A systematic review of the evidence on service user involvement in interpersonal skills training of mental health students

Service user involvement has become a common feature of education programmes for mental health students. However, little is known about the effects of this type of education on the interpersonal skills of students taking part. This paper reports findings from a systematic review that formed part of a wider investigation into service user involvement in teaching interpersonal skills. The review aimed to locate and assess the quality of the published evidence relating to the effects of service user involvement on mental health students interpersonal skills and to synthesize results, using a definition of interpersonal skill that includes attitudes, empathy and skills as its key components. Results from this study indicate that the quality of evidence in this area is poor. However, sufficient synthesis of the evidence base was possible to allow conclusions and recommendations for both research and practice. Conclusions were that the involvement of service users in this area is both acceptable and valuable for students and had specific impacts on attitudes, empathy and skills. Some difficulties and reservations about the style of involvement are discussed. Recommendations for the conduct of future research are also made.

Merkel cell (neuroendocrine) carcinoma of the anal canal: report of a case

Merkel cell tumors are rare neuroendocrine tumors typically found on sun-exposed areas such as extremities. We describe the case of a 42-year-old female with a Merkel cell tumor arising in the anal canal. The tumor was initially thought to represent a hemorrhoid arising during pregnancy and was excised locally after confirmation of extensive metastatic disease. The patient died 13 months after diagnosis with extensive metastatic disease involving the liver. In our search of the world literature there are several reports of neuroendocrine tumors in the rectum; however, no cases of documented Merkel cell tumors arising in the anal canal have been reported. These tumors seem to behave in a very aggressive manner when found in other atypical areas. The presentation symptoms were perianal discomfort and bleeding. Local excision may be the only surgical treatment necessary to control symptoms, given the propensity to early metastases and short life expectancy.

Selection of patients for resection of hepatic metastases: improved detection of extrahepatic disease with FDG pet

A rapidly emerging clinical application of positron emission tomography (PET) is the detection of tumor tissue at whole-body studies performed with the glucose analogue 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG). High rates of recurrence after partial hepatic resection in patients with colorectal cancer liver metastases indicate that current presurgical imaging strategies are failing to show extrahepatic tumor deposits. Although FDG PET cannot match the anatomic resolution of conventional imaging techniques in the liver and the lungs, it is particularly useful for identification and characterization of extrahepatic disease. FDG PET can show foci of metastatic disease that may not be apparent at conventional anatomic imaging and can aid in the characterization of indeterminate soft-tissue masses. Several sources of benign and physiologic increased activity at FDG PET emphasize the need for careful correlation with findings of other imaging studies and clinical findings. FDG PET can improve the selection of patients for partial hepatic resection and thereby reduce the morbidity and mortality associated with inappropriate surgery.

Identification of amyloid-beta binding sites using an antisense peptide approach

The amyloid-beta (A beta) peptide is a cytotoxic peptide implicated in the pathology of Alzheimer's disease (AD). Catalase and the endoplasmic reticulum A beta binding dehydrogenase (ERAB) are both inhibited by characterized fragments of the A beta peptide. In order to target such proteins it is essential to determine which components of these enzymes interact with A beta. This study reports the use of antisense peptide methodology to identify specific A beta-binding domains. Synthetic peptides corresponding to the regions of catalase and ERAB identified showed specific binding to A beta and also prevented A beta cytotoxicity. Antisense peptide methodology has identified A beta recognition sequences and may also be applied to the identification of novel A beta protein interactions to identify targets for use in the treatment of AD.

Value of double-contrast barium enema performed immediately after incomplete colonoscopy

OBJECTIVE

The purpose of this study was to evaluate the ease, completeness, and clinical utility of double-contrast barium enema (DCBE) performed immediately after incomplete colonoscopy.

SUBJECTS AND METHODS

During a 30-month period, a prospective study was performed in 103 patients (79 women, 24 men) to determine the ease and completeness of DCBE immediately after failed colonoscopy and any additional useful information provided by the enema. The ease with which DCBE was performed was graded from 1 (easy) to 10 (difficult).

RESULTS

DCBE revealed the entire colon in 97 patients (94%). Incomplete DCBE was a result of obstruction and incontinence in three patients each. The mean score for ease of performing DCBE was 5.0. In 14 patients (14%), significant additional diagnostic information was provided by the immediate DCBE. In eight patients, abnormalities were identified on DCBE that had not been seen at colonoscopy (five malignant neoplasms, one diverticular mass, two extrinsic masses, and multiple strictures). In four patients, a suspected colonoscopic abnormality was excluded with DCBE findings; and in two patients, a colonoscopic abnormality was further characterized with DCBE.

CONCLUSION

Immediate DCBE after incomplete colonoscopy allows complete colonic evaluation in most cases, often adds vital diagnostic information, and eliminates repeated bowel preparation and unnecessary delay in diagnosis.

Sedation and analgesia in adult patients: evaluation of a staged-dose system based on body weight for use in abdominal interventional radiology

PURPOSE

To evaluate the safety and effectiveness of a systematic protocol for sedation and analgesia in interventional radiology.

MATERIALS AND METHODS

Ninety-one adult patients underwent 113 abdominal interventional procedures. Fentanyl citrate and midazolam hydrochloride were administered in one to five steps (A, B, C, D, E) until the patient was drowsy and tranquil at the effective loading dose (ELD). Doses per step were as follows: A, fentanyl 1 microg per kilogram of body weight; B, midazolam 0.010-0.035 mg/kg; C, repeat dose in A; D, repeat half the dose in B; and E, midazolam 1-2-mg boluses (maximum, 0.15 mg/kg).

RESULTS

The ELD was reached in no procedure after step A, in 70 after B, in 23 after C, and in 18 after D. Step E was needed in two procedures. The mean maximum pain score (scale of 0 to 10) was 3.4; pain scores in 85 (75%) procedures were 4 or less (discomforting). Severe pain occurred in seven (6%) procedures. Hypoxia (oxygen saturation < 90%) occurred in 11 (22%) procedures performed in patients breathing room air and four (6%) performed in those breathing supplemental oxygen (P: =.04). All patients responded to supplemental oxygen.

CONCLUSION

This stepwise "ABCDE protocol" allows safe and effective sedation of patients. It is easy to use and may be useful in training radiology residents, staff, and nurses in the techniques of sedation and analgesia. Supplemental oxygen should be used routinely.

Detection of unsuspected colonic abnormalities using the pneumocolon technique during small bowel meal examination

AIMS

The pneumocolon technique in small bowel meal examination is used to obtain double-contrast views of the distal ileum. The purpose of this study was to determine the proportion of cases in which an overhead pneumocolon radiograph demonstrated clinically relevant findings in the colon.

METHODS

The overhead pneumocolon radiographs in 151 patients who underwent small bowel meals were evaluated retrospectively. A chart review was performed on those patients with positive colonic findings to determine if the suspected abnormalities affected patient management.

RESULTS

Colonic abnormalities were identified in 34 of the 151 patients. One patient had a previously undiagnosed ascending colonic cancer; 17 had evidence of acute or chronic colitis; 13 had diverticulosis; one had a caecal polyp; one had an ileosigmoid fistula; one had a filling defect in the ascending colon. In 25 cases the colonic abnormality was visible only on the pneumocolon radiograph and not on the preceding single-contrast images. Management was altered by the colonic findings in seven cases. False-positive findings occurred in two cases.

CONCLUSIONS

A routine overhead radiograph following use of the pneumocolon technique is a useful adjunct to small bowel meal examination as it can yield unsuspected and clinically significant colonic findings.Chou, S. (2000). Clinical Radiology55, 459-464.

Intraarterial catheter-directed thrombolysis: urokinase versus tissue plasminogen activator

The purpose of this study was to evaluate the differences between tissue plasminogen activator (TPA) and urokinase (UK) in the management of ischemic limbs. A total of 58 limbs (24 in the TPA group and 34 in the UK group) in 53 patients were studied prospectively. The two groups were based on the surgeon's preference for lytic agent. The dose regimen for UK was 150,000 IU/hr over 1/2 to 2 hr followed by a continuous infusion of 50,000 IU/hr. TPA was given as a 5-mg bolus followed by 1 mg/hr. Both groups received heparin at a rate of 400 IU/hr through the side arm of the arterial sheath. There was no significant difference in efficacy between UK and TPA, but TPA acted faster and had a higher incidence of bleeding complications.

Evaluating computerized health information systems: hardware, software and human ware: experiences from the Northern Province, South Africa

Despite enormous investment world-wide in computerized health information systems their overall benefits and costs have rarely been fully assessed. A major new initiative in South Africa provides the opportunity to evaluate the introduction of information technology from a global perspective and assess its impact on public health. The Northern Province is implementing a comprehensive integrated hospital information system (HIS) in all of its 42 hospitals. These include two mental health institutions, eight regional hospitals (two acting as a tertiary complex with teaching responsibilities) and 32 district hospitals. The overall goal of the HIS is to improve the efficiency and effectiveness of health (and welfare) services through the creation and use of information, for clinical, administrative and monitoring purposes. This multi-site implementation is being undertaken as a single project at a cost of R130 million (which represents 2.5 per cent of the health and welfare budget on an annual basis). The implementation process commenced on 1 September 1998 with the introduction of the system into Mankweng Hospital as the pilot site and is to be completed in the year 2001. An evaluation programme has been designed to maximize the likelihood of success of the implementation phase (formative evaluation) as well as providing an overall assessment of its benefits and costs (summative evaluation). The evaluation was designed as a form of health technology assessment; the system will have to prove its worth (in terms of cost-effectiveness) relative to other interventions. This is more extensive than the traditional form of technical assessment of hardware and software functionality, and moves into assessing the day-to-day utility of the system, the clinical and managerial environment in which it is situated (humanware), and ultimately its effects on the quality of patient care and public health. In keeping with new South African legislation the evaluation process sought to involve as many stakeholders as possible at the same time as creating a methodologically rigorous study that lived within realistic resource limits. The design chosen for the summative assessment was a randomized controlled trial (RCT) in which 24 district hospitals will receive the HIS either early or late. This is the first attempt to carry out an RCT evaluation of a multi-site implementation of an HIS in the world. Within this design the evaluation will utilize a range of qualitative and quantitative techniques over varying time scales, each addressing specific aims of the evaluation programme. In addition, it will attempt to provide an overview of the general impact on people and organizations of introducing high-technology solutions into a relatively unprepared environment. The study should help to stimulate an evaluation culture in the health and welfare services in the Northern Province as well as building the capacity to undertake such evaluations in the future.

A prospective blinded randomized trial comparing oral sodium phosphate and polyethylene glycol solutions for bowel preparation prior to barium enema

PURPOSE

A prospective blinded randomized trial to compare oral sodium phosphate (NaP) solution with polyethylene glycol (PEG) preparations as bowel preparation prior to barium enema examination.

PATIENTS AND METHODS

One hundred and ten patients consented to take part and each patient was randomly assigned to receive either NaP (Oral Fleet Prep) or PEG (Lyteprep). The barium enemas were reviewed by two radiologists blinded to the type of bowel preparation the patient had received. The colon was divided into six segments and each segment was assessed for the amount of stool and water present, the adequacy of coating, the ability to exclude inflammatory bowel disease and the presence of polyps. A score of 0-3 (failure to good) was assigned per segment on each of these criteria.

RESULTS

The average individual score for the NaP group was 89.2. The average individual score for the PEG group was 88.81. No significant difference was found in the quality of bowel cleansing between the two agents. In particular there was no significant difference in the scores for water retention (two-tailed P = 0.748) and the difference for the quality of coating was considered not quite significant (two-tailed P = 0.0818).

CONCLUSION

Oral sodium phosphate cleans the colon as well as polyethylene glycol solutions. The use of NaP will result in significant cost savings and improved patient compliance.

The use of metoclopramide for the small bowel meal examination: pre-procedural versus peri-procedural oral administration

Administration of oral metoclopramide reduces the transit time for barium to reach the caecum during a small bowel meal (SBM). Current practice is to administer the metoclopramide 5-10 min prior to the barium. We devised a prospective randomized, controlled trial to assess whether administration of metoclopramide 90 min prior to the barium would further reduce the transit time without adversely affecting the quality of the study. Although administration of oral metoclopramide significantly reduced the transit time when compared with a control population, there was no significant difference in transit time between the groups which received metoclopramide.

The clinical and radiological features of cholecystocolic fistulae

The clinical and radiological features of seven patients presenting with cholecystocolic fistulae are reviewed. The majority of the patients were elderly (age range 43-85 years, mean 70.7 years) and there was a female preponderance (6:1). The condition usually has a benign clinical course. Diarrhoea was the most common presenting symptom and the typical clinical features of gallbladder disease were absent. Cholangitis occurred in only one patient. The time between onset of symptoms and diagnosis varied from 1 week to 2 years (mean 22 weeks). In only one patient was the diagnosis of biliary-intestinal fistula suspected on the basis of the plain abdominal radiograph (Case 5). A diagnosis of cholecystocolic fistula was established by barium enema (5 cases), endoscopic retrograde cholangiopancreatography (ERCP) (1 case) and diagnostic laparotomy (1 case). The only cause identified in this series was acute or chronic cholecystitis.

Whipple's disease presenting with lung involvement

A 31 year old man presented with nonspecific symptoms and a chest radiograph showing several pulmonary nodules which rapidly enlarged. Bronchoscopic examination showed endobronchial lesions, histological examination of which led to the diagnosis of Whipple's disease. The patient made a gradual recovery with prolonged antibiotic therapy and the pulmonary lesions reduced in size. This is the first reported case of Whipple's disease presenting with large pulmonary nodules and endobronchial lesions and is notable for the absence of gastrointestinal features.

Improving visualization of distal and terminal ileum during the small bowel meal: an evaluation of fluoroscopic manoeuvres

This study evaluated a variety of fluoroscopic manoeuvres used during small bowel meals for assessment of the terminal ileum and pelvic loops of small bowel. The purpose was to identify those manoeuvres which provide maximum diagnostic yield. Fifty-six consecutive patients undergoing small bowel meal and pneumocolon entered the study. The individual manoeuvres were graded and their contribution to diagnostic quality determined. An analysis of variance was used to determine the diagnostic value of the manoeuvres. There was a significant difference in the diagnostic quality provided by the different manoeuvres. Compression of the terminal ileum with the 'F spoon' and of the pelvic bowel loops with the compression paddle in the supine position provided the best diagnostic information in single contrast. The double contrast images obtained with the pneumocolon contributed most to the diagnostic quality of the examination. The results enable us to recommend a sequence of manoeuvres which are most likely to provide diagnostic views of the terminal ileum and pelvic ileal loops yielding maximum information and optimizing use of fluoroscopic time.

Acute appendicitis presenting with surgical emphysema and pneumomediastinum

A case is reported of a young man presenting with abdominal pain and surgical emphysema of the neck. A chest x-ray revealed pneumomediastinum but other investigations excluded oesophageal rupture. He was found to have a complicated acute appendicitis. The history and likely causes of this unusual presentation of a common complaint are reviewed.

Preparation of the colon for double-contrast barium enema: comparison of Picolax, Picolax with cleansing enema and Citramag (2 sachets)--a randomized prospective trial

A randomized prospective trial was undertaken on 196 consecutive patients referred for double-contrast barium enema examination to assess the relative efficacy of three colon cleansing regimes: Citramag (2 sachets), Picolax and Picolax with a preliminary cleansing enema. Each of the regimes was preceded by a 5 day low residue diet. The radiographs from the examinations were assessed on a double-blind basis. The quality of bowel preparation was significantly poorer (P < 0.001) in the group receiving the preliminary cleansing enema, notably with respect to mucosal coating, compared with the other two groups. The quality of the preparation was slightly better in the group receiving Picolax alone than in the Citramag group (P < 0.01), the difference being most apparent in the proximal colon. The laxatives were equally well tolerated. The study has formed the basis of a departmental audit. As a result, the bowel preparation has been standardized to a 5 day period of dietary restriction followed by 2 Picolax sachets. This measure has improved efficiency within the department with no sacrifice in quality.

Mathematical modeling of water permeability of surgical fabrics for vascular use

The purpose of this study was to derive new mathemtic formulae that could be used reliably to predict water permeability of surgical fabrics before they are made and tested for water permeability. Such a theoretical prediction of water permeability, Qprd, of surgical fabrics is needed for not only timely characterization but also for assisting in more efficient future design and development of better surgical fabrics. Two mathematic formulae, Qw and Qk, were derived from the Buckingham Pi Theorem, in which relevant fiber and fabric parameters were placed into dimensionless pi groups and computed for 25 commercial and experimental vascular fabrics. Linear regression analysis of the relationship between these pi groups with water permeability on the woven and knitted grafts yielded coefficients for the corresponding pi groups that were required for constructing appropriate mathematic formulae to predict water permeability of vascular fabrics. When proper sources of the experimentally determined water permeability, Qexp, were chosen for comparison, we found that 86% of woven fabrics (6 of 7) and 77% of knitted fabrics (14 of 18) had their Qprd within 10% of their Qexp. This high percentage of close matching (within 10%) between Qprd and Qexp should be considered satisfactory because the experimental error for obtaining Qexp is generally higher than 10%. The difference between Qprd and Qexp ranged from as small as 0.27% to as high as 74.2%, depending on the type of fabrics and source of Qexp.(ABSTRACT TRUNCATED AT 250 WORDS)

Colon cancer detection: an algorithm using endoscopy and barium enema

A review of findings on flexible sigmoidoscopy (FS), colonoscopy and selected double-contrast barium enema (DCBE) radiographs from a group of 66 patients with rectal bleeding was performed to test the value of an algorithm in the detection of colonic cancers and polyps. In this algorithm the FS findings would direct patients either to colonoscopy or to a modified DCBE which focused attention on the colon proximal to the sigmoid. Only patients with neoplasms diagnosed by FS, or by MDCBE after negative FS, would proceed to colonoscopy. The study population contained four cancers, 11 polyps > 5 mm and 11 polyps < or = 5 mm; FS+MDCBE missed four polyps, all < 5 mm. For polyps > 5 mm and cancer, FS+MDCBE had a sensitivity of 100%, a specificity of 82%, a negative predictive value of 1.0 and a positive predictive value of 0.62. Using the algorithm, 24 patients (36%) would have required colonoscopy. The results suggest that FS+MDCBE is a potentially valuable method for screening patients for colonic neoplasia.

Ischaemic colitis: clinical, radiological and pathological correlation in three cases

The clinical and plain radiographic findings in three patients presenting with ischaemic colitis are presented. The radiographic signs were atypical in that featureless dilatation of the large bowel was present with no evidence of gas within the bowel wall or 'thumbprinting', and changes were not localized to the left colon. No thrombotic or embolic vascular occlusion was evident on examination of the resected specimens. We attempt to correlate the pathological and radiological findings, and emphasize the importance of considering this diagnosis in elderly patients who have a dilated featureless colon on plain radiographs.

Technical report: percutaneous cholecystostomy in acute acalculous cholecystitis

Acute acalculous cholecystitis is a significant cause of morbidity and mortality in patients with other serious illnesses (Howard, 1981) and the mortality rate after surgical cholecystostomy may reach 15% (McGahan and Lindfors, 1989). Radiologically controlled percutaneous cholecystostomy is a safe, minimally invasive, procedure which may be curative (McGahan and Lindfors, 1989; Berger et al., 1989). Both cases described here were successfully treated by percutaneous cholecystostomy. A modified Seldinger technique was used in one and a direct 'trocar' puncture in the other. Percutaneous cholecystostomy, which is technically relatively straightforward, is now the treatment of choice for acute acalculous cholecystitis.

Through the colonoscope--a radiologist's view

A series of 1578 consecutive colonoscopies performed by radiologists in training is reviewed, with specific reference to patients with colorectal neoplasms. The contribution of the radiologist to the practice of colonoscopy is discussed. This input to the colonoscopy service of a hospital carries several benefits, including the following: a link is established between radiologists and gastroenterologists which improves the standard of both barium enema and colonoscopic examinations; informed discussion is made possible about the suitability of a barium enema lesion for endoscopic removal; the endoscoping radiologist acquires an impartial view of each examination and is able to choose the more appropriate investigation; direct visualisation of the colonic mucosa and its abnormalities may facilitate the interpretation of barium radiographs and enhance the quality of the radiological training that can be offered. In our experience, participation in a weekly colonoscopy session has had no adverse effect on the routine work of the radiology department.

Use of a bacterial sampler for rapid transfer of microvolumes into microplates

A method has been devised to transfer very small volumes of serum from microplates prepared during routine screening of blood into microplates containing diluent. Simultaneous transfer of 96 samples is achieved without the need for disposable tips, while still avoiding carry-over between different plates. Using this method a mean transfer volume of 0.9 microliters (cv 8.9%) was obtained, which lent itself conveniently to testing for high-titre anti-microbial antibodies for which high dilution factors are required.

The significance of haematomas of the basal ganglia in closed head injury

In a large series of patients with severe closed head injury, 26 (3.2%) had haematomas of the basal ganglia. It is suggested that such haematomas indicate primary brain damage, being part of the spectrum of lesions that may be seen in diffuse axonal injury. Clinical outcome was found to depend on the pattern of brain damage, notably on the additional presence of contusions or of other computed tomographic (CT) evidence of diffuse axonal injury.

Radiological evidence for the polyp/cancer sequence in the colon

Three cases of frank malignancy developing in pre-existing colonic polyps are presented. Although this sequence of events is well recognised, it is rarely demonstrated radiologically. The cases illustrate the importance of identifying and appropriately treating polypoid colonic lesions.

Rapid transfer of small volumes of serum into microplates

A method has been devised to transfer small volumes of serum, as an adjunct to larger volume sampling, into microplates. The Costar Transplate 96 machine is used routinely in our laboratory for transferring serum samples into reaction wells for anti-HIV screening. Using this additional method a mean of 4 microliters of serum was transferred, within acceptable limits of error (coefficient of variation, c.v., 16%).

Transient diverticula of the colon

Transient diverticula are radiological phenomena that can be observed in a minority of patients undergoing barium enema. Radiographs before and after smooth muscle relaxation are required. Diverticula seen on the early radiographs may, in some patients, disappear following the intravenous administration of 20 mg hyoscine-N-butylbromide (Buscopan). Using this technique in 441 examinations, transient diverticula have been observed in 18 patients (4.1%). They exhibit many features of established diverticula which suggests that they represent an incipient stage of the disease.

Ventilation/perfusion mismatch in interstitial fibrosis

Regional pulmonary perfusion defects unmatched by ventilation loss, occurring in a patient with proven interstitial lung fibrosis, is reported. This condition is not a widely recognized cause of ventilation/perfusion mismatch.

Pre-operative or postoperative colonic examination for synchronous lesions in colorectal cancer

A review of 130 consecutive large bowel examinations at which a cancer of the colon or rectum was diagnosed has been undertaken. Of 50 patients examined by colonoscopy, the whole colon was seen in only 21 (42 per cent) and almost half of these had a tumour in the caecum or ascending colon. In most cases, an incomplete examination was the result of narrowing of the lumen by the tumour preventing passage of the endoscope. Of 80 patients examined by double contrast barium enema, the entire length of the colon was visualized in 83 per cent but the quality of the examination was sufficient to confidently exclude synchronous neoplastic lesions in only 51 per cent. The incidence of synchronous cancer in this series was within the expected range, although two such cancers were not detected until laparotomy, but the incidence of synchronous adenomas was two-thirds of the expected number in colonoscopy patients and one-third in those examined by barium enema. It is concluded that, in patients with known colorectal cancer, preoperative investigation is unreliable for the detection of all synchronous neoplasia and that patients should have postoperative colonoscopy.

Treatment of metatarsalgia by sliding distal metatarsal osteotomy

A consecutive series of 113 patients who had distal sliding metatarsal osteotomy performed between 1976 and 1983 at Winford Orthopaedic Hospital were reviewed. All patients originally had symptoms and signs of pressure metatarsalgia. A total of 124 feet in 94 patients were available for assessment. Review was performed using a symptomatic scoring system, clinical examination, AP and lateral standing radiographs, and walking foot pressure studies obtained from a Harris-Beath mat. The mean follow-up period was 3 years and 4 months (range nine to 102 months). Symptomatically, 58 feet (47%) were rated as good, 43 (34%) as fair, and 23 (19%) as poor. Eighteen feet (14%) had required revision procedures prior to the time of review because of persistent symptoms. Persistent tender prominence of one or more metatarsal heads associated with plantar callosities was seen in 49 feet (40%). Results were significantly worse in patients older than 65 years of age, when first and fifth metatarsal osteotomies were performed, and when plaster immobilization was used postoperatively.

Quality of urograms in infants: a comparison of sodium diatrizoate, metrizamide and iohexol

A consecutive series of 314 intravenous urograms performed in infants were reviewed and assessed for quality. The first 106 examinations were performed using sodium diatrizoate (Hypaque 270) as the contrast medium, the next 98 patients received metrizamide (Amipaque 280) and the final 110 received iohexol (Omnipaque 300). Thirty-five patients had to be excluded from the study for a variety of reasons, after which there were totals of 98 in the diatrizoate, 90 in the metrizamide and 91 in the iohexol groups. Assessing quality in terms of nephrographic and pyelographic density, sodium diatrizoate was found to be better than the non-ionic agents. Although the differences reached statistical significance they are small and unlikely to affect the information obtained in clinical practice. There was no difference in overall quality between metrizamide and iohexol. Comparing the degree of pyelographic distension and ureteric visualization using the three agents, no difference was found between the groups.

Acute suppurative appendicitis. A rare associate of Crohn's disease

A case is presented of acute suppurative appendicitis occurring with Crohn's disease. The association is rare (only five other cases described), but if diagnostic uncertainty exists, laparotomy should be performed early. If, at laparotomy for suspected appendicitis, Crohn's terminal ileitis is incidentally found, the appendix should be removed.