Tuberculous infection of the oesophagus is rare. This is confirmed by our present review of cases managed in our teaching hospitals over a period of 18 years which uncovered only 11 patients. The main presentation is that of dysphagia whose algorithm of investigation should seek to differentiate tuberculosis from carcinoma, the more common cause of this symptom. Of the 11 patients, 9 presented with dysphagia while 2 had haemorrhage; 7 had an abnormal plain chest radiograph, of whom 4 had a mediastinal mass lesion (3 were lymphadenopathy and one an abscess). All but one had an abnormal radio-contrast oesophagogram, including a mediastinal sinus in two and a traction diverticulum in another two. The mainstay of investigation was oesophagoscopy through which diagnostic biopsy material was obtained in half of the patients. In the other half diagnosis was by either biopsy of associated mediastinal (3) or cervical (1) lymph node masses or by acid fast bacilli positive sputum (1). The diagnosis was established post-mortem in one patient. Treatment was primarily non-operative with standard anti-tuberculosis drug therapy. Two patients underwent a diagnostic thoracotomy and one a drainage of mediastinal abscess together with resection and repair of oesophago-mediastinal sinus during the early part of the series. Outcome of management was very rewarding in 9 patients and death occurred in 2 patients, one of whom had his anti-tuberculosis drug therapy interrupted by severe hepatitis B virus infection. The other death occurred in a patient whose haemorrhage from an aorta-oesophageal fistula was not established ante-mortem. It is recommended that when biopsy material of the oesophagus is unobtainable or non-diagnostic in patients with dysphagia, especially with an abnormal chest radiograph or human immunodeficiency virus infection, effort should be made to obtain biopsy material from associated lymph nodes, even by thoracotomy if necessary, or culture of biopsy from the radiologically abnormal part oesophagus and sputum for mycobacteria, in order to establish the diagnosis of this rare but eminently treatable cause of dysphagia. Clinicians should be aware of tuberculosis of the oesophagus as a possible cause of haematemesis in patients with otherwise unexplained upper gastrointestinal haemorrhage.

We describe a sensitive assay to measure immune activation of human macrophages in cell culture. Freshly isolated blood monocytes from normal subjects lack the ability to endocytose and degrade mannosyl-terminated glycoconjugates via specific receptors, but acquired this activity after cultivation in autologous serum for -3 d. Addition of specific antigen, purified protein derivative, or T cell mitogens to mononuclear cells prevented the appearance of macrophage mannosyl receptor activity and lymphokine, y-, and a-interferons selectively downregulated receptor activity in monocyte-macrophage targets. The effects of antigen challenge and y-interferon on mannosyl receptors can be prevented by 10-8 M dexamethasone. Dexamethasone also inhibited release of another macrophage activation marker, plasminogen activator, which was increased by both 'y-and a-interferons. These studies show that activation of human macrophages is regulated by opposing actions of lymphokines and glucocorticoids.

The records of 152 patients with pancreatic injury treated over a 5-year period were reviewed. The diagnosis was made at laparotomy in all patients. Gunshot wounds, stab wounds and blunt trauma occurred in 63, 66 and 23 patients respectively with mean ages of 28, 28 and 30 years. Multiple organ injury was most common after gunshot wounds. Intraoperative management was by drainage of the pancreatic injury site alone in the majority of patients in all aetiological groups. The rate of fistula formation was 14 per cent after gunshot wounds, 9 per cent after stab injury and 13 per cent after blunt trauma. Death occurred after 24 h in 8, 2 and 10 per cent of patients following gunshot wounds, stab wounds and blunt trauma respectively, and was attributable to other organ damage. It is concluded that gunshot injury to the pancreas may be more extensive than other injuries, but conservative management with surgical drainage of pancreatic injury is justified irrespective of the mechanism of injury.

Isolated bladder rupture has an insidious presentation which results in delayed diagnosis and management. Forty-four patients, of mean age 33.3 years, were seen over a period of 7 years. There was a history of trauma in 33 patients, although this was minor in 20. Alcohol intoxication, head injury or paraplegia could have led to lack of sensation of the distending and subsequently injured bladder in 18 patients. The mean delay between an identifiable incident or presentation and diagnosis was 5.4 days. The mean admission or preoperative levels of blood urea and creatinine were raised to 19.6 mmol/l and 362 mumol/l respectively in those with a delayed diagnosis. The diagnosis was made by voiding cystourethrography in 36 patients and by laparotomy in eight. When blood urea and creatinine concentrations are increased in a patient with an ill-defined abdominal ailment and a history of trauma or drunkenness, ruptured bladder should be considered.

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