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Patients who present with symptomatic, clinically occult, radiologically evident (SCORE) inguinal hernia represent diagnostic and therapeutic challenge with a wide differential diagnosis of groin pain. Often, diagnosis leads to surgical intervention despite the lack of evidence supporting this practice. This study evaluates patient-reported outcomes following surgical or conservative management of SCORE inguinal hernia. Single-centre retrospective review of radiology database and general surgery outpatient booking system between 2017 and 2018 to identify SCORE hernia patients. Notes review to identify surgical and conservative management groups. Patient-reported outcomes determined using the validated EuraHS-QOL tool. Surveys sent to patients via post with follow-up telephone conversations between October 2019 and June 2020. Replies from the conservative and operative cohorts were compared. Total of 76 patients identified. 63 (83%) replies received and analysed (10 did not answer, 2 declined, 1 deceased). 32 in the surgical cohort and 31 in conservative management cohort. No statistically significant difference was there between cohorts in age, BMI, ASA, Charlson Comorbidity Index. No statistically significant difference was there in pain at the site of hernia (p = 0.535); restrictions of activities (p = 0.406); cosmetic discomfort (p = 0.289) in patient-reported outcomes between surgical and conservative cohorts. There is no difference in pain, restriction to function or cosmesis in symptomatic clinically occult, radiologically evident inguinal hernia patients following either surgical or conservative management. A clear definition and further studies are essential to deliver better care for this population of patients.

Background & aims: Siblings of people with Crohn's disease (CD) share aspects of the disease phenotype (raised faecal calprotectin, altered microbiota), which are markers of risk for their own development of CD. The aim was to determine whether supplementation with prebiotic oligofructose/inulin induces a prebiotic response and impacts the risk phenotype in CD patients and siblings. Methods: Patients with inactive CD (n = 19, CD activity index 50 μg/g) ingested oligofructose/inulin (15 g/day) for three weeks. Faecal microbiota (qPCR), intestinal permeability (lactulose-rhamnose test), blood T cells (flow-cytometry) and calprotectin (ELISA) were measured at baseline and follow-up. Results: Following oligofructose/inulin, calprotectin did not significantly change in patients (baseline mean 537 SD 535 μg/g; follow-up mean 974 SD 1318 μg/g, p = 0.08) or siblings (baseline mean 73 SD 90 μg/g: follow up mean 58 SD 72 μg/g, p = 0.62). Faecal Bifidobacteria and Bifidobacterium longum increased in patients and siblings; Bifidobacterium adolescentis and Roseburia spp. increased only in siblings. Compared with patients, siblings had a greater magnitude change in Bifidobacteria (+14.6% vs +0.4%, p = 0.028), B. adolescentis (+1.1% vs 0.0% p = 0.006) and Roseburia spp. (+1.5% vs −0.1% p = 0.004). Intestinal permeability decreased significantly in patients after oligofructose/inulin to a level that was similar to siblings. Blood T cell abundance reduced in siblings but not patients following oligofructose/inulin. Conclusions: Oligofructose/inulin supplementation did not significantly impact calprotectin, but the prebiotic effect was more marked in healthy siblings compared with patients with inactive CD and was associated with alterations in other CD risk markers. Future research should focus on dietary intervention, including with prebiotics, in the primary prevention of CD.

Throughout 2020, countries worldwide introduced various restrictions and measures to control the COVID-19 pandemic. These restrictions were unprecedented and included limitations on social gatherings and reasons for leaving home. Some studies reported a reduction in STI diagnoses and sexual activities during the COVID-19 pandemic.1–6 Healthcare-seeking behaviour—how and when people seek healthcare—likely also changed due to COVID-19. Individuals may have delayed or forgone sexual health service attendance due to barriers such as fear of exposure to COVID-19 at healthcare clinics.7 8 If this is the case, STI diagnoses may have been delayed or missed, leading to potential increased transmission and negative health sequelae. Victoria is the only Australian state that underwent two significant lockdowns in 2020. The first lockdown occurred from late March to early May 2020, with restrictions on social gatherings, closure of non-essential businesses and a stay-at-home order. The second lockdown occurred in Melbourne from early July to late October 2020, with the strictest restrictions including a curfew from 20:00 to 05:00, limited daily outdoor exercise, mandatory face masks in public and allowance to travel no further than 5 km from one’s home except where essential. Medical …

Introduction Older patients undergoing cancer surgery are at increased risk of post-operative morbidity and mortality. Frailty is particularly prevalent in this patient cohort and is a major contributor to adverse outcomes. A survey was conducted to assess the confidence and knowledge of trainees in obstetrics and gynaecology (O&G) regarding identification and management of perioperative issues encountered in frail gynaecological oncology patients. Methods A web-based survey on the management of frail perioperative patients was disseminated to doctors-in-training (trainees) in O& G in the United Kingdom (UK) and Ireland. Results Of the 666 trainees who participated, 67% (n=425/666) reported inadequate training in the perioperative management of frail patients. Validated frailty assessment tools were used by only 9% (n=59/638) of trainees and less than 1% (n=4/613) were able to correctly identify the diagnostic features of frailty. Common misconceptions included the use of chronological age and gender in frailty assessments. The majority trainees (>75%) correctly answered a series of questions relating to mental capacity; however, only 6% (n=36/606) were able to correctly identify all three diagnostic features of delirium. 87% (n=495/571) of trainees supported closer collaboration with geriatricians and a multi-disciplinary approach. Conclusions O&G trainees reported inadequate training in the perioperative care of frail gynaecological oncology patients, and overwhelmingly favoured input from geriatricians. Routine use of validated frailty assessment tools may aid diagnosis of frailty in the perioperative setting. There is an unmet need for formal education in the management of frail surgical patients within the UK and Irish O&G curriculum.

Technologies are needed to address contamination with energetic compounds at military installations. This research developed and evaluated novel and sustainable materials that can be used to remove munition constituents (MC) from stormwater runoff. Initial work focused on 3-nitro-1,2,4-triazol-5-one (NTO), as it is both highly soluble and ionized at environmentally relevant pH values. Screening cellulosic materials indicated that cationized (CAT) versions of pine shavings (pine, henceforth) and burlap (jute) demonstrated >70% removal of NTO from artificial surface runoff. CAT materials also demonstrated >90% removal of the anionic propellant perchlorate. NTO removal (~80%) by CAT pine was similar across initial pH values from 4 to 8.5 S.U. An inverse relationship was observed between NTO removal and the concentration of the major anions chloride, nitrate, and sulfate due to competition for anion binding sites. Sorption isotherms were performed using a mixture of the three primary legacy explosives (octahydro-1,3,5,7-tetranitro-1,3,5,7-tetrazocine (HMX), hexahydro-1,3,5-trinitro-s-triazine (RDX), 2,4,6-trinitrotoluene (TNT)), the three insensitive MC (nitroguanidine (NQ), NTO, 2,4-dinitroanisole (DNAN)), and perchlorate. Isotherm results indicated that effective removal of both legacy and insensitive MC would best be achieved using a mixture of peat moss plus one or more of the cationized cellulosic materials.

Background & Aims: Dietary restriction of fermentable carbohydrates (a low FODMAP diet) has been reported to reduce symptoms in some patients with irritable bowel syndrome (IBS). We performed a randomized, placebo-controlled study to determine its effects on symptoms and the fecal microbiota in patients with IBS. Methods: We performed a 2x2 factorial trial of 104 patients with IBS (18–65 years old), based on the Rome III criteria, at 2 hospitals in the United Kingdom. Patients were randomly assigned (blinded) to groups given counselling to follow a sham diet or diet low in FODMAPs for 4 weeks, along with a placebo or multistrain probiotic formulation, resulting in 4 groups (27 receiving sham diet/placebo, 26 receiving sham diet/probiotic, 24 receiving low FODMAP diet /placebo, and 27 receiving low FODMAP diet /probiotic). The sham diet restricted a similar number of staple and non-staple foods as the low FODMAP diet; the diets had similar degrees of difficulty to follow. Dietary counselling was given to patients in all groups and data on foods eaten and compliance were collected. The incidence and severity of 15 gastrointestinal symptoms and overall symptoms were measured daily for 7 days before the study period; along with stool frequency and consistency. At baseline, global and individual symptoms were measured, along with generic and disease-specific health-related quality of life, using standard scoring systems. All data were collected again at 4 weeks, and patients answered questions about adequate symptom relief. Fecal samples were collected at baseline and after 4 weeks and analyzed by quantitative PCR and 16S rRNA sequencing. The co-primary endpoints were adequate relief of symptoms and stool Bifidobacterium species abundance at 4 weeks. Results: There was no significant interaction between the interventions in adequate relief of symptoms (P=.52) or Bifidobacterium species (P=.68). In the intention-to-treat analysis, a higher proportion of patients in the low FODMAP diet had adequate symptom relief (57%) vs than in the sham diet group (38%), although the difference was not statistically significant (P=.051). In the per-protocol analysis, a significantly higher proportion of patients on the low FODMAP diet had adequate symptom relief (61%) than in the sham diet group (39%) (P=.043). Total mean IBS- Severity Scoring System score was significantly lower for patients on the low FODMAP diet (173±95) than the sham diet (224 ± 89)(P=.001), but not different between those given probiotic (207 ± 98) or placebo (192 ± 93)(P=.721) Abundance of Bifidobacterium species was lower in fecal samples from patients on the low FODMAP diet (8.8 rRNA genes/g) than patients on the sham diet (9.2 rRNA genes/g) (P=.008), but higher in patients given probiotic (9.1 rRNA genes/g) than patients given placebo (8.8 rRNA genes/g) (P=.019). There was no effect of the low FODMAP diet on microbiota diversity in fecal samples. Conclusions: In a placebo-controlled study of patients with IBS, a low FODMAP diet associates with adequate symptom relief and significantly reduced symptom scores compared with placebo. It is not clear whether changes resulted from collective FODMAP restriction or removal of a single component, such as lactose. Co-administration of the multistrain probiotic formulation increased numbers of Bifidobacterium species, compared with placebo, and might be given to restore these bacteria to patients on a low FODMAP diet. Trial registration no: ISRCTN02275221.

Growing up on a farm is associated with an asthma-protective effect, but the mechanisms underlying this effect are largely unknown. In the Protection against Allergy: Study in Rural Environments (PASTURE) birth cohort, we modeled maturation using 16S rRNA sequence data of the human gut microbiome in infants from 2 to 12 months of age. The estimated microbiome age (EMA) in 12-month-old infants was associated with previous farm exposure (beta = 0.27 (0.12-0.43), P = 0.001, n = 618) and reduced risk of asthma at school age (odds ratio (OR) = 0.72 (0.56-0.93), P = 0.011). EMA mediated the protective farm effect by 19%. In a nested case-control sample (n = 138), we found inverse associations of asthma with the measured level of fecal butyrate (OR = 0.28 (0.09-0.91), P = 0.034), bacterial taxa that predict butyrate production (OR = 0.38 (0.17-0.84), P = 0.017) and the relative abundance of the gene encoding butyryl-coenzyme A (CoA):acetate-CoA-transferase, a major enzyme in butyrate metabolism (OR = 0.43 (0.19-0.97), P = 0.042). The gut microbiome may contribute to asthma protection through metabolites, supporting the concept of a gut-lung axis in humans.Growing up in the rich microbial environment of a farm strongly influences the maturation of the gut microbiome in the first year of life, which helps protect against the development of asthma in children.

This study investigated the effect of a three week supplementation of bilberry extract on glucose metabolism. Overweight volunteers (n = 16; BMI 31) were given three capsules of either 0.47 g bilberry extract (36% (w/w) anthocyanins) or placebo per day for three weeks in a double blinded cross over intervention.The ingestion of the bilberry extract decreased the OGTT AUCi for glucose (20%; p = 0.008) but not for insulin compared with the placebo. There was no change in anti-inflammatory markers (hsCRP, MCP-1, leptin), vascular health markers (Apo A1, sVCAM-1, sICAM-1), reducing potential/ radical scavenging capacity or faecal bacterial microbiota. In vitro studies showed that the bilberry extract decreased α-amylase activity (p

Dietary fibers (DF) can prevent obesity in rodents fed a high-fat diet (HFD). Their mode of action is not fully elucidated, but the gut microbiota have been implicated. This study aimed to identify the effects of seven dietary fibers (barley beta-glucan, apple pectin, inulin, inulin acetate ester, inulin propionate ester, inulin butyrate ester or a combination of inulin propionate ester and inulin butyrate ester) effective in preventing diet-induced obesity and links to differences in cecal bacteria and host gene expression. Mice (n = 12) were fed either a low-fat diet (LFD), HFD or a HFD supplemented with the DFs, barley beta-glucan, apple pectin, inulin, inulin acetate ester, inulin propionate ester, inulin butyrate ester or a combination of inulin propionate ester and inulin butyrate ester for 8 weeks. Cecal bacteria were determined by Illumina MiSeq sequencing of 16S rRNA gene amplicons. Host responses, body composition, metabolic markers and gene transcription (cecum and liver) were assessed post intervention. HFD mice showed increased adiposity, while all of the DFs prevented weight gain. DF specific differences in cecal bacteria were observed. Results indicate that diverse DFs prevent weight gain on a HFD, despite giving rise to different cecal bacteria profiles. Conversely, common host responses to dietary fiber observed are predicted to be important in improving barrier function and genome stability in the gut, maintaining energy homeostasis and reducing HFD induced inflammatory responses in the liver.

Mycotoxin contamination of cereal grains causes well-recognized toxicities in animals and humans, but the fate of plant-bound masked mycotoxins in the gut is less well understood. Masked mycotoxins have been found to be stable under conditions prevailing in the small intestine but are rapidly hydrolyzed by fecal microbiota. This study aims to assess the hydrolysis of the masked mycotoxin deoxynivalenol-3-glucoside (DON3Glc) by the microbiota of different regions of the porcine intestinal tract. Intestinal digesta samples were collected from the jejunum, ileum, cecum, colon, and feces of 5 pigs and immediately frozen under anaerobic conditions. Sample slurries were prepared in M2 culture medium, spiked with DON3Glc or free deoxynivalenol (DON; 2 nmol/ml), and incubated anaerobically for up to 72 h. Mycotoxin concentrations were determined using liquid chromatography-tandem mass spectrometry, and the microbiota composition was determined using a quantitative PCR methodology. The jejunal microbiota hydrolyzed DON3Glc very slowly, while samples from the ileum, cecum, colon, and feces rapidly and efficiently hydrolyzed DON3Glc. No further metabolism of DON was observed in any sample. The microbial load and microbiota composition in the ileum were significantly different from those in the distal intestinal regions, whereas those in the cecum, colon and feces did not differ. IMPORTANCE Results from this study clearly demonstrate that the masked mycotoxin DON3Glc is hydrolyzed efficiently in the distal small intestine and large intestine of pigs. Once DON is released, toxicity and absorption in the distal intestinal tract likely occur in vivo . This study further supports the need to include masked metabolites in mycotoxin risk assessments and regulatory actions for feed and food.

There is growing interest in understanding how diet affects the intestinal microbiota, including its possible associations with systemic diseases such as metabolic syndrome. Here we report a comprehensive and deep microbiota analysis of 14 obese males consuming fully controlled diets supplemented with resistant starch (RS) or non-starch polysaccharides (NSPs) and a weight-loss (WL) diet. We analyzed the composition, diversity and dynamics of the fecal microbiota on each dietary regime by phylogenetic microarray and quantitative PCR (qPCR) analysis. In addition, we analyzed fecal short chain fatty acids (SCFAs) as a proxy of colonic fermentation, and indices of insulin sensitivity from blood samples. The diet explained around 10% of the total variance in microbiota composition, which was substantially less than the inter-individual variance. Yet, each of the study diets induced clear and distinct changes in the microbiota. Multiple Ruminococcaceae phylotypes increased on the RS diet, whereas mostly Lachnospiraceae phylotypes increased on the NSP diet. Bifidobacteria decreased significantly on the WL diet. The RS diet decreased the diversity of the microbiota significantly. The total 16S ribosomal RNA gene signal estimated by qPCR correlated positively with the three major SCFAs, while the amount of propionate specifically correlated with the Bacteroidetes. The dietary responsiveness of the individual’s microbiota varied substantially and associated inversely with its diversity, suggesting that individuals can be stratified into responders and non-responders based on the features of their intestinal microbiota.

Background Sequencing-based analysis has become a well-established approach to deciphering the composition of the gut microbiota. However, due to the complexity of accessing sufficient material from colonoscopic biopsy samples, most studies have focused on faecal microbiota analysis, even though it is recognised that differences exist between the microbial composition of colonic biopsies and faecal samples. We determined the suitability of colonic lavage samples to see if it had comparable microbial diversity composition to colonic biopsies as they are without the limitations associated with sample size. We collected paired colonic biopsies and lavage samples from subjects who were attending for colorectal cancer screening colonoscopy. Results Next-generation sequencing and qPCR validation were performed with multiple bioinformatics analyses to determine the composition and predict function of the microbiota. Colonic lavage samples contained significantly higher numbers of operational taxonomic units (OTUs) compared to corresponding biopsy samples, however, diversity and evenness between lavage and biopsy samples were similar. The differences seen were driven by the presence of 12 OTUs which were in higher relative abundance in biopsies and were either not present or in low relative abundance in lavage samples, whilst a further 3 OTUs were present in higher amounts in the lavage samples compared to biopsy samples. However, predicted functional community profiling based on 16S ribosomal ribonucleic acid (rRNA) data indicated minimal differences between sample types. Conclusions We propose that colonic lavage samples provide a relatively accurate representation of biopsy microbiota composition and should be considered where biopsy size is an issue. Electronic supplementary material The online version of this article (doi:10.1186/s40168-016-0207-9) contains supplementary material, which is available to authorized users.

Crohn's disease (CD) is associated with intestinal dysbiosis, altered blood T cell populations, elevated faecal calprotectin (FC) and increased intestinal permeability (IP). CD-associated features present in siblings (increased risk of CD) but not in healthy controls, provide insight into early CD pathogenesis. We aimed to (1) Delineate the genetic, immune and microbiological profile of patients with CD, their siblings and controls and (2) Determine which factors discriminate between groups.Faecal microbiology was analysed by quantitative PCR targeting 16S ribosomal RNA, FC by ELISA, blood T cell phenotype by flow cytometry and IP by differential lactulose-rhamnose absorption in 22 patients with inactive CD, 21 of their healthy siblings and 25 controls. Subject's genotype relative risk was determined by Illumina Immuno BeadChip.Strikingly, siblings shared aspects of intestinal dysbiosis with patients with CD (lower concentrations of Faecalibacterium prausnitzii (p=0.048), Clostridia cluster IV (p=0.003) and Roseburia spp. (p=0.09) compared with controls). As in CD, siblings demonstrated a predominance of memory T cells (p=0.002) and elevated naïve CD4 T cell β7 integrin expression (p=0.01) compared with controls. FC was elevated (50 μg/g) in 8/21 (38%) siblings compared with 2/25 (8%) controls (p=0.028); whereas IP did not differ between siblings and controls. Discriminant function analysis determined that combinations of these factors significantly discriminated between groups (χ(2)=80.4, df=20, p0.001). Siblings were separated from controls by immunological and microbiological variables.Healthy siblings of patients with CD manifest immune and microbiological abnormalities associated with CD distinct from their genotype-related risk and provide an excellent model in which to investigate early CD pathogenesis.

Changes in cross-sectional area are currently used to assess tumour response to treatment. The aims of this study were to validate a helical CT technique for volume determination using a series of phantoms and to compare tumour responses indicated by one-, two- and three-dimensional measures of tumour size change in patients treated for germ cell cancer or lymphoma. All studies were performed on an IGE HiSpeed Advantage helical CT scanner with an Advantage Windows workstation. Phantom volumes were calculated using volume reconstruction software and compared with reference volumes determined by water displacement. 20 lymph node masses were studied on serial CT scans in 16 patients treated with chemotherapy for germ cell cancer or lymphoma. For each lesion the maximum diameter, maximum cross-sectional area and volume were determined before and after treatment. Tumour response was assessed using the standard World Health Organisation criteria (i.e. changes in cross-sectional area) and the newly proposed unidimensional response evaluation criteria in solid tumour (RECIST). The CT volume measurement error was 1.0-5.1% for regularly shaped phantoms larger than 35 cm3. In the assessment of treatment response there was 90% agreement between one-dimensional (1D) and two-dimensional (2D) measurements and 100% agreement between 2D and three-dimensional (3D) measurements. CT volume measurements are accurate and reproducible, particularly for larger structures. Assessment of tumour response using 1D, 2D and 3D measures had limited influence on the classification of treatment response. However, the impact of CT assessment of tumour response using 1D, 2D and 3D measurements on clinical decisions and patient outcome remains to be determined.

Objective To evaluate the use of laparoscopically assisted vaginal hysterectomy (LAVH) by a cross-section of gynaecologists in Scotland. Design A prospective registration of cases of LAVH carried out by gynaecologists. Case-note review was also performed in selected hospitals. Setting 13 hospitals in seven Scottish Health Boards. Subjects Women undergoing an LAVH. Results 505 LAVHs were reported between April 1994 and March 1996. Of these, 463 (91.7%) were successfully carried out laparoscopically. The uptake of laparoscopic surgery in Scotland overall is low, with a handful of surgeons performing the majority of procedures. Patient satisfaction with the procedure was high. Complication rates were high at 18.2% but this was mostly on account of postoperative infection. Only 34% of surgeons had any formal training in laparoscopic techniques, but this had increased to 55% by the end of the audit. Conclusions Complication rates in the present study were higher than those reported by expert laparoscopic surgeons, but perhaps reflect more accurately those expected from a cross-section of gynaecologists in current practice.

Objective To evaluate the use of laparoscopic procedures in the treatment of ectopic pregnancies by a cross-section of gynaecologists in Scotland Design A prospective registration of cases of laparoscopically treated ectopic pregnancy by gynaecologists. Case-note review was also performed in selected hospitals. Setting 13 hospitals in seven Scottish Health Board areas. Subjects Women having laparoscopic treatment of ectopic pregnancy. Results Between April 1994 and March 1996, 85 ectopic pregnancies were treated laparoscopically. Contraindications for laparoscopic surgery were most commonly size of the ectopic gestation (53%), presence of intraperitoneal bleeding (42%) and tubal rupture (44%). Salpingotomy was performed in 16% overall with only 86% of consultants monitoring serial human chorionic gonadotrophin levels. Conclusions Laparoscopic treatment of ectopic pregnancies in Scotland is infrequent. Lack of availability of adequate equipment and trained staff was often quoted as the reason preventing surgeons from developing their skills in these techniques. Complication rates were low and patient satisfaction high.

A 36-year-old women presented as an emergency to our gynaecology ward for assessment of lower abdominal pain and heavy vaginal bleeding having had three positive home pregnancy tests. She did not w...

Two cases are described of patients who presented with a buttock abscess 3 and 5 years after restorative proctocolectomy for ulcerative colitis. In both the abscess was secondary to a fistula, which was shown on further investigation to be a track traversing the greater sciatic notch. Both patients had had an ileo-anal J-pouch after a proctectomy which had included a mesorectal excision. The possibility that these unusual fistulae might be more common following removal of the mesorectum rather than a close rectal dissection is explored.

BackgroundAppendiceal neoplasms are rare and most present unexpectedly as acute appendicitis. The classification and management are confusing, and there are few substantial reports in the literature.MethodsA systematic literature review was performed to access relevant publications on the presentation, pathology and management of appendiceal tumours.ResultsAppendiceal tumours account for 0·4 to 1 per cent of all gastrointestinal tract malignancies and are found in 0·7 to 1·7 per cent of appendicectomy specimens. Carcinoid tumours are most common. Most are cured by simple appendicectomy if the tumour is less than 2 cm in size and does not involve the resection margin or mesoappendix. Epithelial tumours may present with, or in time develop, pseudomyxoma peritonei, the optimal management of which involves complete tumour resection and intraperitoneal chemotherapy, usually available only in specialized centres.ConclusionSuggested algorithms for the management of unexpected appendiceal tumours are provided. Recommendations are made for follow-up of patients with a perforated appendiceal epithelial tumour.

In July 1999, the Swinfen Charitable Trust in the UK established a telemedicine link in Bangladesh, between the Centre for the Rehabilitation of the Paralysed (CRP) in Dhaka and medical consultants abroad. This low-cost telemedicine system used a digital camera to capture still images, which were then transmitted by email. During the first 12 months, 27 telemedicine referrals were made. The following specialties were consulted: neurology (44%), orthopaedics (40%), rheumatology (8%), nephrology (4%) and paediatrics (4%). Initial email replies were received at the CRP within a day of referral in 70% of cases and within thee days in 100%, which shows that store-and-forward telemedicine can be both fast and reliable. Telemedicine consultation was complete within three days in 14 cases (52%) and within three weeks in 24 cases (89%). Referral was judged to be beneficial in 24 cases (89%), the benefits including establishment of the diagnosis, the provision of reassurance to the patient and referring doctor, and a change of management. Four patients (15% of the total) and their families were spared the considerable expense and unnecessary stress of travelling abroad for a second opinion, and the savings from this alone outweighed the set-up and running costs in Bangladesh. The latter are limited to an email account with an Internet service provider and the local-rate telephone call charges from the CRP. This successful telemedicine system is a model for further telemedicine projects in the developing world.

Introduction Crohn’s disease (CD) is associated with genetic risk, intestinal dysbiosis, altered blood T-cell phenotype, increased faecal calprotectin (FC) and intestinal permeability (IP). Factors shared by CD patients and unaffected siblings may be implicated in CD pathogenesis. Aims Delineate the genetic, immune and microbial phenotype of patients, siblings and healthy controls (HC); identify factors associated with CD that discriminate siblings from HC. Methods Faecal microbiota, FC, blood T-cell phenotype, IP and genotype risk over 72 CD risk loci, were measured by qPCR, ELISA, flow cytometry, sugar permeability and Illumina Bead Array respectively, in 22 patients with inactive CD, 21 of their healthy siblings and 25 HC. Results In addition to genotype risk, siblings shared aspects of the phenotype of CD patients, distinct from HC, as previously reported.1 Direct discriminant function analysis revealed that the variables maximally separating siblings from HC (Function 2) were: increased β7 integrin expression by circulating naive CD4+ T-cells and an increased proportion of memory CD4+ T-cells as well as reduced faecal Roseburia spp. (Image 1). In contrast, the variables differentiating CD patients from HC (Function 1) were: elevated FC and altered faecal microbiota (reduced Faecalibacterium prausnitzii , Cluster IV Ruminococcus spp. Bacteroides-Prevotella and Clostridial cluster IV). Conclusion Healthy siblings of CD patients manifest immune and microbiological abnormalities associated with CD, distinct from their genetic risk. Unaffected siblings of CD patients are an excellent model in which to investigate early CD pathogenesis. Disclosure of Interest None Declared Reference Hedin et al. Gut 2012; 61: Suppl. 2 A22-A23.

Introduction The gut microbiota plays a key role in Inflammatory Bowel Disease (IBD) pathogenesis and is also involved in colorectal neoplastic progression. In particular, the “dysbiosis” theory has evolved from work which has shown IBD sufferers to have different microbiologic profiles to normal controls. There is strong evidence to demonstrate that individuals harbour a unique microbiota with faecal and mucosal ecosystems being distinct. This would indicate that faecal samples are not appropriate surrogate markers for mucosal samples and other alternative sampling options should be considered. The aim of the study was to assess the microbial diversity of paired biopsies and faecal aspirates to determine whether faecal aspirate can be used as a suitable surrogate for colonic biopsies. Methods Bacterial DNA was extracted from 21 paired mucosal biopsies and faecal aspirates, and subjected to denaturing gradient gel electrophoresis (DGGE) and q-PCR analysis to quantify the relative abundance of the following major bacterial groups: Bacteroidetes, Ruminococcaceae , Lachnospiraceae and Enterobacteriaceae . The relative abundance of bacterial groups was expressed as a percentage of total bacteria. Results Increased variation was found across the faecal aspirates compared to biopsies with regards to relative abundance of the four bacterial groups analysed by q-PCR (Table 1). This indicates that microbial diversity of faecal aspirates is more variable than mucosal biopsies. When the mean abundance of each bacterial group across the biopsies and across the faecal aspirates was compared using a Paired t-test, there was a significant difference in levels of Bacteroides (62.3% vs 44.4%; p = Conclusion Substantial microbial diversity differences exist between faecal aspirate and biopsy samples. Faecal aspirates demonstrate considerably more variation than biopsies, and there would appear to be no correlation between paired samples. These results suggest that faecal aspirate is not a suitable microbiological surrogate for mucosal biopsies. Disclosure of Interest None Declared.

Introduction Hypertensive disorders in pregnancy are associated with significant risks to both mother and baby. NICE recommends women at high risk of pre-eclampsia to be given 75 mgs of Aspirin from 12 weeks gestation until delivery. Aim To review current practise on use of low dose aspirin in pregnancy for prevention of pre-eclampsia and to establish safety and benefit of its use. Method Data were collected retrospectively for 295 patients who booked in for antenatal care between Jan 2010 and Jan 2011. The presence of risk factors for pre-eclampsia, use of low-dose aspirin, antenatal complications and delivery outcomes were recorded on a database and analysed. We investigated whether all eligible women were given aspirin and compared outcomes amongst those eligible who were given aspirin against those eligible who were not given aspirin. Results 26% of all antenatal bookers were eligible for low dose aspirin of which only 18% were given aspirin. None of the patients who were eligible and prescribed aspirin developed pre-eclampsia as opposed to 7% in those who were eligible and did not receive aspirin. There was also a reduction in induction of labour (21% and 38%) with use of low dose aspirin, but no influence on gestation at delivery, mode of delivery, birth weight or admission to NNU. Conclusions The use of low-dose aspirin is safe with no side effects in study group and beneficial in prevention of pre-eclampsia. Midwives have been issued with pocket guides to indications for aspirin to improve compliance.

Introduction Inflammation in Crohn9s disease (CD) is driven by the intestinal microbiota, however, microbial manipulation with prebiotics is ineffective in treating active disease. 1 Siblings of patients are at risk of developing CD, and some share aspects of the CD phenotype including raised faecal calprotectin (FC) and dysbiosis. Prebiotics may alter these risk markers. Methods Patients with inactive CD (n=19, CD activity index Results In patients and siblings, Bifidobacteria and Bifidobacterium longum increased post-FOS. In siblings but not patients, Bifidobacterium adolescentis and Roseburia spp. also increased (Abstract PMO-237 table 1). Compared with patients, siblings had a greater median percentage point change in Bifidobacteria (+14.6% vs +0.4%, p=0.028), B adolescentis (+1.1% vs 0.0% p=0.006) and Roseburia spp. (+1.5% vs −0.1% p=0.004). Of those with raised FC at baseline, it decreased post-FOS in only 7/19 patients (37%), compared with 4/5 (80%) siblings (p=0.142). The change in FC was significantly negatively correlated with baseline FC in siblings (r=−0.715, p=0.009) but positively correlated with baseline FC in patients (r=+0.352, p=0.140). Conclusion In contrast to inflamed CD, 1 a prebiotic effect with FOS occurs to a limited extent in non-inflamed CD, and also occurs, more markedly, in at-risk siblings. Furthermore, FC decreased in siblings post-FOS, but did not change significantly (and even tended to rise) in patients with inactive CD. Prebiotics may best be employed in disease prevention rather than treatment. Competing interests C Hedin: Grant/Research Support from: Clinical Research Fellow funded by Core charity, P Louis: None declared, F Farquharson: None declared, S McCartney: None declared, A Stagg: None declared, J Lindsay: None declared, K Whelan: None declared. Reference 1. Benjamin JL , Hedin CR et al. Gut 2011; 60 :923–9.

The standard of obstetrics care by general practitioners in Bradford was assessed by reviewing the case records of all women who in 1988 were booked for delivery under their general practitioner but subsequently required transfer to consultant care. A total of 5885 women were delivered in Bradford during 1988. Of 1289 booked under their general practitioner, 637 required transfer to consultant care. In 259 cases transfer occurred during labour; only 37 of these women were visited by their general practitioner. Many of the problems that precipitated transfer were predictable and some were considered preventable: 263 of the women transferred were considered unsuitable for booking by general practitioners. The perinatal mortality among women booked under their general practitioner was 10.1/1000 and the stillbirth rate 7.8/1000. These figures are high and suggest a need for tighter controls over the qualifications and experience of doctors participating in a fully integrated system of obstetric care.

To investigate bladder neck and urethral function after radical hysterectomy, 21 patients were investigated before and 3 months after the operation. Each patient had an excretory urogram, CO2 cystoscopy, uroflowmetry, water cystometry and a urethral pressure profile, using a dual sensor microtransducer catheter, at rest and during stress. Postoperatively there was a significant reduction in urethral length and urethral closure pressure; however, pressure transmission ratios were maintained, indicating no loss of bladder neck support with stress. Of the six patients with pre-operative bladder neck weakness, two (33%) had stress urinary incontinence at the 3 months assessment. No patient with a normal pre-operative assessment developed this complication. Fifteen (71%) voided by abdominal straining and this manoeuvre emptied the bladder effectively. These data suggest that patients with pre-operative evidence of an incompetent bladder neck may be predisposed to develop stress urinary incontinence after radical hysterectomy because of a reduction in the urethral closure pressure.

Using an indirect immunofluorescence technique, circulating liver membrane antibodies against normal rabbit hepatocytes and ethanol-altered rabbit hepatocytes have been sought in a series of patients with histologically confirmed alcoholic liver disease. Liver membrane antibodies against normal hepatocytes were found in 18 (28%) of the 65 sera examined, but with ethanol-altered hepatocytes as substrate liver membrane antibodies were found in 48 (74%) of the sera. Isolation of F(ab')2 fragments confirmed that the positive results were due to antibody binding. Liver membrane antibodies against ethanol-altered hepatocytes are peculiar to alcoholic liver disease, and there is a similar incidence in the various histological types of alcoholic liver disease. Absorption studies suggest that the liver membrane antibodies are directed against new or altered antigens which are not present in normal hepatocytes. These new or altered antigens may also appear after pretreatment with other primary alcohols and seem likely to be induced by a haptenic effect of the alcohol or a metabolic break-down product. These studies represent a novel approach to the further investigation of the possible role of immunological mechanisms in alcohol-induced liver injury.

Wangensteen in 1949 was the first to advocate the use of second-look surgery in patients with cancer of the bowel in an attempt to improve survival by detecting, and if necessary removing, residual tumour at six monthly intervals [1]. Since then gynaecologists have, with varying degrees of enthusiasm, come to accept it as a part of the optimal management of patients with epithelial ovarian cancer. It is being increasingly advocated to assess disease status after chemotherapy, not only to enable further debulking to be accomplished and for changes in therapy to be instituted but, where negative, to allow chemotherapy to be stopped altogether [2,3,4].

A growth survey of four groups of Nepali children from birth to 12 years was undertaken and the growth patterns related to diet. The patterns are those of children suffering from malnutrition in the second and third year and not those of a genetically small race. Diet histories showed inadequacies of diet, mostly preventable, occurring during the same period. Privileged children within the groups showed a different pattern and a significantly better growth.

The fibreoptic laryngoscope is described, and its method of use detailed. Seventy patients were submitted to this examination. Its advantages and disadvantages in the assessment of the various groups of laryngeal disorders in these patients are discussed and compared with indirect and direct laryngoscopy. Its teaching and research possibilities are also mentioned. The technique shows considerable promise and will, we believe, achieve an accepted place as an addition to our diagnostic armamentarium in the investigation of laryngeal disorders.