Laparoscopic colorectal surgery was being performed by a small minority of members of the ACPGBI although more surgeons had started to work in this field in recent years. The main areas of concern appeared to be a wide variation in the range of experience as indicated by the number of operations performed and limited formal training for consultants.

LETTERS TO THE EDITOR 487 tumour cells. No additional metastases were identified in a thorough search. Such an occurrence may be coincidental but it makes one wonder whether intra-operative seeding of tumour cells should not be a real concern of the surgeon, and what can be done about it?Ami Schattner, Adi Shani Kaplan Hospital, 76100 Rehovot, Israel.Carcinoma of the splenic flexure -a case for extended right hemicolectomy?Sir, We have recently managed a patient with a splenic flexure colonic carcinoma, who had an unusual distribution of lymph node metastases. This questions the validity of transverse colectomy for this condition.The classical treatment of resectable colonic carcinoma has been excision in continuity with its vascular supply in an attempt at reducing local recurrence by removing involved or potentially involved lymph nodes. This is based on Jamieson and Dobson's work' which suggested that the lymphatic drainage ofthe colon followed its main blood supply. However, blood supply to the splenic flexure has been shown to be somewhat variable. Griffiths2 demonstrated that it was supplied by the inferior mesenteric artery via the left colic in 89% of cases and by the superior mesenteric artery via the middle colic in 11 %. He also noted that the middle colic was absent in 22% of cases. These findings were confirmed by Sierocinski3 who found in 100 post-mortem dissections that the middle colic vessel supplied the splenic flexure in only 19. Where the middle colic is absent, the ileocolic supplied the transverse colon and the left colic supplied the splenic flexure.Goligher4 has advocated transverse colectomy for splenic flexure carcinoma, ligating both middle colic at its origin and the ascending branch of the left colic to remove those nodes most likely to be involved.We report the case of an 83 year old female admitted as an emergency with vomiting and abdominal pain. Plain abdominal X-rays and a gastrografin enema revealed a stenotic lesion at the splenic flexure with complete obstruction. At laparotomy a splenic flexure carcinoma was found and an extended right hemicolectomy performed with an end to end ileocolic anastomosis. The patient made an uneventful recovery and was discharged home.Histological examination of the specimen showed a moderately differentiated adenocarcinoma of the splenic flexure with one of eight local lymph nodes involved (Duke's stage C Jass Class IV). However, one node at the ileo-colic junction showed adenocarcinomatous deposits.Aldridge5

Eleven patients are described in whom myelomatosis was complicated by the laboratory and clinical features of the hyperviscosity syndrome (HVS). The myeloma type was IgA in nine and IgG3 in two. In those patients with IgA myeloma the HVS was related to the presence of high molecular weight complexes in the serum. Remission of clinical features was obtained in all patients by plasma exchange. Clinical improvement coincided with reduction of whole blood viscosity and in those patients with IgA myeloma, with a parallel reduction of the high molecular weight complexes. The relationship between the IgA complexes and blood viscosity has been examined by physicochemical analysis of purified IgA monomer and polymers and evidence is presented to show that the IgA polymer has a higher intrinsic viscosity and axial ratio than the larger IgM molecule. The significance of these observations is discussed.

No abstract

This comprehensive review reports on methodological quality of 162 single-case studies on augmentative and alternative communication for communication and challenging behavior in individuals diagnosed with autism or intellectual disabilities and with complex communication needs. Following review for inclusion criteria, documents were excluded if they failed to meet basic methodological standards. Each remaining study was evaluated for 10 detailed quality criteria. No studies met all standards without reservations. Only three of the included studies met all of the standards with reservations and the remainder met some but not all standards, with or without reservations. The included studies reported adequate detail for half of the quality indicators, but insufficient details for participant, setting, maintenance, and generalization, and social validity descriptions. An increased quantity and quality of research were found in over four decades. More recent studies have adequately reported half of the criteria investigated, including describing the materials, defining the outcome variables, describing baseline and intervention procedures, and evaluating procedural integrity. After identifying quality features, the authors report in more detail on low rated quality indicators particularly relevant to studies addressing social-communication interventions. The literature infrequently reported race, ethnicity, or home language. Future research should report characteristics of participants to ensure that research becomes representative of the population.