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A retrospective cohort of 823 patients with ulcerative colitis who resided at the time of diagnosis in one of three defined geographical areas (West Midlands region, Oxford region, England and Stockholm County, Sweden) was assembled. The patients were first seen at named hospitals in these areas and the diagnosis of ulcerative colitis established within five years of onset of symptoms between 1945-1965. All patients were 15 years of age or more at onset of disease and were followed for a minimum of 17 years and a maximum of 38 years. Ninety seven per cent completeness of follow up was achieved. Examining the colorectal cancer risk in the series relative to the risk in the general population by standardised morbidity ratios, there was an eight fold increased risk of cancer in the series as a whole. Dividing the series by extent of colitis, extensive colitis patients showed a 19 fold increase in risk. A four fold increased risk was shown in the remainder of the series (left sided colitis, proctitis and extent unknown). Life table analyses in extensive colitis gave cumulative risks of 7.2% (CI 3.6-10.8) at 20 years from onset of disease and 16.5% (CI 9.0-24.0) at 30 years from onset. No significant effect of age at onset, sex or referral centre could be detected. Examination of the data by interval from onset to cancer and by actual age at development of cancer suggests that patients who develop colorectal cancer will do so in a distribution around 50 years of age independent of duration of disease in adult onset ulcerative colitis (greater than 15 years at onset of disease). An inverse relationship was shown between age at onset of disease and interval from onset of disease to cancer. Further age specific rates for cancer increased up to 50 years and decreased thereafter. These results suggest that extensive colitis patients have a genetic predisposition to colorectal cancer and that longstanding inflammation is not of primary importance in the initiation/promotion of cancer in this disease.

Reliability evaluation techniques have reached a stage at which they can be applied to real systems in a very effective and efficient manner. However, the economic impact of system reliability, or more specifically system unreliability, on users and customers is not so readily available. In order to achieve this, there is a need to know customer and user outage costs and their evaluation of reliability worth. During the past 5 years, major surveys of domestic, commercial and industrial customers have taken place in the UK in order to provide this information. These outage costs can then be used as input data to cost implications and worth assessments of system planning and operational decisions. This paper first reviews these outage cost data and secondly describes how this information can be used in system planning considerations. Although this paper deals with the electricity supply industry, the concepts are equally applicable to all types of systems.

Background—The appropriate medical treatment of patients with ulcerative colitis is determined largely by the severity of symptoms. Hospital assessment of the severity of disease activity includes investigation of laboratory indices and sigmoidoscopic assessment of mucosal inflammation.Aims—To develop a simplified clinical colitis activity index to aid in the initial evaluation of exacerbations of colitis.Methods—The information for development of the simple index was initially evaluated in 63 assessments of disease activity in patients with ulcerative colitis where disease activity was evaluated using the Powell-Tuck Index (which includes symptoms, physical signs, and sigmoidoscopic appearance). The new index was then further evaluated in 113 assessments in a different group of patients, by comparison with a complex index utilising clinical and laboratory data, as well as five haematological and biochemical markers of disease severity.Results—The newly devised Simple Clinical Colitis Activity Index, consisting of scores for five clinical criteria, showed a highly significant correlation with the Powell-Tuck Index (r=0.959, pr=0.924, pConclusions—This new Simple Colitis Activity Index shows good correlation with existing more complex scoring systems and therefore could be useful in the initial assessment of patients with ulcerative colitis.

Summary The course, prognosis and management of 62 patients with Crohn's disease aged 55 years or over at diagnosis has been reviewed. The distal ileus was the commonest site of disease in the older patient, where the characteristic presentation was acute after initially mild symptoms. Early local resection was often required, particularly where there was diagnostic doubt or suspicion of caecal malignancy. Recurrence rates were much lower in the older patient than after resection in younger patients. Medical treatment played a minor role in the management of patients with distal ileal disease, in part because stricture formation was present at diagnosis and the acute nature of symptoms at presentation led to early surgical treatment. Colonic Crohn's disease was usually confined to the distal or left side of the colon and initially could be difficult to distinguish from diverticular disease. Extensive colonic Crohn's disease was rare. The apparently limited disease was not necessarily associated with a good prognosis, since disease at this site sometimes progressed rapidly, necessitating urgent surgical resection. Medical treatment (corticosteriod therapy, with or without azathioprine) was usually effective initially for treatment of symptomatic colonic Crohn's disease, but sustained remission was rare. Those patients with persistent symptoms were restored to good health with surgical treatment but at a price, in that nearly half eventually required a permanent stoma.

The surgical resection rates among parous women with distal ileal and colonic Crohn's disease have been compared with resection rates among distal ileal (n = 197) and colonic (n = 332) Crohn's disease patients. Thirty of 44 parous women with distal ileal Crohn's disease and 28 of 44 with colonic Crohn's disease had achieved their first pregnancy on average 8 years and 6.2 years respectively before the diagnosis of Crohn's disease was established. Resections for each patient were negatively correlated with parity in both groups. (Distal ileal disease (p = 0.034, rs = 0.3207), colonic disease (p = 0.051, rs = -0.2960)). Patients with distal ileal Crohn's disease and a history of pregnancy at diagnosis (n = 30, mean follow up = 15 years) had fewer resections/patient when compared with the published resection group: mean (SD); 1.17 (0.65) v 1.57 (1.05), p = 0.006. Patients with colonic Crohn's disease and a history of pregnancy at diagnosis (n = 28, mean follow up = 16.5 years) had fewer resections/patient when compared with the published resection group: mean (SD); 0.68 (0.77) v 1.05 (0.77), p = 0.019. In summary, patients with distal ileal and colonic Crohn's disease, who had been pregnant in the past subsequently need fewer surgical resections. Pregnancy could influence the natural history of Crohn's disease either by decreasing immune responsiveness or by retarding fibrous stricture formation, which is the commonest indication for surgical intervention.

The increased prevalence of gall stones in Crohn's disease is thought to be related to depletion of the bile salt pool due either to terminal ileal disease or after ileal resection. This study was designed to examine whether this hypothesis is correct and explore alternative explanations. Two hundred and fifty one randomly selected patients (156 females, 95 males, mean age 45 years) were interviewed and screened by ultrasonography to determine the prevalence of gall stones in a large population of patients with Crohn's disease. Sixty nine (28%) patients had gall stones proved by ultrasonography (n = 42), or had had cholecystectomy for gall stone disease (n = 27). The risk factors for the development of gall stones including sex, age, site, and duration of disease, and previous intestinal resection were examined by multivariate analysis. Age and duration of disease were positive risk factors for gall stones and were covariables. The site of disease and of previous intestinal resection did not predispose to gall stones. Previous surgery was an independent risk factor for the development of gall stones, the risk increasing with number of laparotomies. It is suggested that mechanisms other than ileal dysfunction may predispose to gall stones. Postoperative gall bladder hypomotility with biliary sludge formation may be precursors of gall stone formation in patients with Crohn's disease.

Neutrophil superoxide anion production was measured in healthy subjects and in patients with quiescent and active Crohn's disease using superoxide dismutase inhibitable cytochrome C reduction. Three stimuli were used: phorbol 12-myristate 13-acetate (PMA1), phorbol 20-oxo-20-deoxy 12-myristate 13-acetate (PMA2), and Candida albicans in serum. Normal neutrophils produced significantly more superoxide anion than Crohn's disease neutrophils with both PMA1 (mean (SD) 9.6 (2.2) v 8.6 (1.8) nmol/10(6) cells/5 minutes, p = 0.04) and PMA2 (1.8 (0.8) v 0.8 (0.77) nmol/10(6) cells/5 minutes, p = 0.00004). With C albicans in serum, normal and Crohn's disease neutrophils produced similar amounts of superoxide anion (4.4 (1.5) v 4.3 (1.7) nmol/10(6) cells/30 minutes, not significant). Results were independent of disease activity. Superoxide anion production by PMA-stimulated Crohn's disease neutrophils is significantly lower than by normal neutrophils.

A previously fit 23 year old adult male who presented with a sudden onset of profound autonomic neuropathy, for which no cause could be found, is described. The patient subsequently developed ischaemic enterocolitis that ultimately necessitated colectomy and subtotal enterectomy. Potential neural and humoral mechanisms are discussed.

Thirteen strains of endospore-forming bacteria were isolated from geothermal soils at Cryptogam Ridge, the north-west slope of Mt Melbourne, and at the vents and summit of Mt Rittmann in northern Victoria Land, Antarctica. 16S rRNA gene sequencing, SDS-PAGE and routine phenotypic characterization tests indicated that the seven isolates from the north-west slope of Mt Melbourne represent a novel species of Brevibacillus and that the six isolates from Cryptogam Ridge and the vents and summit of Mt Rittmann represent a novel species of Aneurinibacillus. Brevibacillus strains were not isolated from the sites at Mt Rittmann or Cryptogam Ridge and Aneurinibacillus strains were not isolated from the north-west slope of Mt Melbourne. Preliminary metabolic studies revealed that l-glutamic acid, although not essential for growth, was utilized by both species. The Brevibacillus species possessed an uptake system specific for l-glutamic acid, whereas the Aneurinibacillus species possessed a more general uptake system capable of transporting other related amino acids. Both species utilized a K+ antiport system and similar energy systems for the uptake of l-glutamic acid. The rate of uptake by the Brevibacillus species type strain was 20-fold greater than that shown by the Aneurinibacillus species type strain. The names Brevibacillus levickii sp. nov. and Aneurinibacillus terranovensis sp. nov. are proposed for the novel taxa; the type strains are Logan B-1657T (=LMG 22481T=CIP 108307T) and Logan B-1599T (LMG 22483T=CIP 108308T), respectively.

Summary We report a case of bilateral endogenous Escherichia coli endophthalmitis in an insulin-dependent diabetic. This condition appears to occur almost exclusively in diabetics, and is invariably related to a urinary tract infection. Treatment of any infection in diabetics should be aggressive, and any deterioration in vision should be addressed promptly.

A 31 year old man from Gambia, resident in the United Kingdom for two years, presented with a two month history of unproductive cough, malaise, weight loss, non-specific abdominal pain, and episodic diarrhoea. Acid alcohol fast bacilli were identified in his sputum, together with Strongyloides stercoralis larvae and Giardia lamblia cysts in his stools. This case illustrates that latent strongyloidiasis can become overt in the presence of tuberculosis, and the diagnosis of strongyloidiasis must be borne in mind in patients who have previously resided in endemic regions.

The communication system is essential to the performance of automated distribution systems. It is necessary to perform reliability assessments of communication facilities in carrying out the control functions. The paper describes an approach for reliability evaluation of the communication and control. This approach is based on the event tree methodology, and by using it sensitivity studies are performed to predict the impact of a communication system. The results of the studies are discussed and the importance of the communication system on the reliable automation performance is demonstrated in the paper.

Therapy of Digestive Disorders . Edited by Wolfe MM, Cohen S, Davis GL, et al . (Pp 881; hardback; illustrated; £85.) Philadelphia: WB Saunders, 1999. ISBN 0 72167 340 6. This is a substantial book edited by Dr Michael Wolfe with six of his colleagues acting as section editors. Many of the hundred or so contributors are members of the Boston home team. The others are from the key centres in North America with a smattering of contributors from Canada, Europe, Israel, and South America. This is in effect a GI textbook, but stripped largely of pathogenesis, pathophysiology, diagnosis, and differential diagnosis. Five …

Three patients with Crohn’s disease are described who were treated by ileal resection for intestinal obstruction. Histological examination of the resected specimen in each case established the diagnosis of adenocarcinoma of the small intestine complicating Crohn’s disease. This diagnosis should be considered in patients with longstanding macroscopic Crohn’s disease who present with severe or recurrent symptoms. The diagnosis may not be apparent on routine radiological examination or even macroscopically at laparotomy.

The risk of developing colorectal cancer has been compared in two identically selected cohorts of patients with extensive Crohn's colitis (n = 125) and extensive ulcerative colitis (n = 486). In both groups the effects of selection bias have been reduced wherever possible. There was an 18-fold increase in the risk of developing colorectal cancer in extensive Crohn's colitis and a 19-fold increase in risk in extensive ulcerative colitis when compared with the general population, matched for age, sex, and years at risk. The absolute cumulative frequency of risk for developing colorectal cancer in extensive colitis was 8% at 22 years from onset of symptoms in the Crohn's disease group and 7% at 20 years from onset in the ulcerative colitis group. The relative risk of colorectal cancer was increased in both ulcerative colitis and Crohn's disease among those patients whose colitis started before the age of 25 years. Whether the absolute risk is greater in the younger age group or merely reflects that the expected number of carcinomas increases with age is uncertain. While there is an increased risk of developing colorectal cancer in extensive colitis the number of patients with Crohn's disease who actually develop colorectal cancer is small because many patients with extensive Crohn's colitis undergo colectomy early in the course of their disease to relieve persistent symptoms unresponsive to medical treatment.

The colorectal cancer risk in Crohn's disease eliminating all known biases was assessed in a cohort of 281 patients with Crohn's disease who resided in the West Midlands at the time of diagnosis, and were first seen within five years of onset of symptoms between 1945-1975. All patients were 15 years of age or more at onset and were followed up from 12-35 years (total 5213 person years at risk (PYR)). The colorectal cancer risk in the series compared with the risk in the general population was computed by applying sex and age specific PYRs to the date of death or end of the study period 31 December 1991. There were six colonic and two rectal cancers. Six of the eight colorectal cancers were diagnosed 20 or more years after the onset of Crohn's disease. The relative risk (RR) of colorectal cancer for the series as a whole was 3.4 (p < 0.001), with a fivefold excess in the colon, but no significant excess in the rectum. Patients with extensive colitis showed an 18-fold increase in risk (RR = 18.2, p < 0.001), which decreased with increasing age at onset. This study shows that there is a statistical excess risk of developing colorectal cancer in patients who develop their Crohn's disease at a young age of onset (less than 30 years of age).

This chapter summarizes our current knowledge of the role of the oral contraceptive pill in the pathogenesis of inflammatory bowel disease (IBD), followed by a review of fertility in women and men. The next section considers IBD and pregnancy, including the impact on the fetus and the mother with ulcerative colitis or Crohn’s disease. The chapter then considers the safety of drug treatment and the outcome of surgical treatment during pregnancy and the problems that may be encountered during pregnancy in patients with an ileostomy or ileoanal pouch. The chapter closes with a review of the short- and long-term prognosis of ulcerative colitis and Crohn’s disease after parturition.

Diffuse jejunoileitis is an uncommon, but important manifestation of Crohn's disease because of the associated high morbidity and challenges in medical management. Despite this there have been no studies of prognosis or management of diffuse jejunoileitis for nearly 20 years. This study analysed the outcome among 34 patients (20 women and 14 men) with diffuse jejunoileitis diagnosed between 1960 and 1991 including clinical features, medical and surgical management, death rates, current status, and prognosis. Diffuse jejunoileitis presents in younger patients (mean age at diagnosis 26.4 years) than those with distal ileal Crohn's disease (mean age at diagnosis 33.3 years). Nearly all presented with clear cut abdominal symptoms including a combination of colicky abdominal pain (91%), weight loss (62%), and diarrhoea (53%). Most patients had severe symptoms reflected by the fact that 77% had been treated with corticosteroids for periods of more than six months at some stage during their follow up. The mean follow up from diagnosis was 16 years. Twenty eight patients (82%) had at least one operation for diffuse jejunoileitis and two thirds of the patients (n = 21) required two or more operations. The frequency of surgical intervention was particularly high in the younger patients (r = 0.71, p < 0.001). The proportion of patients requiring surgery was highest in the first year after diagnosis. The annual operative rate was 15% for the first 10 years and then it fell to 5.2% in years 11-15, and 2.6% in years 16-20. The data suggest that the disease does burn itself out over time. The increasing use of strictureplasty for short strictures and the minimal use of resection has eliminated problems associated with the short small bowel syndrome. The longterm prognosis of this patients is good. Only two patients died (one of perforation of the jejunum and another of an unrelated bronchogenic carcinoma). After a mean interval from diagnosis of 16 year, 24 of 32 living patients are well and symptom free. Only eight have abdominal symptoms of whom three are receiving corticosteroid treatment and one azathioprine. The combination of anti-inflammatory drugs with the relief of recurrent obstructive symptoms by strictureplasty can together produce a good longterm prognosis in most patients with diffuse jejunoileitis.

Cultural and serological studies have provided limited, often conflicting, evidence of a role for mycobacteria in the pathogenesis of Crohn's disease. Interest has focussed on Mycobacterium paratuberculosis, previously considered to be common in the environment with no major role as a human pathogen. Whether a specific serum antibody response to mycobacteria occurs in Crohn's disease or ulcerative colitis was investigated. Sera from patients with Crohn's disease (n = 38), ulcerative colitis (n = 15), and a healthy control population (n = 30) were assayed in an enzyme linked immunosorbent assay (ELISA) using eight filtered sonicate mycobacterial preparations and a purified protein derivative made from the bovine tubercle bacillus. In addition, IgG, IgM, and IgA levels to M paratuberculosis were determined in sera from patients with active (n = 24) or inactive (n = 29) Crohn's disease and the control populations. There was strong evidence of contact with environmental mycobacteria in all patients and control populations, with the greatest responses to preparations of M avium, M tuberculosis, and M kansasii. A large proportion of patients with Crohn's disease had antibodies that bound most antigens tested but there were no statistical differences between these values and those of the control population. Similarly, there were no differences in antibody levels to M paratuberculosis in patient and control groups. Although a subset of patients with active Crohn's disease (25%) had IgG concentrations that exceeded the control mean by more than 2 SD, this phenomenon may not be specific to Crohn's disease: 20% of a small group of patients with coeliac disease had similarly raised IgG levels to M paratuberculosis. These findings do not provide serological evidence of a role for this organism in the pathogenesis of Crohn's disease.

Ulcerative colitis and Crohn’s disease are uncommon conditions, so that most hospital doctors and family practitioners see few such patients. A follow-up clinic provides a focus for them and the accummulated experience provides the background for rational and consistent advice and care. The resources of medical and surgical follow-up can be linked to stoma care, first class radiology, histopathology and laboratory services. The provision of outpatient and in-patient services in adjacent areas familiarises the patient with the available in-patient facilities which they may need in the future.

A strict definition of the natural history of a disease is its course and outcome without medical or surgical intervention. It is only possible to follow the true natural history of inflammatory bowel disease in a few patients at the benign end of the spectrum since perforce in practice the course is modified in nearly all patients by medical or surgical treatment.

Two men with longstanding ulcerative colitis who were treated with sulphasalazine for several years and who developed chronic renal failure are reported. Renal biopsy specimens showed histological changes consistent with drug induced chronic intestinal nephritis. Extensive investigation made other causes of chronic renal failure unlikely. One of these patients underwent renal transplantation, the other has impaired but stable renal function.

SUMMARY Culture studies have suggested that Mycobacterium paratuherculosis may play a role in the aetiology of Crohn's disease. However, evidence of sensilizalion to mycobactcrial antigens amongst patients with Crohn's disease has not yet been adequately demonstrated. Previous studies of cell-mediated immunity (CMI) in Crohn's disease were restricted to responses of peripheral blood mononuclcar cells (PBMC) to mycobacterial antigens. In this study we have investigated the proliferativc responses of both PBMC and mesenteric lymph node mononuclcar cells (MLNMC) to a range of mycobacterial and non-mycobactcrial antigens. There was no evidence of specific sensitization in the responses of MLNMC and PBMC from patients with inflammatory bowel disease (IBD) to the mycobacterial antigens. However, anergy to M. paratuherculosis could not be excluded. IBD MLNMC responses to most antigens were generally greater than those of PBMC. which were often undetectable. When compared with controls, there was evidence of increased CM 1 to a range of non-mycobactcrial antigens, especially Yersinia enterocolitica. amongst both MLNMC and PBMC from patients with Crohn's disease and ulcerative colitis (UC). These results do not provide support to the proposed role of mycobacteria in the pathogcnesis of Crohn's disease, but indicate that further investigation may determine a role for bacterial-specific T cell-mediated responses in the palhogcncsis of IBD.

The ability of normal and Crohn's disease neutrophils to kill Candida albicans has been studied using neutrophils isolated from peripheral blood and suspended in phosphate buffered saline at 5 x 10(6) cells per ml. C albicans was grown to a stationary phase in broth culture and suspended in phosphate buffered saline at 10(7) organisms/ml. Neutrophils and Candida were then incubated together at 37 degrees C in a shaking water bath in the presence of fresh serum. At 30 and 60 minutes samples were withdrawn, neutrophils lysed, and Candida survival assessed by colony counting. Results were compared with control suspensions of Candida incubated with serum alone. After 30 and 60 minutes in the presence of autologous serum normal neutrophils had killed significantly more Candida than Crohn's disease neutrophils (mean (SD) 61.0 (16.7)% v 40.5 (16.2)% at 30 minutes, p less than 0.0001; 83.2 (7)% v 70.8) 16)% at 60 minutes, p less than 0.005). The results did not alter significantly when normal neutrophils were incubated with Candida in the presence of Crohn's disease serum instead of normal serum. When Crohn's disease neutrophils were incubated with Candida in the presence of normal serum instead of autologous serum there was some improvement in candidacidal ability at 30 minutes (48.9 (20.6)% v 40.5 (16.2)%, p less than 0.03) but not at 60 minutes. Phagocytosis, measured using a radiometric assay, was normal. Neutrophils from patients with Crohn's disease have an impaired ability to kill this granuloma provoking organism. It is not due to serum inhibitors or defective phagocytosis.

Peptic ulcer is the most common cause of acute hemorrhage in the upper gastrointestinal tract, accounting for about 50 percent of cases1–14. There are approximately 150,000 hospitalizations per year in the United States for evaluation and treatment of bleeding ulcers (based on 1985 estimates and excluding federal hospitals)15. Although hospitalization and surgery for uncomplicated ulcers have decreased in the United States and Europe over the past 20 to 30 years, the number of hospital admissions for hemorrhage associated with ulcers has remained relatively unchanged15–17. It is noteworthy that the incidence of bleeding ulcers appears to . . .

ELISA and immunofluorescence tests were carried out on sera from patients with Crohn's disease and ulcerative colitis. The results indicate that mean antibody levels to Yersinia enterocolitica types O:9 and O:3 and Klebsiella pneumoniae, but not Pseudomonas maltophilia, are significantly higher in these patients than in control subjects. There are differing antibody levels in ileal and colonic disease, and there is a significant fall in antibody levels 9-12 months after remission from clinical symptoms in patients providing serial serum samples. However, there is no correlation between the severity of the disease and antibody titres.

These investigations were conducted to measure the prebreakdown current and breakdown voltage between stainless steel electrodes using 50 Hz alternating and direct voltages. The measurements were made at room temperature and liquid nitrogen temperature using uniform field electrodes. The range of electrode spacings for the current measurements was 0.1-2.1 mm and for the breakdown voltage with temperature and electrode spacing was very similar with both types of voltage application. Also with both types of voltage, the prebreakdown current obeyed a cold-cathode emission law, analytically similar to the Fowler-Nordheim relation. In both cases an ambient pressure greater than about 10-6 Torr caused the current to be suppressed though this was found to be a reversible effect.

Intestinal disaccharidase and dipeptidase activities were measured in mucosal biopsies from the proximal jejunum in 20 patients with Crohn's disease apparently confined to the distal ileum or large bowel, 14 patients with ulcerative colitis, and 14 healthy volunteers who acted as controls. The dissecting microscopy and histological appearance of the biopsies were normal (Gd 0-1) except for two which showed grade 2 changes. tbiopsy morphometry showed a reduction of jejunal mucosal surface area and an increase in mucosal volume in patients with Chron's disease when compared with the other two groups. The mucosal enzymes studies demonstrated that patients with Crohn's disease had a significant reduction in brush-border enzymes (disaccharidase) but no change in cytoplasmic enzyme activity (dipeptidases). The enzyme levels in patients with ulcerative colitis did not differ from the healthy controls. The reduction of brush-border enzymes with normal cytoplasmic enzymes in the presence of abnormal morphometry is further evidence of the concept of Crohn's disease as a diffuse lesion of the gastrointestinal tract. It also suggests that there is either specific damage to the microvilli or some other abnormality such as impairment of enzyme synthesis.

Summary Methods for hydrolyzing and solvolyzing conjugated bile acid sulfates were compared on reference mixtures of conjugated and unconjugated bile acid SUIfates using gas-liquid chromatography to assess recovery, and thin-layer chromatography and zonal scanning to define the products occurring after hydrolysis. Conventional methods in which solvolysis preceded vigorous alkaline saponification gave incomplete recoveries. However, essentially complete recovery of primary and secondary bile acid sulfates was obtained with a mild alkaline saponification procedure followed by acidification and extraction into ether, in which complete solvolysis was shown to occur within 12 hours. Based on these findings, we developed and validated a simple hydrolysis-solvolysis procedure; the method features mild alkaline hydrolysis, acidification to pH 1, and extraction with ether followed by a I-hour incubation.

A random sample of 170 patients (88 men) with chronic inflammatory bowel disease (75 ulcerative colitis) were first interviewed in 1978 about their employment status, problems at work, and influence of surgery. Surgery had been carried out on 120 and 53 had an ileostomy. After six years 144 (92%) of the 156 survivors replied to a follow up postal questionnaire. Of the initial sample, 122 (72%) were working and there were only three (1%) registered unemployed. After six years a similar proportion were working and only seven (5%) were unemployed. Continuity of employment was good with 57% in the same job. Changes in work because of health had been made by 72 patients mainly caused by bowel disease. After surgery 10% completely changed and 22% modified their work while a few had to retrain or retire. Panproctocolectomy and ileostomy resulted in more changes and longer time off work after surgery than colectomy and ileorectal anastomosis, with 35% and 17% respectively off work after one year. Problems at work, in particular general malaise and arthritis were experienced by 34 (28%) patients. Fewer problems were experienced by patients with a stoma who also had less sickness absence than those without a stoma. Colleagues and employers were usually supportive although some patients encountered discrimination especially those with a stoma or working in the food industry. Few patients had been counselled on their work. In general employment prospects and time off work were good and employers should be encouraged to take an optimistic and supportive role. Doctors should consider that convalescence after surgery may be longer than they perceive and must provide better counselling for patients.

The cellular infiltrate of the proximal jejunum has been compared between 20 subjects without gastrointestinal disease, 20 subjects with ulcerative colitis, and 26 subjects with Crohn's disease. A significant increase (P smaller than 0.001) in the plasma cell infiltrate was noted in subjects with ulcerative colitis and a more marked increase in subjects with Crohn's disease (P smaller than 0.001). Such increases may be relevant to raised serum IgA levels following panproctocolectomy for ulcerative colitis or recurrence in the small intestine in Crohn's disease.

Fifty male patients with proctitis were examined and the clinical, microbiological, serological and proctological features compared with 51 known male homosexuals attending the genitourinary (GU) clinic at the same hospital. The homosexuals had a short history of bowel symptoms, minor sigmoidoscopic and histological changes on rectal biopsy and many positive serological markers of sexually transmitted infection. There was some evidence of sexually transmitted disease in the IBD patients and three were homosexuals. IgG antibodies were positive for chlamydia trachomatis (n = 10) and hepatitis A (n = 7). One had a positive screening test for syphilis. Stool examination and rectal swab cultures were positive in two patients for cryptosporidium and cytomegalovirus respectively. Gastroenterologists must be aware of the possibility of specific infection in IBD patients and a clinical history should include sexual preferences and practices. If homosexuality is admitted, specific infection must be sought and excluded.

One hundred and twenty seven patients undergoing elective surgery for inflammatory bowel disease were divided into three groups according to their preoperative ideal body weight (less than 80%, 80-90%, and greater than 90%). The groups were well matched in respect of age, sex, corticosteroid therapy, pre-existing sepsis, peroperative antimicrobial chemotherapy, and resection site. None received peroperative nutritional support. The postoperative outcome was similar in each of the three nutritional groups including the incidence of postoperative sepsis, duration of hospital stay, and mortality. Serial peroperative changes in weight, fat, and muscle bulk were assessed by anthropometric measurements in 21 of these patients. The deficits in weight, fat, and muscle bulk were similar at 10 and 21 days postoperatively in the three groups. At 84 days those malnourished preoperatively had recovered their nutritional status faster than the well nourished patients. We conclude that in these patients undergoing elective resection for inflammatory bowel disease preoperative weight loss did not adversely affect the postoperative outcome.