Serum levels of insulin-like growth factors (IGF-I and IGF-II) and their binding protein (IGFBP-3) are not elevated in pancreatic cancer

CONCLUSION

Serum levels of IGF-I, IGF-II, and IGFBP-3 are not elevated in pancreatic cancer and do not appear to have a significant role in glucose homeostasis in this group of patients.

BACKGROUND

The insulin-like growth factors (IGFs) and their binding proteins (IGFBPs) have been implicated recently in the pathogenesis of pancreatic cancer, and increased serum levels of IGF-I or IGF-II have been reported previously in a number of other gastrointestinal malignancies.

METHODS

Serum levels of IGF-I, IGF-II, and IGFBP-3 were measured by RIA in 20 patients with pancreatic cancer and 20 age-matched healthy control subjects and correlated with serum glucose, C-peptide, and glucose tolerance.

RESULTS

No significant difference was observed in serum levels of IGF-I (13 vs 17 nmol/L, respectively), IGF-II (0.67 vs 0.91 U/mL), or IGFBP-3 (2.3 vs 2.3 mg/L) between the two groups of patients. Twelve (60%) patients had impaired glucose tolerance, but no correlation was observed between the serum levels of the IGFs and glucose tolerance.

Demand on primary health care after day surgery

We have audited the frequency and nature of demands made on general practitioners, and the rate of surgical and anaesthetic complications within the first 7 days after day surgery. Semi-structured questionnaires were posted to the general practitioners of patients who attended the hospital's day care ward for a surgical procedure over a 6 month period. In all, 1798 questionnaires were sent, of which 1533 (85.3%) were returned. A total of 247 (16.7%) patients consulted their general practitioners after day surgery, the principal reason being pain (113 patients). Patients who underwent incisional intermediate surgery had the highest rate (31.5%) of general practitioner consultations. This audit has quantified the workload which day surgery places upon general practitioners. It also demonstrates the importance of categorising the various procedures performed on a day case basis when examining patient outcome. Patients who underwent non-incisional minor surgery consulted their general practitioner less often than those who underwent incisional minor surgery, who in turn consulted their practitioner less often than those who underwent incisional intermediate surgery. It seems likely that an increase in workload for general practitioners is inevitable if more complex procedures are performed on a day case basis.

Activities of phospholipase A2 and diacylglycerol lipase are increased in human colorectal cancer

Experimental, clinical and epidemiological studies have implicated arachidonic acid and its metabolites as important mediators in colorectal carcinogenesis. Although arachidonic acid levels are increased in tumour membrane lipids, its availability for metabolic processes is not known. The activities of phospholipase A2 (PLA2) and diacylglycerol lipase therefore were assessed in tumour and normal mucosal specimens from 20 patients with colorectal cancer using 14C-radiolabelled substrates. The median (interquartile range) PLA2 activity was increased in tumour tissue (10.5 (6.0, 18.5) pmol arachidonic acid mg-1 h-1) compared with that in normal mucosa (5.6 (2.5, 8.5) pmol arachidonic acid mg-1 h-1) (P < 0.001, Wilcoxon signed rank test). Activity of diacylglycerol lipase was also greater in tumoral tissue (47.4 (21.6, 82.1) pmol arachidonic acid mg-1 h-1) than in mucosa (19.1 (9.4, 42.9) pmol arachidonic acid mg-1 h-1) (P < 0.005). There was no correlation between either PLA2 or diacylglycerol lipase activity and myeloperoxidase activity, suggesting that these increases were not directly attributable to tumour inflammatory cell infiltrate. Augmentation of arachidonic acid release in colorectal tumours may have implications for therapy.

Lipid peroxidation and prostaglandins in colorectal cancer

Dietary fat, arachidonic acid metabolism and lipid peroxidation have all been implicated in colorectal carcinogenesis. Fatty acids, prostaglandins (PGE2, PGF2 alpha) and malondialdehyde (MDA), the stable end-product of lipid peroxidation of polyunsaturated fatty acids (PUFAs), were studied in paired tumour and normal mucosa of 20 patients with colorectal cancer. Levels of arachidonic acid and total PUFAs were increased in the phospholipid fraction of tumours (P < 0.05). Levels of PGE2 and MDA were also higher in tumours (P < 0.001) and there was a significant correlation between MDA and PGE2 concentrations (rs = 0.69, P < 0.01). In contrast to previously reported in vitro studies, this work suggests that lipid peroxidation may be enhanced in human colorectal tumours. As PGE2 and MDA have been shown to be involved in carcinogenesis, these may be considered potential therapeutic targets for preventing or treating colorectal carcinoma.

Unconjugated faecal bile acids in familial adenomatous polyposis analysed by gas-liquid chromatography and mass spectrometry

Previous studies have suggested reduced formation of secondary bile acids in patients with familial adenomatous polyposis (FAP). Developments in the collection, extraction and analysis of faecal bile acids as well as in the accurate diagnosis of FAP by DNA markers prompted reinvestigation of this hypothesis. The median (interquartile range (i.q.r.)) faecal bile acid concentration (3.69 (1.66-5.36) mumol per g dry weight) and daily excretion rate (60.5 (29-149) mumol per g per 24 h) in ten patients with FAP were similar to those of nine control subjects (3.31 (0.65-8.38) mumol per g dry weight and 30.1 (7.9-228) mumol per g per 24 h). Although the median (i.q.r.) concentration of only one bile acid (12-oxo-lithocholic acid) was significantly different between patients with FAP and controls (49 (34-70) versus 0 (0-20) nmol per g dry weight, P = 0.006), the derivatives of chenodeoxycholic acid (3.35 (1.76-5.32) versus 0.51 (0.13-2.37) mumol per g dry weight, P = 0.02) and cholic acid (1.63 (0.42-2.34) versus 0.80 (0.13-3.57) mumol per g dry weight, P = 0.006) were increased in those with polyposis. These results show increased bacterial biotransformation of faecal bile acids in patients with FAP.

Cholesterolosis in patients with chronic acalculous biliary pain

The outcome of patients with cholesterolosis was compared with that of those with chronic cholecystitis operated on for chronic acalculous biliary pain. A total of 55 patients with acalculous biliary pain with a median symptom duration of 24 (range 6-120) months were investigated by dynamic cholescintigraphy and followed for a median of 24 (range 12-60) months. Thirty-five patients underwent cholecystectomy, of whom 22 had a low gallbladder ejection fraction (under 35 per cent), with symptomatic improvement in 21 of these (P < 0.01). All four patients with a normal ejection fraction (35-50 per cent) improved after cholecystectomy but only four of nine with a high ejection fraction (over 50 per cent) did so. Results of histological examination were available in 32 patients and revealed cholesterolosis in 20. A low ejection fraction was found in 16 patients with cholesterolosis, of whom 15 showed symptomatic improvement after cholecystectomy; the other four patients had a high fraction and all improved after cholecystectomy. Overall, symptoms in 19 of 20 patients with cholesterolosis improved after cholecystectomy compared with only seven of 12 with chronic cholecystitis (P = 0.03).

Analysis of faecal neutral sterols in patients with familial adenomatous polyposis by gas chromatography-mass spectrometry

Previous studies have suggested that patients with familial adenomatous polyposis (FAP) have increased faecal excretion of cholesterol but a reduction in cholesterol metabolites. It was consequently proposed that the degree of faecal cholesterol degradation could be used as a means of diagnosis. Developments in the extraction and analysis of faecal neutral sterols as well as the accurate means of diagnosing FAP by DNA analysis and indirect ophthalmoscopy has necessitated a re-examination of this proposal. Faecal neutral sterols were analysed in 10 patients with untreated FAP following a complete 5-day stool collection and compared with 9 healthy control subjects (including 4 siblings) closely matched for age and sex. The median [25 and 75, percentiles] stool wet weights were similar between the FAP (97.5 [69, 192] g.24 h-1) and the control (116 [61.5, 137] g.24 h-1) groups. Faecal cholesterol concentration was similar in the two groups (FAP = 2.3 [1.4, 4.2]; control = 3.5 [1.0, 6.0] mumol.g-1 dry wt) as was the concentration of total neutral sterols not including plant sterols (FAP = 17.2 [13.4, 21.0]; control = 18.2 [7.4, 21.6] mumol.g-1 dry wt). There were no significant differences in the proportions of cholesterol metabolised between the FAP (82.3 [74.2, 93.5]%) and control (72.1 [5.7, 81.3]%) groups. This study does not support the notion that faecal neutral sterol metabolism is uniquely different in patients with FAP.

Radioimmunoscintigraphy of recurrent colorectal carcinoma using 111In-labelled murine monoclonal antibody B72.3: a comparison with contrast-enhanced computed tomography

Ten patients underwent contrast-enhanced abdominal computed tomographic (CT) carcinoembryonic antigen (CEA) measurement and murine 111In-B72.3 monoclonal antibody radioimmunoscintigraphy for recurrent or residual colorectal carcinoma. All patients had undergone primary colorectal tumour resection at a median of 3 (range 1-18) months previously. Histological analysis of pelvic tissue biopsies confirmed that six patients had recurrent or residual colorectal cancer and that four were tumour free. Whilst scintigraphy correctly showed all six patients with recurrent or residual disease, both CT and CEA measurement were correct in only four patients. In the four patients without recurrent cancer, CT was correct in two patients whilst scintigraphy and CEA measurement were accurate in three patients. Six out of the 10 patients showed marked nonspecific colonic excretion of radiolabelled antibody which was correctly interpreted in five patients. Future prospective studies comparing CT scans, CEA estimation and B72.3 radioimmunoscintigraphy in a larger group of patients with suspected residual or recurrent colorectal adenocarcinoma may help to define the respective sensitivity and specificity of these techniques.

Spontaneous rupture of the spleen in association with idiopathic thrombocytopaenic purpura

Spontaneous rupture of the spleen is rare and has not been previously reported in association with idiopathic thrombocytopaenic purpura. Its rarity makes familiarity with its presentation difficult and may result in a potentially fatal delay in diagnosis and treatment.

Oestrogen and progesterone receptors in colorectal cancer and human colonic cancer cell lines

Receptors for oestrogen (ER) and progesterone (PR) were assayed in tissue from 17 patients with colorectal cancer and five colonic cancer cell lines using enzyme immunoassays. ERs and PRs were detected in 15 and 17 cancers respectively, although the levels detected were low: median (range) ER 1.3 (0-11.3) and PR 3.9 (0.3-10.2) fmol per mg protein. These values were not significantly different from median (range) levels of ER (1.1 (0.6-3.0) fmol/mg) and PR (1.9 (0.5-3.2) fmol/mg) detected in normal mucosa. There were significant positive correlations between the levels of ER and PR for cancer tissue (tau = 0.56, P < 0.005; r(log transform) = 0.68, P < 0.003; n = 17) but not for mucosa, and between levels of ER in cancer tissue and mucosa (tau = 0.55, P < 0.05; r(log transform) = 0.70, P < 0.025; n = 10) but not between the corresponding PR values. In maintenance media, which contained phenol red and unstripped fetal calf serum, the median (range) concentration of ER was 1.9 (1.2-10.4) fmol/mg and that for PR 24.3 (9.1-63.2) fmol/mg in the five cell lines studied (HT-29, LS174T, SW620, LoVo, COLO 320DM). The addition of oestradiol (10 nmol/l) to phenol red-free medium containing 5 per cent dextran-coated charcoal-treated fetal calf serum had little effect on the concentration of ERs or PRs in SW620, LoVo and COLO 320DM cells after 7 days' culture. It is concluded that ERs and PRs are expressed in malignant and normal colonic mucosa. ERs appear to be a feature of the colonic mucosa rather than the malignant process, but in carcinoma may regulate synthesis of PRs, suggesting a degree of oestrogen responsiveness.

Faecal unconjugated bile acids in patients with colorectal cancer or polyps

The unconjugated faecal bile acid profiles of 14 patients with colorectal cancer, nine patients with polyps and 10 controls were compared using gas liquid chromatography, controlling for such confounding variables as cholecystectomy, gall stones and hepatic function. Patients with adenomatous polyps had a higher concentration of faecal bile acids (5.23 mumol/g, 2.16-13.67 (median, range) v 1.96, 0.91-6.97; p = 0.016) lithocholic acid (2.41, 0.88-3.22 v 1.07, 0.38-2.03; p = 0.013) and total secondary bile acids (5.23, 2.16-13.4 v 1.96, 0.73-6.63; p = 0.02) compared with control subjects. Patients with colorectal cancer had an increased (p = 0.029) proportion of secondary faecal bile acids (mol%) compared with controls (100, 96.5-100 v 95.19, 81.73-100) and the ratios of the primary bile acids, cholic and chenodeoxycholic acid, to their respective derivatives (secondary bile acids) were significantly lower in cancer patients compared with control and patients with polyps (p = 0.034 to 0.004). This study lends further support to the theory that bile acids may play a role in the development of polyps and colorectal cancer.

Reduction of mucosal crypt cell proliferation in patients with colorectal adenomatous polyps by dietary calcium supplementation

The crypt cell production rate was measured in 14 patients with adenomatous colorectal polyps, 17 patients with colorectal cancer and 12 control subjects. The median (interquartile range) rate (cells per crypt per hour) was found to be significantly higher (P less than 0.001) in the polyp (2.45 (1.94-3.20)) and cancer (3.01 (2.35-3.68)) groups compared with controls (1.25 (0.70-1.85)). A double-blind cross-over study was performed in patients with adenomatous polyps consisting of 2 months' treatment, 2 weeks' washout, followed by 2 months' treatment with dietary calcium supplementation (1.25 g day-1) versus placebo. A significant reduction in the crypt cell production rate occurred with calcium treatment compared with the placebo (1.25 (0.6-2.25) versus 2.15 (1.58-3.08) cells per crypt per hour, P = 0.035). This study demonstrates a significant reduction in mucosal cell proliferation by dietary calcium supplementation in patients with adenomatous polyps. Such treatment may be worthy of further investigation in patients at high risk of developing colorectal polyps.

Use of the OM-11-906 monoclonal antibody for determining p62 c-myc expression by flow cytometry in relation to prognosis in colorectal cancer

The expression of the c-myc protein product (p62 c-myc) and deoxyribonucleic acid (DNA) ploidy status was determined by a flow cytometric technique in 83 patients with colorectal cancer followed up for a median of 30 months (range 6-60 months). The OM-11-906 antibody, used to detect p62 c-myc, revealed a 62 kDa and 45 kDa band on Western blots in tumours. Correlation of quantitative dot blotting of tumour mRNA to flow cytometric p62 c-myc expression was good (r = 0.87, P less than 0.01). Levels of p62 c-myc varied in colorectal cancer and low levels (less than 20 fluorescein units) correlated with improved survival (log rank chi 2 = 4.69, df = 1, P = 0.03), and this was a better prognostic index than DNA ploidy (log rank analysis chi 2 = 2.38, df = 1, P less than 0.1). Although expression of the c-myc gene was found, using the OM-11-906 antibody, to be a prognostic feature in colorectal cancer, these and other results need to be interpreted with caution given the presence of two protein bands by Western blotting.

Colon perforation during colonoscopy: surgical versus conservative management

A survey of endoscopy units in the West Midlands, UK, was undertaken to ascertain the management of colonic perforation during colonoscopy. Fifteen perforations were reported from a total of 17,500 colonoscopies performed in 14 units (a rate of 0.09 per cent). In seven patients the diagnosis was suspected or diagnosed immediately and in the remaining eight 2-72 h later. Four patients with associated pathology (carcinoma, Crohn's disease, ulcerative colitis and a polyp) had resection and primary anastomosis. Seven patients had a simple oversew, four of these having had a delayed diagnosis. In four cases the site of perforation was not identified, but only one patient had conservative treatment. Three patients had drainage and a defunctioning colostomy. There was no significant morbidity following treatment. It is recommended that patients who have had a good bowel preparation should be treated conservatively unless there is a large perforation or an underlying carcinoma.

Intraluminal pressure adjacent to left colonic anastomoses

A cumulative total of 89 h of pressure data was acquired from both sides of a left colonic anastomosis in 15 patients over a median period of 7 postoperative study days. Patients had a colonic ileus lasting 3-10 days and during this proximal and distal inactivity the intraluminal pressure remained within 6 mmHg of atmospheric pressure. After recovery of activity, pressures proximal to the anastomosis in excess of 10 mmHg occurred during less than 1 per cent of the recording time. Distal peak pressures were significantly elevated with respect to the proximal site (P less than 0.001). Two-thirds of the distal pressures recorded were between 10 and 20 mmHg and 98 per cent were less than 50 mmHg; the peak distal pressure was 90 mmHg. Four patients had distal repetitive tonic contractions creating a pressure difference across the anastomosis with a mean of 20 mmHg and a peak of 45 mmHg. Each contraction persisted for 15-20 min. Intraluminal pressures are unlikely to play a role in anastomotic dehiscence.

Comparison of deoxyribonucleic acid ploidy and nuclear expressed p62 c-myc oncogene in the prognosis of colorectal cancer

A simultaneous flow cytometric assay of the nuclear expressed protein product of the c-myc oncogene p62 and deoxyribonucleic acid (DNA) ploidy in archival paraffin-embedded tumor material was undertaken in 179 patients with colorectal cancer, followed for up to 9 years. DNA ploidy showed a survival advantage for diploid tumors (chi 2(1) = 5.39, p = 0.020) and could be used to further divide patients with Dukes' A tumors (chi 2(1) = 4.87, p = 0.027) and Dukes' C tumors (chi 2(1) = 5.33, p = 0.021). By dividing patients into 2 levels of tumor expression of p62 c-myc, there was a trend for improved survival in patients with low expression (chi 2(1) = 3.65, p = 0.056). A combination of ploidy status and p62 c-myc expression improved upon survival prediction by ploidy alone in providing 3 groups (chi 2(2) = 7.86, p = 0.0197). While these results do not suggest a replacement for the Dukes' staging for prognosis (chi 2(3) = 33.82, p less than 0.00001), they strongly support the concept that enhanced expression of c-myc oncogene is associated with the progression of colorectal cancer.

A comparison between imipenem and metronidazole prophylaxis against sepsis following appendicectomy

A single preoperative dose of imipenem/cilastatin was compared with metronidazole for the prevention of infectious sequelae following emergency appendicectomy. Patients with established sepsis received in addition 72 h of either intravenous imipenem or ampicillin, gentamicin and metronidazole postoperatively. Two hundred and sixty-eight patients were studied. Wound infection rate in low-risk patients was 9% for metronidazole and 8% for imipenem. When sepsis was already established intraperitoneally the wound infection rate was 24% for the triple therapy regimen and 8% for imipenem. There was no statistically significant difference between the infection rates in the two groups of treatment whatever the state of the appendix, but there was a trend in favour of imipenem in those patients with a perforated appendix.

Effect of Roux-en-Y biliary diversion on Campylobacter pylori

To assess the effect of biliary diversion on gastric colonization by Campylobacter pylori, we undertook a retrospective histologic study of 24 patients with symptomatic bile reflux after peptic ulcer surgery, who had endoscopic gastric biopsies performed before and after a Roux-en-Y operation. The time interval between the preoperative and postoperative endoscopic examinations ranged from 0.8 to 9.8 yr (mean 4.7 yr). The partial gastrectomy specimen, which had been resected at the initial operation, was available for assessment in 12 patients (50%). Biopsy specimens were assessed for the presence of C. pylori and scored for severity of reflux gastritis by the use of a histologic grading system. Ten of the 12 partial gastrectomy specimens (83%) were C. pylori-positive. Only 13 of the 24 patients (54%) were C. pylori-positive before the Roux-en-Y operation, rising to 22 (92%) after biliary diversion (p = 0.008). The median reflux score was 6 in the partial gastrectomy specimens; it rose to 11 before the Roux-en-Y operation and fell again to 6 after biliary diversion (p less than 0.001). These results suggest that C. pylori may recolonize the gastric remnant after biliary diversion.

Intraperitoneal penetration of cefpirome

Twenty-six patients undergoing elective gastrointestinal surgery received a 1 g intravenous dose of cefpirome before operation. Serum and peritoneal fluid samples, obtained 0.5-7.6 h following administration, were assayed for cefpirome by a microbiological assay. The serum half-life of cefpirome was 2.1 h. The mean concentration of cefpirome in peritoneal fluid 0-2 h after administration was 44.4 micrograms/ml. The half-life of cefpirome in peritoneal fluid was 2 h, with mean concentrations of less than 10 micrograms/ml measured 6 h after administration. The mean percentage of intraperitoneal penetration of cefpirome over the study period was 97.7%. The therapeutic implications are discussed.

Clinical follow-up and treatment of locally recurrent colorectal cancer

Following 630 potentially curative resections, three patients had reoperations for metachronous tumors and 36 for local recurrences. Twenty-four of the latter were identified at follow-up clinic, but 12 presented as emergencies with obstruction. At reoperation only five patients had obvious hepatic metastases. Further colon resections were performed in ten patients. Nine of the 36 survived more than 12 months and three are alive and well over five years after reoperation.

Effect of Roux-en-Y reconstruction on the gastric emptying of a solid meal

The gastric emptying of a solid meal was measured in 39 patients after Roux-en-Y reconstruction and compared with that in 27 patients after truncal vagotomy and pyloroplasty and that in 22 patients after Polya gastrectomy. There were no significant differences among the groups. It is concluded that despite the disruption of the normal motor pathway produced by the Roux-en-Y reconstruction it does not lead to clinically significant delay in gastric emptying.

Tissue penetration and metabolism of ciprofloxacin

The tissue penetration of ciprofloxacin was studied by two methods. Penetration into inflammatory fluid following oral administration (500 mg) was 117 percent; following intravenous administration (100 mg), penetration was 121 percent. The penetration of ciprofloxacin into uninflamed peritoneum following intravenous administration (100 mg) was 95 percent.

Intraperitoneal penetration of ticarcillin/clavulanic acid (Timentin)

Thirty-eight patients undergoing elective abdominal surgery were given 3.0 g ticarcillin plus 0.2 g clavulanic acid as a single intravenous injection at varying times prior to the operation. Sterile assay discs were placed on the peritoneal surface in order to measure peritoneal fluid levels of each agent. Simultaneous serum levels were also measured. A total of 38 serum and peritoneal samples were analysed. There was rapid penetration of both agents into peritoneal fluid. The mean peritoneal fluid levels of ticarcillin were 70% (S.D. 13) of the serum level and 67% (S.D. 4) for clavulanic acid. The peritoneal levels of both agents declined in parallel to the serum levels (the half-lives being about 1 h) and the ratio of ticarcillin-clavulanic acid in serum and peritoneal fluid did not vary significantly with time.

The pharmacokinetics and tissue penetration of imipenem

Two studies were performed to investigate the penetration of imipenem into chemically induced inflammatory exudate and into peritoneal fluid. In the first study six volunteers received 500 mg of imipenem, alone and with 500 mg cilastatin. Little difference was noted in the pharmacokinetics or inflammatory fluid penetration of imipenem when given with or without cilastatin. The only significant alteration was the urine recovery (an increase from a mean of 14.7% to 55.6% in the presence of the enzyme inhibitor). The mean inflammatory fluid level of imipenem at 30 min was 6.2 mg/l (or 35% of the plasma level). The inflammatory fluid levels exceeded the plasma levels after 2 h. The overall penetration of imipenem/cilastatin into inflammatory fluid was 67.8% (+/- 13.8) and imipenem alone 73.2% (+/- 13.9). The mean elimination half-life of imipenem from plasma was 1.1 h and from inflammatory fluid 1.4 h (with or without cilastatin). In the second study, 29 patients received 1 g imipenem plus cilastatin before elective surgery and plasma and peritoneal levels were measured over 4 h. There was considerable penetration of the peritoneum, imipenem levels in excess of 30 mg/l being found 15 min after administration declining to 5-7 mg/l by 3-4 h. The mean percentage penetration was 73.4% (+/- 22.1). A brief review of the literature on imipenem tissue penetration is included.

Campylobacter pyloridis and associated gastritis: investigator blind, placebo controlled trial of bismuth salicylate and erythromycin ethylsuccinate

An investigator blind trial was performed comparing bismuth salicylate, erythromycin ethylsuccinate, and placebo in the treatment of Campylobacter pyloridis associated gastritis in patients without peptic ulceration. Fifty patients fulfilled the study criteria. There was a strong correlation between the presence of C pyloridis and histologically confirmed gastritis. Clearance of organisms led to improvement of the gastritis. C pyloridis was cleared from 15 patients; of these, 13 had gastritis initially, which resolved in 12. Conversely, gastritis resolved in only four of 32 patients not cleared of organisms (p less than 0.0001). There was significantly greater improvement in endoscopic appearances in the patients cleared of C pyloridis compared with those whose infection persisted (p less than 0.001). In the three treatment groups organisms were cleared from 14 of 18 patients receiving the locally active bismuth salicylate, only one of 15 patients receiving erythromycin ethylsuccinate, and none of 17 patients taking placebo. These findings suggest that the ideal antimicrobial for the successful eradication of C pyloridis associated gastritis should be locally active, stable at low pH, and should penetrate gastric mucus. The resolution of gastritis and improvement in endoscopic appearances associated with clearance of C pyloridis support the view that these organisms may play a part in this condition.

Mortality in patients with obstructing colorectal cancer

Of 1,033 patients with colorectal carcinoma, 238 (23%) presented with obstruction. The majority of tumours (74%) were potentially curable (Dukes B/C) at presentation. Tumours situated at the splenic flexure, transverse or descending colon were most likely to obstruct. Perioperative mortality was high following either primary resection (31%) or fashioning of a defunctioning stoma alone (25%) but was twice as high (40%) in patients over 70 than those under 70 (20%). Cardiorespiratory complications accounted for 55% of this mortality, while fatal technical complications occurred in 19%. Sixty seven patients (28%) had two operations, 51 patients (21%) had three operations.

Teicoplanin, its pharmacokinetics, blister and peritoneal fluid penetration

The pharmacokinetics of a 440 mg iv dose of teicoplanin were studied in six male volunteers. The levels of the compound were measured microbiologically in serum, blister fluid and urine. The mean serum level 0-5 h after injection was 44.6 mg 1(-1), falling to 3.6 mg 1(-1) at 49 h. The serum elimination half-life of teicoplanin when fitted to a two-compartment model was 34.2 h; a three-compartment model gave a longer half-life. The apparent distribution half-life was 1.5 h. Penetration into cantharides induced blister fluid was moderately fast, the mean maximum concentration (14.8 mg 1(-1)) occurring at 2.7 h, the mean percentage penetration being 77.4%. Urinary recovery of the drug was 48.3% by 96 h. The drug penetrated rapidly into the non-inflammed peritoneal fluid of 34 patients undergoing elective surgery. The percentage penetration being 40% within the first hour, and 94.6% over the period of the study.

Emergency presentation and mortality from colorectal cancer in the elderly

We have assessed the influence of age on the mode of presentation and perioperative mortality in 1033 patients with colorectal cancer. There were 522 patients (51 per cent) over 70 years (group I) and 511 patients (49 per cent) under 70 (group II). In group I, 301 patients (58 per cent) were admitted as emergencies compared with only 222 (43 per cent) in group II (P less than 0.001). Perioperative mortality was especially high in the elderly emergencies, 38 per cent, compared with 18 per cent for elective operations. Of the patients presenting as emergencies in either age group 66 per cent had localized "potentially curable' disease. The incidence of colorectal cancer is highest in the elderly. A larger number of these elderly patients present as emergencies and die from the consequences of complications of localized disease. Earlier diagnosis by pre-symptomatic screening is therefore especially desirable in these old patients.

A comparison of cefotetan and cephazolin for prophylaxis against wound infection after elective cholecystectomy

In a prospective randomized study 168 patients received a single dose of either cephazolin or cefotetan (1 g) as a prophylactic against wound infection after cholecystectomy. In the cephazolin group 10.3% and the cefotetan group 14.4% developed wound infections (Chi-squared = 0.34 P = less than 0.6 greater than 0.5).

Metronidazole and Augmentin in the prevention of sepsis after appendicectomy

Two hundred and fifty patients were admitted to a prospective randomized trial to compare the efficacy of Augmentin with metronidazole in the prevention of sepsis after appendicectomy. Pre-operatively they received either 500 mg metronidazole or 1.2g Augmentin intravenously. Those patients with gangrenous or perforated appendices received eight additional doses of the trial drug at 8 hourly intervals. Overall there were 13 wound infections in the Augmentin group (11 per cent) and 21 in the metronidazole group (18 per cent). The 90 per cent confidence limits for the overall 7 per cent difference in infection rates were +/- 8.5 per cent. There were high rates of wound infection in the gangrenous group (Augmentin 8 per cent versus metronidazole 19 per cent) and especially in the perforated group (Augmentin 33 per cent versus metronidazole 63 per cent). There was no statistically significant difference between the infection rates with the two antibiotics but our study suggests that Augmentin, which is active against both aerobes and anaerobes, may be more effective than metronidazole in reducing wound sepsis after appendicectomy.

Intramural gas in the small bowel followed by chronic obstruction

A 63 year old male presented with recurring abdominal pain dating from an acute episode 3 months previously. Abdominal X-rays in the acute phase demonstrated small intestinal intramural gas. A jejunal stricture with panmural necrosis was resected.

Pitfalls in the diagnosis of recurrent ulceration after surgery for peptic ulcer disease

We have studied the accuracy of diagnostic methods in achieving a diagnosis in 75 patients with 81 proven episodes of recurrent ulceration. When the endoscopic findings did not permit an accurate diagnosis, radiology usually provided no additional information. The sensitivity of a combined diagnostic approach was not different from that of endoscopy alone, and so the routine use of upper GI radiographs in addition to endoscopy should, therefore, be abandoned. We also assessed observer variation among endoscopists prospectively in 38 patients investigated for dyspepsia after operation for peptic ulcer. Major observer variation in diagnosing suspected recurrent ulceration occurred in 11% of patients, with a sensitivity and specificity higher than 77 and 94%, respectively. As not all the postoperative gastroduodenojejunal mucosal breaches are peptic, we suggest that acid output and enterogastric reflux assessments are useful diagnostic adjuncts to endoscopy.

Metronidazole and ticarcillin in the prevention of sepsis after appendicectomy

Ticarcillin was compared with metronidazole in the prevention of wound infection after appendicectomy. Two hundred nine patients with a diagnosis of acute appendicitis were admitted to a prospective, randomized study and received 500 mg of metronidazole or 5 g of ticarcillin intravenously before operation. Those patients with gangrenous or perforated appendices received two additional doses of the trial drug at 8 hourly intervals. The overall incidence of wound infections in both the metronidazole and the ticarcillin groups was 9 percent. There were no intraabdominal abscesses. Metronidazole abolished anaerobic wound infections. All the early wound infections (between 2 and 4 days after operation) occurred in patients with gangrenous or perforated appendices. We conclude that ticarcillin is as effective as metronidazole in the prevention of wound infection after appendicectomy, but in high-risk patients, (those with gangrenous or perforated appendices) longer courses of antibiotics should be employed.

Intraperitoneal penetration of cefotetan

The intraperitoneal penetration of cefotetan was studied after a 1-g intravenous injection in 25 patients undergoing elective gastrointestinal surgery. Levels of peritoneal fluid were high within 10 min after administration and increased to 44% of the serum levels after 30 min, rising to 115% at 3 h. The mean concentration of cefotetan between 3 and 5 h after administration was 32.3 micrograms/ml. These findings suggest that 1 g of cefotetan administered before abdominal surgery would result in intraperitoneal cefotetan levels necessary to inhibit susceptible pathogens for 5 h or more.