phase V, of 95 mm Hg or more on bendrofluazide, 5 mg daily (or an equivalent dose of a thiazide diuretic) were randomised to additional pinacidil (n = 127), 25 mg up to 100 mg daily, or nifedipine (n = 130), 20 mg up to 80 mg daily. The treatment groups were similar at entry for QL scores, average DBP of 103 +/- 6 (SD) mm Hg, and average age of 56 +/- 10 (SD) years. Eighteen patients on pinacidil and 12 on nifedipine withdrew due to side effects, such as oedema (both drugs) and flushing (nifedipine). The maximum antihypertensive effect was achieved within 6 weeks and maintained, resulting in a significant fall in SDBP of 13.7 mm Hg on pinacidil and 15.5 mm Hg on nifedipine at the end of the trial. There was no significant difference in the antihypertensive effect. The target SDBP was achieved in 57% of pinacidil-and 63% of nifedipine-treated patients. The average number of symptomatic complaints fell in both groups, with significant decreases in the reporting of blurred vision and headaches on nifedipine. Complaints of growth of body and facial hair increased on pinacidil but there were no significant between-drug comparisons with respect to side effects. In measures of psychological well being, patients on pinacidil showed a significant (p less than 0.05) improvement in total and cognitive function scores compared to nifedipine.(ABSTRACT TRUNCATED AT 250 WORDS)

Operative cholangiography: a perspective

Two hundred and eighty-seven patients having operative cholangiograms were identified from a prospective study of 346 patients undergoing surgery for gallstones. Forty-two patients (14.6%) had filling defects and bile duct (BD) exploration. The false-positive exploration rate was 2.8%. Eight patients (2.8%) had unexpected BD calculi with no abnormality in pre-operative liver function tests or ultrasound. If a policy of selective operative cholangiography is pursued, then failure to detect a small number of duct stones must be expected, although unnecessary duct exploration is likely to be eliminated. The clinical significance of undetected BD calculi remains debatable.

Experience with biliary audit

Experience with an audit of surgery for gallstones is discussed. Three hundred and forty-six patients were treated in a three and a half year period. There was no mortality. There was a duct exploration rate of 17%, an infection rate of 8.6%, and a re-operation rate for retained bile duct stone of 1.6%. Bile was cultured from 278 gall-bladders and culture was positive in 66 cases (23.7%). The most common organisms grown were coliforms and streptococci. Our antibiotic policy has changed as a result of this study. Audit is becoming increasingly necessary in surgical practice, not only for research purposes, but also to monitor performance. The design can be broad, to identify groups of patients for further study, or narrow, to concentrate on a particular problem. Someone must be responsible for checking the completed forms for accuracy before the data are entered into the computer. It is important that the form be as simple as possible. Forms which are too detailed will be filled in inaccurately or not at all.

Monolayer culture of parenchymal rat hepatocytes on collagen-coated microcarriers. A hepatocyte system for short- and long-term metabolic studies

A method is described for the attachment to and monolayer culture of adult rat hepatocytes on collagen-coated or fibronectin-coated microbeads or both in a chemically defined serum-free medium. Protein synthesis measured by the incorporation of [3H]leucine into protein was four-fold higher in the hepatocyte microcarrier cultures than in isolated hepatocyte suspensions. The hepatocyte microcarrier cultures showed acute responsiveness to insulin of fatty acid synthesis, glucose incorporation into glycogen, and decarboxylation of [1-14 C]pyruvate. Microcarrier-cultured hepatocytes have the combined advantages of monolayer culture and suspension systems. They are a potential tool for the study of long-term as well as acute effects of hormones.

Psychological implications of mastectomy

Some recent studies on the psychological trauma endured by patients with breast disease are summarized and a number of conclusions are drawn. There appear to be a number of stages through which a patient with a breast lump passes psychologically. Breast cancer attitudes in a community are dependent upon accumulated experience and cannot be changed overnight. Delay in presentation results from unconscious factors which may not be amenable to rational public health appeals. It is possible to identity a group of patients high at risk in breast surgery, although human resilience is such that the outcome if often satisfactory. There is a great need for controlled prospective studies in many areas of breast surgery rehabilitation. Some personal observations are included to stimulate discussion and interest in the area.

Why don't doctors understand "PSYCHOLOGISTS"?

There are various factors which cause a communication gap between doctors and other members of the health team. Some of these are simple differences in language, but others go much deeper and involve basic issues of philosophy and outlook. Some of the views presented here may be indigestible in some quarters.

Ruptured choledochal cyst: recognition and management

A case is described of the rupture of a choledochal cyst in a 21-year-old man involved in a motor vehicle accident. At laparotomy, a haemoperitoneum was traced to a large haematoma in the lesser omentum which extended into the mesocolon and was found to be tinged with bile. Eventually it became apparent that the primary pathological condition was a large choledochal cyst into which opened the gallbladder. This cyst had split longitudinally down its anterior surface from the porta hepatis to the duodenum. Bile leakage was controlled by inserting a Foley catheter into the common hepatic duct, and inflating the balloon. Postoperative cholangiography showed massive cystic dilation of the intrahepatic ducts. Five days after the initial operation, a Roux-en Y cystjejunostomy was performed, and the patient has been well since. Crucial points in the emergency management of this condition appear to be in its recognition, and the provision of an adequate method of primary biliary drainage, if the condition of the patient demands staged management. End-to-end cystjejunostomy provides a satisfactory method of final drainage.

Mastectomy in a large public hospital

Thirty women undergoing mastectomy for carcinoma of the breast in a large teaching hospital were interviewed. All indicated a very real need to discuss their experiences, and felt that the interview had been beneficial to them. Most had found the "lump" themselves--but often described it as a "hardness", a "ridge", or a "thickening". More than half felt that the counselling afforded to them had been inadequate--especially in the realm of sexual adjustment--but, if their marriages had been stable before operation, subsequent deterioration was unlikely. The threat of malignancy, rather than that of breast loss, was uppermost in the minds of most patients. It should not be assumed that postmastectomy problems do not exist because patients do not mention them, especially in large busy follow-up clinics, where privacy may be inadequate. If doctors are unable or unwilling to afford this service to their mastectomy patients, it may be necessary to delegate it to other health professionals and mastectomy volunteers.

What shall we teach our students about breast cancer? A personal view

The incidence of breast cancer in Australia is as high as in most parts of the world. The usual presentation is with a breast lump. Invasive and preinvasive malignant changes may be identified in both duct and lobular epithelia. There are clinical features of malignancy, but histological proof is necessary. Aspiration of cysts and reexamination of clinically benign lumps are acceptable in certain circumstances, but a tissue diagnosis should be made by needle or open biopsy. Earlier diagnosis is possible by radiological screening of asymptomatic patients, but the cost is high. Total excision of the breast (simple mastectomy) is the minimum treatment advisable for infiltrating cancer; If there is a high chance that the draining lymph nodes will contain tumor, they should be treated by surgical excision or radiotherapy. Early chemotherapy does reduce the incidence of systemic metastases after mastectomy, but its precise place in management is not yet clear. The social impact of mastectomy is considerable and deserves more attention than has been paid to it in the past. Clinical trials of treatment should continue, as they are beginning to answer some fundamental questions.

The dilemma of stage III breast cancer: a study of preoperative radiotherapy

The results of treatment of 68 patients with Stage III breast cancer treated by preoperative radiotherapy and subsequent mastectomy have been compared with those in 68 patients treated by more conventional methods, matched individually for age, stage, and year of treatment. Preoperative radiotherapy delayed the time of the first local recurrence, but did not improve overall survival. It is concluded that preoperative radiotherapy may be justified in patients with Stage III breast cancer in an attempt to control local disease, but is unlikely to improve control of systemic recurrence.

An electron microscopic study of the mode of donor cell death in unmodified rejection of pig liver allografts

The only type of cell death found in pig liver allografts 1 week after technically successful operation was apoptosis. Its extent paralleled the degree of mononuclear cell infiltration of the liver parenchyma, and mononuclear cells were found applied to the surfaces of hepatocytes showing early stages of the process. The results suggest that cellular immune attack induces apoptosis of donor cells, and that the action is a direct one. However, implication of other factors such as vascular damage in the induction of apoptosis in the grafts could not be excluded.

Acute pancreatitis: the Queensland scene

One hundred patients suffering from acute pancreatitis and studied in two large teaching hospitals in Brisbane between 1959 and 1973 were reviewed. Gallstones were present in 43 patients (of whom 31 were female), and a history of alcoholic excess were elicited in 23. Sixty-three patients were aged over 50 years. Characteristic clinical features included spreading epigastric pain with radiation to either of the upper quadrants of the abdomen. Left-sided upper abdominal peritonitis associated with severe repetitive vomiting was suggestive of the diagnosis. The serum level in most cases fell below the arbitrary diagnostic level of 500 Somogyi units/100 ml within 72 hours of the onset of the pain. Acute haemorrhagic necrosis of the pancreas was positively diagnosed in 15 patients, six of whom died. The overall mortality rate in the series was 9%.

Breast cancer in Queenland fifteen years after treatment

The incidence of carcinoma of the breast in this Australian series is as high as in most countries of the world, and remains high with increasing age. The mortality rate from cancer is highest in the first three years after treatment of the primary disease, but, even after 10 years, deaths from cancer are nearly as frequent as those from intercurrent disease. At least 25% of patients had advanced disease at initial presentation. A 25% 15-year survival rate is reported in a series of mixed stage at the time of initial treatment, which was by simple mastectomy and radiotherapy in 75% of cases. Large tumours without evidence of axillary metastasis T3N0M0) often had a surprisingly good prognosis. The site of first reappearance of the tumour was local in 30-6% of cases, systemic in 38-4% of cases, and in the opposite breast in 7-6% of cases. It was not possible to classify the remaining 23-4% either because of incomplete information or, more usually, because of synchronous development of local and systemic recurrence. Of patients who developed local recurrence in this group, 83% showed generalized metastatic disease within 10 years of the appearance of the recurrent disease.

Fifteen years on

Sixty students who graduated from the University of Queensland in 1958 were traced 15 years later. Sixty per cent were in private practice and 40% were in full-time salaried jobs. Those who ultimately became physicians had the best average course performance. After specialization, there appeared to be a tendency for the less academically able students to take on full-time salaried jobs rather than to enter private practice. Seventy per cent of women were still in substantially full-time practice.

Early jaundice after pig liver transplantation

Of a series of pigs surviving orthotopic liver allotransplantation with end-to-end anastomosis of the bile duct, 70% were noted to be jaundiced at the end of the first week after transplantation. Seven animals in a subsequent series were investigated biochemically, but operative cholangiography, and by liver biopsy seven days after transplantation, when the jaundice was maximal. There was definite cholangiographic obstruction in only one animal, and this finding was subsequently confirmed at autopsy. This was also the only animal in which bile culture was positive. Jaundiced animals appeared to have more marked histological evidence of rejection than non-jaundiced ones. The jaundice was probably a result of transient rejection and usually resolved spontaneously without immunosuppression.

Liver function in the pig. 1. The effects of 30 minutes' normothermic ischaemia

A preparation was developed in the pig in which transhepatic samples could be taken, and the duration for which the pig liver would tolerate ischaemia was studied. Total occlusion of the hepatic artery, portal vein and inferior Venn cava was caused after studies of the effects of occlusion of the portal vein or the vena cava alone. Adequate splanchnic decompression was provided by a splenojugular bypass.

Reversible changes were noted in the acid/base status and potassium levels after ischaemia. Aspartate transaminase (SGOT) levels rose and remained elevated during the hour of study following occlusion. Alkaline phosphatase and glucose levels changed but remained within normal laboratory limits, although there appeared to be a release of glucose from the hepatic veins after occlusion. Portal pressure increased reversibly after ischaemia and returned to normal within 1 hour. Bile flow ceased during inflow occlusion and resumed 15 minutes after the release of the clamps.

The surgical significance of methaemalbuminaemia

A quantitative estimation of plasma methaemalbumin can be useful. In pancreatitis, it usually indicates severe and haemorrhagic disease, and is thus of prognostic importance, as well as indicating the need for the full therapeutic regime for conservative management of the disease. It may be helpful diagnostically in some patients with pancreatitis in whom it remains elevated after the serum amylase has returned to normal.Raised levels may indicate laparotomy in patients in whom the diagnosis of pancreatitis is considered but who are not responding to conservative measures. Such patients may occasionally be suffering from intestinal infarction or other surgically remediable condition.However, it has been found that the level of methaemalbumin in the plasma may be raised above the upper limit of the normal range of 5.5 mg% in occasional cases of gastrointestinal bleeding and soft tissue trauma and is not always raised in haemorrhagic pancreatitis.