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Abstract: Background: There is debate as to whether recurrent biliary complications are more common in patients who do not have elective cholecystectomy after endoscopic retrograde cholangiopancreatography (ERCP) management of common bile duct (CBD) stones. The aim of this study was to determine the fate of patients with intact gallbladders who have had CBD stones removed at ERCP, and to assess their risk of recurrent biliary symptoms. Methods: We retrospectively identified all patients in our large tertiary center population with intact gallbladders who had an ERCP for CBD stones from December 1999 to March 2002. We determined which patients had subsequent elective cholecystectomy, and the outcomes of patients who did not have elective surgery. Results: 309 patients had CBD stones at ERCP during the study period, of which 139 had intact gallbladders at the time of ERCP. Of these 139 patients 59 had subsequent elective cholecystectomy, 11 by open operation and 48 laparoscopically. Of these 139 patients, 27 had cholecystectomy planned; 47 patients were managed with a wait-and-see strategy, 30 of whom were poor surgical candidates. Of these 47 patients in whom a wait-and-see policy was adopted, 9 (19%) developed complications including recurrent pain and/or abnormal liver function tests (LFTs), recurrent biliary colic, and pancreatitis. Eight of these nine patients were from the poor surgical candidate group. Sphincterotomy had been performed at initial ERCP in all patients. Conclusions: Over half of our population of 139 patients with CBD stones at ERCP and intact gallbladders had actual or planned elective cholecystectomy. For those patients in whom a decision to wait-and-see was made, almost 20% developed complications. Elective cholecystectomy after a finding of choledocholithiasis is supported by many and is a common strategy in our experience. Recurrent biliary complications are relatively common in those who do not undergo elective cholecystectomy, especially those patients who represent a high operative risk.

Abstract: Background: There is debate as to whether recurrent biliary complications are more common in patients who do not have elective cholecystectomy after endoscopic retrograde cholangiopancreatography (ERCP) management of common bile duct (CBD) stones. The aim of this study was to determine the fate of patients with intact gallbladders who have had CBD stones removed at ERCP, and to assess their risk of recurrent biliary symptoms. Methods: We retrospectively identified all patients in our large tertiary center population with intact gallbladders who had an ERCP for CBD stones from December 1999 to March 2002. We determined which patients had subsequent elective cholecystectomy, and the outcomes of patients who did not have elective surgery. Results: 309 patients had CBD stones at ERCP during the study period, of which 139 had intact gallbladders at the time of ERCP. Of these 139 patients 59 had subsequent elective cholecystectomy, 11 by open operation and 48 laparoscopically. Of these 139 patients, 27 had cholecystectomy planned; 47 patients were managed with a wait-and-see strategy, 30 of whom were poor surgical candidates. Of these 47 patients in whom a wait-and-see policy was adopted, 9 (19%) developed complications including recurrent pain and/or abnormal liver function tests (LFTs), recurrent biliary colic, and pancreatitis. Eight of these nine patients were from the poor surgical candidate group. Sphincterotomy had been performed at initial ERCP in all patients. Conclusions: Over half of our population of 139 patients with CBD stones at ERCP and intact gallbladders had actual or planned elective cholecystectomy. For those patients in whom a decision to wait-and-see was made, almost 20% developed complications. Elective cholecystectomy after a finding of choledocholithiasis is supported by many and is a common strategy in our experience. Recurrent biliary complications are relatively common in those who do not undergo elective cholecystectomy, especially those patients who represent a high operative risk.

Abstract This paper describes how the concept of an IP-enabled infrastructure has been developed to deliver the next generation of ICT-based services. It will explore how the basic capability has been extended out into the customer’s premises and used to build more comprehensive solutions. In particular, it will look at the service layer as the pivot for component integration and as the key for providing an holistic family of capabilities. This is underpinned by an operational support systems infrastructure, aligned to emerging industry standards and which places more control in the end customer’s hands. Finally we will show how this capability, which is already rolled out to a number of large clients, fits closely with BT’s next generation network architecture strategy.

DNA double-stranded breaks (dsb) activate surveillance systems that identify DNA damage and either initiate repair or signal cell death. Failure of cells to undergo appropriate death in response to DNA damage leads to misrepair, mutations, and neoplastic transformation. Pathways linking DNA dsb to reproductive or apoptotic death are virtually unknown. Here we report that metabolic incorporation of 125I-labeled 5-iodo-2'deoxyuridine, which produces DNA dsb, signaled de novo ceramide synthesis by post-translational activation of ceramide synthase (CS) and apoptosis. CS activation was obligatory, since fumonisin B1, a fungal pathogen that acts as a specific CS inhibitor, abrogated DNA damage-induced death. X-irradiation yielded similar results. Furthermore, inhibition of apoptosis using the peptide caspase inhibitor benzyloxycarbonyl-Val-Ala-Asp fluoromethylketone did not affect CS activation, indicating this event is not a consequence of induction of apoptosis. ATM, the gene mutated in ataxia telangiectasia, is a member of the phosphatidylinositol 3-kinase family that constitutes the DNA damage surveillance/repair system. Epstein-Barr virus-immortalized B cell lines from six ataxia telangiectasia patients with different mutations exhibited radiation-induced CS activation, ceramide generation, and apoptosis, whereas three lines from normal patients failed to manifest these responses. Stable transfection of wild type ATM cDNA reversed these events, whereas antisense inactivation of ataxia telangiectasia-mutated gene product in normal B cells conferred the ataxia telangiectasia phenotype. We propose that one of the functions of ataxia telangiectasia-mutated gene product is to constrain activation of CS, thereby regulating DNA damage-induced apoptosis.

Two isolates of chicken anaemia agent (CAA) were made from livers obtained from broiler flocks with runting stunting syndrome. Following primary isolation in SPF chicks, both isolates were propagated in MDCC-MSB1 cells. Both were resistant to heat and chloroform-treatment, and were antigenically related to the Cux-1 isolate of CAA by cross-immunofiuorescence and cross-neutralisation tests. The isolates produced anaemia and characteristic lesions in 100% of experimentally inoculated 1-day-old susceptible chicks, but anaemia was observed in only 15 to 20% of inoculated 7-day-old chicks.

The pregnancies of 13 ewes which were inoculated intrauterine with one of two strains of ovine ureaplasmas resulted in 9 normal and 3 abnormal births, and one ewe was found to be no longer pregnant on postmortem examination. Vaginal ureaplasma infection was detected in the majority of ewes only after lambing. Of the 12 ewes examined at postmortem, ureaplasmas were isolated from the uterus of 5 out of the 6 necropsied up to 21 days post-partum. The vulvar/preputial areas of the majority of lambs that survived were infected with ureaplasmas for the duration of the experiment, but infections of the nasal cavity and eye areas, detected at birth in 4 lambs, were resolved within 8 days post-partum.

Parr of Atlantic salmon Salmo salar(mean weight, 25 49 g) were maintained in recirculated freshwater and injected intraperitoneally with one of four inocula. Inoculum 1 was prepared from tissue homogenates taken from Atlantic salmon smolts with acute-stage pancreas disease. Inoculum 2 was a 0.22-µm-filtered preparation of inoculum 1. Inoculum 3 was prepared from tissues harvested from Atlantic salmon parr 8 and 10 d after inoculation with inoculum 1. Inoculum 4 (negative control) was prepared from tissues from Atlantic salmon smolts from a farm with no previous history of pancreas disease. The sequential development of lesions is described up to 23 d postinoculation. Inocula 1–3 produced pancreatic and cardiac lesions similar to those previously described in Atlantic salmon with naturally occurring pancreas disease. Negative-control fish developed no lesions, This is the first description of cardiac lesions resulting from experimentally induced pancreas disease. The results support the theory that a transmissible agent is the cause of pancreas disease.

Many different surgical techniques of vasovasostomy can be successful. Many factors, both technical and nontechnical, play a role in determining pregnancy. Theoretical considerations such as leakage of sperm, obstruction and narrowing of the anastomosis, suggest that a stentless technique with exact approximation of mucosal edges will result in a better success rate. Careful macroscopic surgery with the use of fine suture material, and experience on the part of the surgeon, will give good results and pregnancy rates of up to 50%. Microsurgery becomes quite important when the anastomosis is performed in the convoluted portion of the vas and epididymis. The microscope allows more mobility in permitting one to determine if the patient has a block proximal to the vasectomy site, and then bypass these blocks. Conventional macroscopic techniques do not allow for this freedom of choice. Factors other than technique are also important and are discussed.

The penis, scrotum, and testicles of a 31-year-old man were cut off in a fight. Fourteen hours later the penis and one testicle were reattached, but the testicle later had to be removed. By 3 weeks normal urinary function returned but the penis was misshapen. The patient had suicidal intentions. His partner was sexually supportive but afraid to touch the penis. By 10 weeks penile swelling occurred in response to a movie with frank sexual content. By 12 weeks the penile swelling was sufficient for entry but the partner was acutely afraid that her vaginal contractions would tear the scars. The man was concerned because he experienced only mild sexual tensions. Physical examination reassured both, and they gained hope for recovery. At 16 weeks erections were still not full but active intercourse was attempted and he experienced seminal seepage and mild orgasmic sensations; she was relaxed enough to have orgasm. Testosterone was administered at regular intervals from the 19th week on, with immediate improvement of erection. By 32 weeks full erection, ejaculation, and orgasmic functions returned and the couple resumed their normal sexual practices.

Abstract: The wavelength dependence of the fragmentation of gallstones was investigated using pulsed excimer, ruby and Nd-YAG lasers. Fracturing is due to the shock waves produced by the plasma formed at the irradiated surface. The fluence threshold for plasma production and the associated acoustic signal was found to depend on the absorption coefficient at the laser wavelength. Using a simple model based on a thermal mechanism for plasma production the fluence threshold at different wavelengths can be predicted and the effect of the duration of the irradiating pulse can be qualitatively explained.

Recent investigations provided evidence that the sphingomyelin signal transduction pathway mediates apoptosis for tumor necrosis factor alpha (TNF-alpha) in several hematopoietic and nonhematopoietic cells. In this pathway, TNF-receptor interaction initiates sphingomyelin hydrolysis to ceramide by a sphingomyelinase. Ceramide acts as a second messenger stimulating a ceramide-activated serine/threonine protein kinase. The present studies show that ionizing radiation, like TNF, induces rapid sphingomyelin hydrolysis to ceramide and apoptosis in bovine aortic endothelial cells. Elevation of ceramide with exogenous ceramide analogues was sufficient for induction of apoptosis. Protein kinase C activation blocked both radiation-induced sphingomyelin hydrolysis and apoptosis, and apoptosis was restored by ceramide analogues added exogenously. Ionizing radiation acted directly on membrane preparations devoid of nuclei, stimulating sphingomyelin hydrolysis enzymatically through a neutral sphingomyelinase. These studies provide the first conclusive evidence that apoptotic signaling can be generated by interaction of ionizing radiation with cellular membranes and suggest an alternative to the hypothesis that direct DNA damage mediates radiation-induced cell kill.

Examines differences between the genders. Attitude; Body; The genetic code; The estrogen factor; Stress syndrome; Brain plan; Spatial-visual; Verbal. INSET: Remarkable differences..

Discusses the ways Supreme Court Justice Sandra Day O'Connor is expected to impact the Court's rulings on three abortion-rights issues considered this fall. Personal life; Childhood; Career development. INSET: The Court's next move..

The purpose of this report is to describe a case in which the sole clinical manifestations were those of right ventricular outflow tract obstruction. At operation this was found to be due to a myocardial metastasis in the infundibulum of the right ventricle. In retrospect there were radiological changes which might have suggested that the lesion was not congenital as had been presumed pre-operatively.The patient was a 52-year-old lady who had had intermittent swelling of the ankles for several years. In 1957 an ejection systolic murmur had been recorded at the left sternal edge and in March, 1969 she had developed severe swelling of the ankles and shortness of breath and was hospitalised and treated with digoxin and diuretics. From that time she remained short of breath on exertion and in June, 1969 had three episodes of paroxysmal nocturnal dyspnoea. She also complained of dysphagia and had lost 19 lb. in weight. There was no relevant past medical history or family history.Physical examination revealed a small, thin lady with a marked thoracic kyphoscoliosis. The pulse was regular at 80/minute and of low amplitude and the blood pressure was 120/80 mm Hg. There were 5 to 6 cm a and v waves in the jugular venous pulse. Examination of the heart was complicated by the severe chest deformity, but there was considered to be right ventricular enlargement, a loud pan systolic murmur at the left sternal edge, an ejection systolic murmur in the pulmonary area, and a third heart sound.

Lymphograms performed on 131 patients with malignant reticuloses have been analysed and the results assessed by correlation with other radiological, clinical and histological findings and subsequent course.Lymphography is shown to be of value in diagnosing abnormality of retroperitoneal nodes and thus in planning therapy and assessing response to it in patients with an established histological diagnosis of a malignent reticulosis. Where histology has not yet been obtained it may be of value in showing a suitable site for biopsy, but the appearances are not specific enough to allow therapy without histological diagnosis.The value of inferior venacavography and pyelography as complementary procedures is described and the present policy of investigation of reticuloses and P.U.O. is outlined.

Two cases of congenital double gall-bladder are described which were demostrated radiologically and proved at surgery. Contrast examination must demonstrate two cystic ducts before a definite radiological diagnosis of this rare condition may be made. Some features such as two parallel rows of gall-stones, or two separate loculi seen at contrast examination, are suggestive, but not diagnostic, findings. The literature is reviewed and reasons for the difficulty in obtaining an accurate estimate of the number of recorded cases is given. It is concluded that there are unlikely to be more than 150 proved cases in the world literature, and that of these only 15 cases have been demonstrated radiologically and subsequently proved at operation.The evidence indicates that such gall-bladders are more prone to disease than normal ones, a fact suggested by some previous authors; the associated pathology recorded in the literature is reviewed.

Computed tomography (CI) examinations of the brain, liver, and upper abdomen were obtained in M) previously untreated patients with histologically proven small cell carcinoma of the lung (SC'C'I.I. These results, together with clinical findings and laboratory investigations including radionuclide scans, determined the final staging of the patients. Computed tomography changed the stage from limited to extensive disease in three patients and from extensive to limited disease in seven patients. Overall. 10of60 patients (l6) had their final stage altered by CI'. This study indicates that CI' examinations may yield valuable information in some cases of small cell lung cancer but that it is of limited value in the routine staging of these patients.

Although the association of tuberous sclerosis and renal angiomyolipomas is well established, the occurrence of hepatic hamartomatous lesions in this disease is less well documented. We describe two cases of tuberous sclerosis with associated multiple intrahepatic angiomyolipomas, and we review the literature on this subject. Radiologically, angiomyolipomas can range from entirely lipomatous to completely solid, features which are present in our cases. A characteristic finding of the hepatic involvement in this disease appears to be the multiplicity of the lesions. We suggest that in the setting of tuberous sclerosis it is reasonable to assume that intrahepatic lesions represent angiomyolipomas. However, in nontuberous sclerosis patients with similar findings malignancy cannot be excluded.

This paper describes a cross-sectional case control study to measure the prevalence of psychological morbidity in first year medical students and compare it to the prevalence in in a randomly selected control group of other first year students at Edinburgh University. The study was conducted anonymously using the 60 item General Health Questionnaire. Participation rates were over 90% in both subjects and controls. A total of 17% of medical students had symptoms of psychological morbidity which may benefit from treatment and a further 29% of medical students had symptoms of psychological distress which would be expected to remit spontaneously. A similar rate was found in the control group of students. This suggests that if medical students or doctors, later in their careers, fare badly in terms of mental health then this may well be related to aspects of their lives and is not an intrinsic characteristic.

Treatment of Rh2(O‐Ac)4(MeOH)2 with (II) in MeOH under reflux gives a Rh(II),Rh(II) complex (78% yield), similar to (III), as its monosodium salt.

To the Editor.—In our article correlating abdominal bruits with angiographic findings (232:1238-1242, 1975) we attempted to present the facts, leaving the reader to draw his own conclusions about their clinical significance. This was perhaps unfortunate since your editorial (232:1270-1271, 1975) attributes to us an implication that we certainly do not endorse.Although we stated that "an epigastric bruit cannot usually be ascribed to any other cause, unless celiac stenosis has been excluded by lateral aortography," this does not mean that we advocate aortography in all such patients. On the contrary, we would stress the innocent nature of most epigastric bruits and recommend no further action in the absence of other significant findings. Even in patients with other findings including hypertension, celiac stenosis is still the most likely cause of an epigastric bruit, which should be interpreted with caution.Second, we cannot agree that we implied that bruits are always