SirI have read with interest the paper by Truskett et al. (Br J Surg 1987; 74: 63942) and the correspondence in response to this paper by Gouma et al. (Br J Surg 1987; 74: 1188). I have also read the answer to the above correspondence by Truskett et al. (Br J Surg 1987; 74: 1188). A decrease in bile flow and sludge formation has been noted in pigs when the total parenteral nutrition (TPN) solution was infused intravenously or intragastrically'. The daily injection ofcholecystokinin in pigs receiving intravenous infusion of TPN did not prevent hepatobiliary dysfunction'. Doty et al. have shown that daily injection of cholecystokinin octapeptide (5 ng kg-' min-' for 10 min) prevents TPN-induced gallbladder stasis'. But in this study gallbladder stasis was assessed by the ratio of gallbladder to hepatic bile 3Hcholic acid specific activity; and the definitive study of prophylaxis of gallstone formation was not done. The solutions used in the TPN are hyperosmolar (1800-2400 mo~mol/l)~. Intravenous injection of hypertonic glucose solution causes a decrease in bile flow4. Blood and bile are isotonic and changes in osmotic pressure of blood are followed by parallel changes in osmotic pressure of bileS. Haberich et al. have shown the existence of osmoreceptors in the portal vein or liver6. Reversal of abnormalities in liver function often follows replacement of continuous TPN with cyclic TPN'.'. TPN-induced cholestasis occurs more frequently with high calorie and nitrogen intake which usually require more hyperosmolar solutions9. In guinea-pigs, intravenous infusion of TPN produces a decrease in hepatic bile flow and this is associated with an increase in bile osmolality'O. In patients receiving TPN, hypocaloric (500 kcal day-') oral fluid intake prevents liver function abnormalities". High output fistulae usually produce more than 200ml fluid per day and this fluid is rich in electrolytes'2. Reinfusion of fluid from high output fistulae into the distal stoma of patients receiving TPN produces normalization of liver function abnormalities as reported by Gouma et al. (Br J Surg 1987; 74: 1188). This is likely to be due to the enteral infusion of fluid containing electrolytes and biliopancreatic secretions leading to an increase in the intestinal motility and release of gastrointestinal hormones.Thus TPN-associated hepatobiliary dysfunction is likely to be due to hyperosmolar solutions used in the TPN and continuous infusion of TPN, in addition to the absence of enteral stimulation and release of gastrointestinal hormones.M. V. Math National University Hospital Singapore 1. 2.3. 4. 5. 6.7. 8. 9. 10. 11. 724Morgan WP, Truskett PG, Rose MA, Ham JM. Is TPN related hepato-biliary dysfunction secondary to deprivation of enteral stimulation? Gut 1986; 27: A1271. Doty JE, Pitt HA, Porter-Fink V, Denbesten L. Cholecystokinin prophlaxis of parenteral nutrition induced gallbladder disease. Influence of metabolizable and non-metabolizable sugars on liver bile secretion. American Journal of Digestive Diseases 1940; VlI : 382-5. Gilm...

Objectives & BackgroundPre-hospital application of pelvic binders is recommended by the 2016 NICE guidelines for Major Trauma in any patient with blunt high-energy trauma and suspected active bleeding from a pelvic fracture. The Emergency Medical Retrieval Service (EMRS) provide a pre-hospital critical care team by road and air to for the West of Scotland to a mixed rural and urban catchment area. The EMRS SOP mandates pelvic binder application to patients with suspected pelvic fractures including all polytrauma with significant mechanism of injury. We aimed to ascertain the incidence of pelvic fractures in this group of patients and whether this mechanism predicted significant pelvic injury.MethodsRetrospective analysis of all trauma patients attended by EMRS between 2011 and 2015 who had a pelvic binder applied and were not declared dead at scene. 140 patients were identified – of these, 11 were excluded due to lack of access to imaging. Data was obtained from the EMRS database and in-hospital systems including TrakCare, Portal and PACS. Information was collected and analysed using Microsoft Excel. Parametric data was analysed using Students T-test and non parametric data was analysed using Mann-Whitney test on Stata v12.ResultsOf the 129 trauma patients who had pelvic binders applied, 32 (25%) had evidence of active bleeding and 28 (22%) had a pelvic fracture identified on imaging. The ‘fracture present’ versus ‘fracture not present’ populations were compared. This data is summarised in Table 1. Most common mechanisms to cause pelvic fracture were being either the car occupant in an RTC (29% of fractures) or a pedestrian in an RTC (29%). Motorcyclists made up 19% of patients to whom a pelvic binder was applied, but they only represented 7% of the pelvic fracture population.ConclusionApplication of a pelvic binder to this group of patients seems an appropriate action as a significant proportion subsequently have a pelvic fracture identified on imaging. The population of pelvic fracture patients seen by EMRS are more commonly patients involved in road traffic collisions (as opposed to ‘falls from height’ seen more commonly in purely rural populations) with an ISS of more than 15 to constitute ‘major trauma’. Table 1Epidemiology of all trauma patients with a pelvic binder applied pre-hospitally by EMRSPelvic fracture presentPelvic fracture not presentp valueAge, years (mean)43440.760Gender (% male)46%72%0.010*Median ISS17130.211Suspicion of bleeding (%)39%21%0.0517 day mortality (%)4%10%0.317X-ray AND CT imaging of pelvis in hospital89%53%<0.001*Mechanism of InjuryLow Fall (<10 ft)4%3% High Fall (>10 ft)14%15% RTC – vehicle occupant32%40% RTC – pedestrian29%12% RTC – motorcyclist7%19% RTC – cyclist4%8% Other11%4%

We report a case of paratesticular leiomyosarcoma in an 84-year-old man. The tumor was firm and nodular, and attached to the upper pole of the left testis. Light microscopy showed a sarcoma with numerous mitoses. On electron microscopy tumor cells contained 7 nm. microfilaments, with regular dense bodies, micropinocytotic vesicles and the other hallmarks of smooth muscle differentiation, in addition to prominent pools of glycogen. This case illustrates the value of electron microscopy in the investigation of unusual urological tumors.

No abstract

Harry Counihan was involved in many extra curricular activities and was a prominent member of the IMA, where he always had a penchant for asking very searching questions before a meeting ended.In 1974, he declined a request to become triple President of the BMA, Canadian MA and the IMA. He was Editor of the IMA Journal, where he served for 10 years after Mr. Bill Doolin had retired and many of his editorials were on matters of public concern and are widely quoted. He also wrote on medical topics in newspapers on the costs of hospital services to promote better and more rational services. He did a special study of health services in other countries, and had a deep knowledge of them and new ideas in the health service.Harry was involved in many extra curricular activities during his career, and achieved many important distinctions, five of which were appointments by the Minister of Health.However, one of his special interests was his commitment to the disabled and mentally handicapped. He was greatly honoured in 1999, when he was awarded ''Doctor of the Year'' and featured on RTE.