Background and objective: Endoscopic retrograde cholangiopancreatography (ERCP) is a technically demanding endoscopic procedure that varies from a simple diagnostic to a highly complex therapeutic procedure. Simple outcome measures such as success and complication rates do not reflect the competence of the operator or endoscopy unit, as case mix is not taken into account. A grading scale to assess the technical difficulty of ERCP can improve the objectivity of outcome data. Methods: A I to IV technical difficulty grading scale was constructed and applied prospectively to all ERCPs over a 12 month period at a single centre. The procedures were performed by two senior trainees and two experienced consultants (trainers). The grading scale was validated for construct validity and inter-rater reliability at the end of the study using the χ 2 test and κ statistics. Results: There were 305 ERCPs in 259 patients over the 12 months study period (males: 112, females: 147, age range 17-97, mean 70.3 years). There was overall success in 244 (80%) procedures with complications in 13 (4%): bleeding in five (1.6%), cholangitis in one (0.3%), pancreatitis in five (1.6%), and perforation in two (0.7%). Success rate was highest for grade I, 49/55 (89%), compared with grade IV procedures, 8/11 (73%). There was a significant linear trend towards a lower success rate from grade I to IV (p=0.021) for trainees, but not for trainers. Complications were low in grade I, II, and III procedures, 12/295(4%), compared with grade IV procedures, 1/11(9%). The inter-rater reliability for the grading scale was good with a substantial agreement between the raters (κ=0.68, p<0.001). Conclusion: Success and complications of ERCP by trainees are influenced by the technical difficulty of the procedure. Outcome data incorporating a grading scale can give accurate information when auditing the qualitative outcomes. This can provide a platform for structured objective evaluation. E ndoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure that is not only technically challenging, but also associated with a risk of serious complications. The procedure itself varies from a simple, straightforward diagnostic ERCP to a highly specialised therapeutic ERCP. A recent survey in the UK showed wide differences between endoscopists in success rates (from 76% to 95%) and serious complications (0% to 16%).1 It is far from acceptable to have such a variation in practice and outcomes in any health care system. Studies have shown that skill and experience have a huge impact on the outcomes of ERCP. 3Success and complications depend not only on the endoscopist's experience, but also on the technical difficulty. Auditing ERCP procedures by simple outcome measures such as complication and success, without taking into account the experience and technical difficulty, does not reflect the actual competence of the unit or an individual endoscopist. Units dealing with advanced, therapeutic ERCP procedures may not be achieving the same success rat...

Background. Irritable bowel syndrome (IBS) is a chronic, difficult to treat condition. The efficacy of Aloe vera in treating IBS symptoms is not yet proven. The purpose of this study was to determine if Aloe vera is effective in improving quality of life. Methods. A multicentre, randomised, double-blind, cross-over placebo controlled study design. Patients were randomised to Aloe vera, wash-out, placebo or placebo, washout, Aloe vera. Each preparation (60 mL) was taken orally twice a day. Patient quality of life was measured using the Gastrointestinal Symptoms Rating Score, Irritable Bowel Syndrome Quality of Life, EuroQol and the Short-Form-12 at baseline and treatment periods 1 and 2. Results. A total of 110 patients were randomised, but only 47 completed all questionnaires and both study arms. Statistical analysis showed no difference between the placebo and Aloe vera treatment in quality of life. Discussion. This study was unable to show that Aloe vera was superior to placebo in improving quality of life. Drop outs and other confounding factors may have impacted on the power of the study to detect a clinically important difference. Conclusion. This study failed to find Aloe vera superior to placebo in improving quality of life proven Irritable Bowel Syndrome patients.

The health scares restricting the use of hormone replacement therapy have made women tend to opt for 'natural' remedies that are generally perceived as safe. Unfortunately, there is lack of definite opinion on the safety of herbal remedies. Black cohosh is commonly used for postmenopausal symptoms. We present two cases of liver toxicity related to this and recommend close monitoring of women on this herbal preparation.

1. Serum carnosinase activity was assayed in a group of alcoholic patients with and without histologically proven atrophy of type II skeletal muscle fibres, and in control subjects. No significant activity was detected in muscle biopsy samples or washed erythrocytes. 2. Serum carnosinase activity was significantly lower in chronic alcoholic patients compared with a group of age-matched controls. Alcoholics with abnormal muscle biopsies had significantly lower enzyme activities than either those patients with normal muscle biopsies or the controls. Serum enzyme activities in patients with normal muscle biopsies were not significantly different from controls. 3. Serum carnosinase activity was inversely correlated with the degree of muscle atrophy as measured by the type II fibre atrophy factor. There was a positive correlation between the enzyme activity and skeletal muscle mass as reflected by the creatinine-height index. Furthermore, the enzyme activity significantly increased, with resolution or improvement in the myopathy, in patients who abstained from alcohol. 4. Kinetic studies showed that the reduced carnosinase activity was due mainly to a decrease in the apparent Vmax. The apparent Km was significantly higher in the myopathic compared with non-myopathic alcoholics. Mixing serum from controls and patients with myopathy gave the expected values, indicating the absence of a serum enzyme inhibitory factor. Acute alcohol loading had no effect on the serum carnosinase activity. 5. The decrease in serum carnosinase activity in alcoholics was not related to the severity of their liver disease. Assays of serum carnosinase in chronic alcoholics, can thus be used as a marker of their associated myopathy.

SUMMARY The effects of an acute dose of ethanol (75 mmol/kg body weight; ip) on protein synthesis were investigated in the small intestine of the rat (n=6). Control rats (n=6) were injected with isovolumetric 0.15 mol/l NaCI, ip. After 2 5 h, fractional rates of protein synthesis (defined as the percentage of tissue protein renewed each day by synthesis and RNA efficiencies (defined as the amount of protein synthesised per unit RNA) were measured with a large flooding dose (0.3 Ci/mol; 150 mmol/l; 150 [tmol/100 g body weight; iv) of [43H]-phenylalanine. Rats were killed 10 minutes after injection of the isotope and portions of the small intestine were rapidly dissected and frozen. Tissues and plasma were processed for phenylalanine specific radioactivities to obtain fractional rates of protein synthesis or protein synthesis rates relative to RNA. Rates of protein synthesis in mixed tissue proteins fell approximately 15-25% (p ranged from <0005 to >005), in response to acute ethanol dosage. The decrease in the synthesis rates of the cytoplasmic protein fraction was similar (p<0.025). Proteins extracted from the smooth muscle contractile apparatus, however, showed a greater response to ethanol -that is, 40-50% inhibition in protein synthesis (p<0.001). It is therefore possible that the functional disturbances in the ethanol-exposed gut may be because of changes in smooth muscle protein turnover with decreased amounts of contractile apparatus.Approximately one third of patients being treated for chronic alcohol abuse have symptoms of gastrointestinal disturbances.' Diarrhoea is a frequent manifestation of alcohol abuse and may be accompanied by malabsorption.23 The basis of these metabolic disturbances is unknown. Studies in the laboratory rat have shown that acute ethanol exposure causes morphological changes in the small intestine, including haemorrhagic erosions of jejunal villi and enterocyte loss from villus tips,4 associated with changes in permeability.5 However, the effects of ethanol on the smooth muscle contractile apparatus have received very little attention. Robels et al have shown in man an inhibition of type I (forward progress) and type III (propulsion) waves.6