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Introduction Creation of gastrointestinal stomas is a common colorectal procedure associated with early or late complications, some of which demand advanced technical skills and expertise for optimal management. Case History A 63-year-old male underwent a defunctioning loop colostomy for locally advanced rectal cancer with liver metastasis. Three months later, he had developed a skinfold over his stoma that resulted in a horizontal skin crease traversing through the stoma, causing the stoma to ‘sink’ leading to obliteration of the stomal opening. This scenario led to ineffective attachment of a stoma appliance, resulting in painful peristomal ulcers. After excision of the anterior abdominal wall, assessment of colostomy opening was carried out, followed by closure of the subcutaneous tissues and drain fixation. An elevated colostomy with an adequate functional opening was seen after wound closure. The patient made an uneventful recovery and was discharged home. After 3 weeks, he had a fully opened, normally functioning colostomy and peristomal ulcers were almost healed. Conclusions This case highlights the challenges of stoma management, its related risks, avoidance of delay in chemotherapy, a patient wish for early return to work, and the novel approach we adopted to deal with these issues.

Exposure to environmental odour can result in annoyance, health effects and depreciation of property values. Therefore, many jurisdictions classify odour as an atmospheric pollutant and regulate emissions and/or impacts from odour generating activities at a national, state or municipal level. In this work, a critical review of odour regulations in selected jurisdictions of 28 countries is presented. Individual approaches were identified as: comparing ambient air odour concentration and individual chemicals statistics against impact criteria (maximum impact standard); using fixed and variable separation distances (separation distance standard); maximum emission rate for mixtures of odorants and individual chemical species (maximum emission standard); number of complaints received or annoyance level determined via community surveys (maximum annoyance standard); and requiring use of best available technologies (BAT) to minimize odour emissions (technology standard). The comparison of model-predicted odour concentration statistics against odour impact criteria (OIC) is identified as one of the most common tools used by regulators to evaluate the risk of odour impacts in planning stage assessments and is also used to inform assessment of odour impacts of existing facilities. Special emphasis is given to summarizing OIC (concentration percentile and threshold) and the manner in which they are applied. The way short term odour peak to model time-step mean (peak-to-mean) effects is also captured. Furthermore, the fundamentals of odorant properties, dimensions of nuisance odour, odour sampling and analysis methods and dispersion modelling guidance are provided. Common elements of mature and effective odour regulation frameworks are identified and an integrated multi-tool strategy is recommended.

Background Evidence of significant variations in clinical biochemistry practice in Wales led to the formation of the All Wales Clinical Biochemistry Audit Group (AWCBAG) in 1993, with the aim of auditing laboratory services to ensure that they are optimally used. As part of this process, clinical guidelines are produced and circulated to all clinical biochemistry departments in Wales. The current aim of the AWCBAG is to assess the extent and impact of adoption of these guidelines across Wales. Methods Three surveys were despatched at intervals over a decade to all clinical biochemistry departments in Wales to investigate practice in: (1) urine albumin testing to screen for diabetic nephropathy; (2) biochemical investigation of menopausal status and the monitoring of hormone replacement therapy; (3) screening for Cushing's syndrome. Results The results show that laboratories across Wales are generally following guideline criteria and are adapting their practice in-line with changing recommendations. Conclusion The introduction of AWCBAG guidelines has been widely accepted by clinical biochemistry departments in Wales. These guidelines have led to a more efficient and effective use of laboratory services.

Investigations of the equine peripheral vascular system have been constrained by the lack of a non-invasive method of examining the arteries and veins of the limbs of the conscious horse. Precise correlations were established between the gross anatomical features of the peripheral vessels and their B-mode sonographic appearance in each thoracic limb of 35 horses. A sonographic imaging protocol was established. Additional Doppler sonographic recordings defined the arterial waveforms and demonstrated that blood flow to the foot could be evaluated in the lateral proper digital artery, distal to the level of the coronary band. Valves (with 2-4 cusps) were identified in the lumina of the medial and lateral palmar common digital veins and those of the medial and lateral palmar proper digital veins. Spontaneous echo contrast, a smoke-like haze of echoic blood, was seen in the lateral and medial palmar common digital veins, the distal deep palmar venous arch and communicating branches, and the palmar proper digital veins, and occasionally seen in the distal deep palmar arterial arch and distal proper palmar digital arteries. The value of duplex sonography (B-mode and Doppler) for anatomical and physiological studies of the peripheral vasculature of the horse was clearly established. Such data could be applied to the investigation of diseases affecting the peripheral circulation.

Quasi-three-dimensional volume imaging provides an inexpensive means of evaluating the usefulness of three-dimensional imaging. The technique works most efficiently with water-skin interfaces and therefore we investigated its application in obstetrical ultrasonography. Three-dimensional perspectives of the normal and abnormal fetal head and face were spectacular and at times provided more information than the two-dimensional images. The ability of an inexperienced observer to interpret the three-dimensional image more easily may have a role in training sonographers and counseling parents whose fetuses have structural defects. Volume imaging has certain limitations and can only be used as a complementary technique.

A commercial method for N-acetyl-β-glucosaminidase (NAG) is described for use on a discrete analyser. Timed overnight urine was obtained from 20 healthy volunteers and 60 Type I diabetic patients for estimation of NAG (expressed in relation to creatinine) and albumin excretion rate (AER). The upper reference limit for NAG excretion in the control patients was found to be 0·25 U/mmol creatinine but was abnormally raised in 60% of Type I diabetic patients before any increase in AER (greater than 20 μg/min), and in 82% of patients with AER greater than 200 μg/min. A positive correlation was found between NAG excretion and AER in Type I diabetes ( r = 0·61, p < 0·01), but not with glycaemic control as measured by serum fructosamine levels. We conclude that measurement of NAG excretion in diabetes indicates renal tubular dysfunction or damage before any significant change in albumin excretion rate.

Real-time three-dimensional views of the fetus can be obtained with minor modification to conventional scanners. The modification consists of placing a divergent lens in the out-of-scan plane of the transducer to generate a beam fan-beam in the insonated volume. All of the echoes from which insonates a volume rather than a slice of tissue. Scanning is performed using oblique angles of incidence to provide total reflection conditions. Echoes are then received only from anterior surfaces, automatically generating the three-dimensional views. Intriguing portrayal of fetal detail can be obtained with this form of imaging which is likely to expand the clinical utility of sonographic examinations. Copyright © 1994 International Society of Ultrasound in Obstetrics and Gynecology

In transvaginal scanning the tissues intervening between the fetus and transducer are relatively thin. The average thickness in the first trimester is 25 mm and reduces to 15 mm by the third trimester; the minimum thicknesses are 14 and 8 mm, respectively. Two models are proposed for calculating exposure in transvaginal scanning. The models are considered in terms of the overlying tissues and the target tissues. A fixed path, constant attenuation of 0.3 dB/MHz describes the properties of the overlying tissues throughout pregnancy. In the model used in first-trimester scanning, the target tissues of the embryo/fetus are considered to have properties similar to those of soft tissues, and they attenuate the energy at the same rate as the overlying tissues. In the model used in second- and third-trimester scanning, the bony structures of the fetus are the target tissues. These reflect 30% of the incident energy and attenuate all of the transmitted energy at their surface.

Several studies have suggested that dietary protein quality may be an important determinant in the natural history of renal disease. We have therefore studied the effects of a predominantly vegetarian diet in eight patients with Type 1 diabetes mellitus and an albumin excretion rate (AER) in excess of 30 micrograms min-1. The AER was measured after an 8-week run-in period on the patient's usual diet, and again after 8 weeks of a predominantly vegetarian diet in which the proportion of vegetable protein was supplemented in order to minimize the reduction in total dietary protein intake. The median fractional albumin clearance fell during the study from an initial value of 188 x 10(-+) (range 58-810 x 10(-4)) at the end of the run-in period to 87 x 10(-4) (23-829 x 10(-4)) at the end of the period on low animal protein diet (difference 79 x 10(-4) (95% Cl 9-149 x 10(-4)), p less than 0.05). The AER then returned to values similar to those obtained at the beginning of the study after a further 8 weeks in those patients returning to their usual diet. No significant changes in blood glucose control or in arterial pressure were observed. A predominantly vegetarian diet may therefore have important beneficial effects on diabetic nephropathy without the need for a heavily restricted total protein intake.

Transvaginal images, under matched conditions, are in general superior in quality to transabdominal sonograms. The difference is, however, not dramatic and instances frequently occur when the same quality and even inferior images are obtained on transvaginal examinations. The dominant factor is the amount of overlying tissues. For the same thickness, subcutaneous tissues have greater degrading characteristics. Subcutaneous tissues also mar the quality of images by giving rise to strong multiple reflection artifacts. The major factors for image degradation are associated with a moderate increase in the width of the ultrasonic beam and a large increase in the side lobes. The dramatic superiority of transvaginal imaging described in previous comparison studies is due principally to the use of higher frequencies, more strongly focused beams and closer positioning of tissues to the transducer. Copyright © 1991 International Society of Ultrasound in Obstetrics and Gynecology

We compared axillary, rectal and tympanic temperatures in children admitted with severe malaria. The axillary temperatures were 0.74 degrees C (95% limits of agreement -0.85 to 2.33 degrees C) less than rectal temperatures and tympanic temperatures 0.42 degrees C (95% limits of agreement -0.16 to 2.44 degrees C) less than rectal temperatures. The difference was greater on admission than 24 hours later. These differences may be important in defining criteria for clinical syndromes.

In ultrasonic volume imaging, the effect of rotating the transducer about the central axis of the imaging plane is equivalent to rotation of the insonified volume. The authors present schematics to depict the action and sonograms in two cases (a hand immersed in water and a 36-week fetus) to demonstrate this phenomenon. This maneuver can be used to "rotate" the imaged structures, which enhances their three-dimensional representation.

In six normal adult horses, pulsed-wave Doppler sonographic inspections were made of the left and right lateral palmar proper digital artery (LPPDA) of each thoracic limb. Using a two-period, crossover design with repeated measures, each LPPDA was inspected on four occasions throughout the day over a 7 hour period and, on each occasion, with the limb weight bearing and non-weight bearing. In comparison with the observations made during weight bearing, there were significant increases (P

Pompholyx is a form of acute dermatitis localised to the palms and soles, presenting as an itchy eruption with vesicles that can amount to bullae if severe. Chronic dermatitis may be hyperkeratotic, and secondary skin changes include uncomfortable desquamation, painful fissuring, and secondary infection. The functional consequences of chronic, severe palmoplantar dermatitis can be debilitating, with difficulty in walking or in using the hands. The mainstays of treatment are topical corticosteroids or preparations containing corticosteroids plus antimicrobials, with or without an occlusive dressing to aid penetration, but the response to treatment can be unpredictable and only partially successful. Second line treatments such as systemic corticosteroids, psoralen-UVA photochemotherapy, or ciclosporin have occasionally to be considered. Azathioprine is a mercaptopurine immunosuppressive drug used widely across many medical specialties, probably most often as a steroid sparing agent. It is not often used as the sole treatment for pompholyx, but excellent responses have been described.1 The main problem with azathioprine is acute myelotoxicity manifesting as pancytopenia. Advances in the understanding of azathioprine metabolism have been made over recent years, and it is now known that the risk of acute myelotoxicity can be obviated by measuring, before treatment, the enzyme responsible for inactivating azathioprine (thiopurine methyltransferase (TPMT)). Publications on the measurement of erythrocyte TPMT activity first appeared as long ago as 1978 and on mercaptopurine pharmacogenetics in 1980.2 3 Others have since drawn attention to the importance of this in clinical practice,4–8 and prior measurement of TPMT activity is now recognised as best practice in several authoritative guidelines in dermatology. …

To correct distortion in ultrasonic images caused by refraction at fat-muscle interfaces in the subcutaneous tissues.A forward-propagation technique was developed that used a priori information of the acoustic properties of the layers. The thickness and shape of these tissues were measured, and a correction was applied for the different velocities in the tissues. A synthetic-aperture scanning technique was used to allow correction to be applied with data obtained in a single scan. The technique was tested in three tissue phantoms with overlying aberrating layers (six images) and in eight volunteer subjects (37 images). The superior mesenteric artery and the aorta were used as test sites within the body, because it is relatively easy to obtain double images of these vessels owing to refraction of the scanning beam by the rectus muscles.Distortions such as double-image artifacts and texture disruption were corrected with use of this technique. Six of the six phantom images and 22 of the 37 images in humans were corrected with use of this technique.The forward-propagation technique compensates for refraction at subcutaneous fat-muscle interfaces.

Aims (1) To identify the yield of aetiological medical investigations in neonates confirmed to have permanent unilateral hearing loss (UHL) following detection by the newborn hearing screening, (2) To identify the association between aetiological medical investigations, risk factors for deafness, audiological profile and stability of hearing loss. Method This was a 14-year retrospective case-note study of 59 newborns with permanent UHL confirmed by Auditory Brainstem Response test performed at a tertiary Paediatric Audiovestibular Medicine Department following referral by newborn hearing screening. The associations between the aetiological medical investigations, risk factors for deafness and audiological profile were analysed using χ 2 statistics. Results High yields were obtained with MRI of internal auditory meati and with CT of the petrous temporal bones (75% and 80%, respectively). Investigation of congenital Cytomegalovirus infection gave a yield of 22%. Significant associations were found between the presence of physical examination signs and a positive CT finding (p=0.005) and the type of UHL (p=0.004). Degree of UHL had a strong association with a positive MRI result (p Conclusion We recommend prioritising imaging studies (MRI and/or CT) and investigation of congenital Cytomegalovirus infection in newborns confirmed with UHL. The results highlight the importance of a comprehensive physical examination as it will guide the medical investigation protocol, especially imaging studies. Those newborns confirmed with congenital Cytomegalovirus infection will benefit from longitudinal follow-up to detect progression of hearing loss. Future research with a larger sample is required for further recommendations.

Summary A 30 year old male patient with thyrotoxic crisis presenting as status epilepticus is reported. The aetiology, manifestations and management of this medical emergency are discussed. The importance of prompt, vigorous and comprehensive treatment of thyrotoxic crisis is emphasized. Rapid control of hyperthyroidism as well as other supportive measures are essential if the high fatality rate is to be reduced. Comprehensive management reduces mortality from 90% to 20%.

Summary. The waveforms of vessels supplying the ovaries of women on an in-vitro fertilization (IVF) programme were studied using transvaginal B-mode and Doppler ultrasound. There were 125 scans recorded in 65 women at weekly intervals from 3 days after embryo transfer or 5 days after gamete intrafallopian transfer (GIFT) until confirmation of pregnancy or onset of menses. At each examination the signals obtained from vessels supplying the ovaries were recorded and quantified using a resistance index (RI). Fifteen patients became pregnant of whom one has subsequently miscarried. There was a highly significant difference in the RI values between patients who became pregnant and those who did not; no patient who became pregnant had a RI greater than 0.5. Oestrogen to progesterone ratios were calculated in the subgroup of non-pregnant patients and there was no correlation between these values and the RI values. This new technique enables prediction of IVF treatment failure earlier than has been reported previously and may reflect the inadequacy of the corpus luteum.

Neonatal screening for congenital hypothyroidism was introduced in the City of Birmingham in 1980 by measuring concentrations of both thyroid stimulating hormone and thyroxine in plasma. Over two years 30 108 babies were tested. Thirty one babies were recalled because of thyroid stimulating hormone concentrations greater than 40 mU/l, of whom 12 were treated with replacement thyroxine. Six babies were found to have low thyroxine concentrations because of reduced thyroxine binding globulin and five raised thyroxine values because of increased thyroxine binding globulin. As a result of this study screening was continued with measurement of thyroid stimulating hormone only as the primary test for congenital hypothyroidism, the thyroxine value being measured only when the concentration of thyroid stimulating hormone exceeded 20 mU/l.

Fourteen children with salt losing and five children with non-salt losing congenital adrenal hyperplasia were studied. Venous samples were collected for measurement of plasma renin activity, serum 17 alpha-hydroxyprogesterone, testosterone, sodium, and creatinine. Overnight urinary sodium and creatinine excretions were measured after collection on an outpatient basis. Eight 'salt losers' had a raised plasma renin activity despite mineralocorticoid treatment, as did one 'non-salt loser'. Six of the children in whom clinical and biochemical control was inadequate, including the 'non-salt loser', had an increase in the dose of fludrocortisone. When the investigations were repeated one month later, a fall in plasma renin activity accompanied by a fall in 17 alpha-hydroxyprogesterone in all but one patient were found. The dose of mineralocorticoid may be as critical as the dose of glucocorticoid in the management of congenital adrenal hyperplasia, and regular determination of plasma renin activity should be made, particularly if clinical control is difficult.

There are many different flaps available for head and neck reconstruction. The latissimus dorsi myocutaneous flap has been widely used in this unit on 80 occasions in the past three years, both as a pedicled and as a free microvascular flap following the excision of head and neck malignancy, the commonest pathology being intraoral squamous cell carcinoma.There were nine cases of complete or substantial flap loss requiring a further reconstructive procedure. Few of the patients who underwent total glossectomy suffered from overspill or aspiration and the fistula rate was low.Reference is made to the anatomy and the technique of raising this versatile flap which provides a large volume of tissue and has been particularly useful following total glossesctomy when combined with a hyoid hitch.

The first North American collection of the European pine sawfly, Neodiprion sertifer (Geoff.), was made in Somerset County, New Jersey, in 1925 (Hamilton, 1943). It was first recorded in Canada near Windsor, Ontario, in 1939 (Raizenne, 1957), and by 1946 it had spread as far east as London (Watson, 1946). This serious pest of pines has continued to spread, and is now found throughout most of southwestern Ontario (Fig. 1) (Sippell and MacDonald, 1958). This is the only infestation of this species in Canada.

An abnormal haemoglobin, which on paper electrophoresis has the mobility of Hb J, has been found in two brothers and, in the heterozygous state at least, is not associated with serious clinical abnormality. The structure of this hitherto unreported haemoglobin is α 120 (H3) Ala → Glu and it is named Haemoglobin J Birmingham.

L-Glyceric aciduria (primary hyperoxaluria type 2; McKusick 26000) was originally reported in four patients, three of whom were siblings, by Williams and Smith (1968), the disease being characterized by oxalate renal calculi with haematuria (Williams and Smith, 1968; Dent and Stamp, 1970). The disorder is distinguished from primary hyperoxaluria’ type 1’ (glycollic aciduria) by the greatly increased excretion of L-glycerate into the urine in addition to raised oxalate excretion, with normal glycollate excretion (Chalmers and Lawson, 1982). It occurs because of deficient activity of D-glycerate dehydrogenase (EC 1.1.1.29) (Williams and Smith, 1968). Since the original report no further cases have occurred in the literature suggesting, by comparison with the more than 150 cases of the type 1 form (glycollic aciduria), that this form of primary hyperoxaluria is very rare. We present here a report of four previously-unidentified cases in two unrelated families, suggesting that the type 2 disorder may be more common and indicating the need for careful classification of patients with hyperoxaluria.

A form of range ambiguity in Doppler ultrasound has been identified. It occurs when a high pulse repetition frequency (prf) is used with a superficial range gate. "Phantom" range gates are then generated at depths beyond the desired range gate, and these may produce artifactual signals. Extremely high prf values should not normally be used, and duplex machines should be programmed to display phantom range gates wherever they fall within the displayed field of view.

During 1978-81 there were about 43,500 births in Birmingham, of which 10.3% were to Negroes and 22.6% to Asians. Cellulose acetate electrophoresis of red cell haemolysates from capillary specimens collected for phenylketonuria screening was performed for these babies to assess the feasibility, cost, and benefits of detecting sickle haemoglobinopathies early. Eight babies had important haemoglobinopathies; four were homozygotes for haemoglobin S (HbS), three were mixed heterozygotes for HbS and haemoglobin C (HbC), and one had haemoglobin E (HbE) and beta-thalassemia. Also, 534 (1.19%) were heterozygotes for HbS or haemoglobin D (HbD) and 205 (0.46%) for HbC or HbE, 453 (1.01%) were heterozygotes with a fast-moving band, one was a heterozygote for haemoglobin Norfolk, and one a heterozygote for both HbS and haemoglobin G Philadelphia. The cost of neonatal screening for haemoglobinopathies was 12.5 p per baby (705 pounds for each serious abnormality).