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Completion of foundation doctors' assessments by hospital consultants is viewed as a low priority. These assessments are being completed to a large extent by fellow doctors in training. The learning opportunities are consequently less educationally productive. F2 doctors want more opportunities for valued consultant interaction with timely feedback. Suggestions are proposed to improve WPBA implementation. The present WPBA process lacks integrity and a change in approach is urgently required.

Background-Resection is the treatment of choice for lung cancer, but may cause impaired cardiopulmonary function with an adverse eVect on quality of life. Few studies have considered the eVects of thoracotomy alone on lung function, and whether the operation itself can impair subsequent exercise capacity. Methods-Patients being considered for lung resection (n = 106) underwent full static and dynamic pulmonary function testing which was repeated 3-6 months after surgery (n = 53). Results-Thoracotomy alone (n = 13) produced a reduction in forced expiratory volume in one second (FEV 1 ; mean (SE) 2.10 (0.16) versus 1.87 (0.15) l; p<0.05). Wedge resection (n = 13) produced a nonsignificant reduction in total lung capacity (TLC) only. Lobectomy (n = 14) reduced forced vital capacity (FVC), TLC, and carbon monoxide transfer factor but exercise capacity was unchanged. Only pneumonectomy (n = 13) reduced exercise capacity by 28% (PṼ O 2 23.9 (1.5) versus 17.2 (1.7) ml/min/kg; diVerence (95% CI) 6.72 (3.15 to 10.28); p<0.01) and three patients changed from a cardiac limitation to exercise before pneumonectomy to pulmonary limitation afterwards. Conclusions-Neither thoracotomy alone nor limited lung resection has a significant eVect on exercise capacity. Only pneumonectomy is associated with impaired exercise performance, and then perhaps not as much as might be expected.

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Seat-belt stomach transection is a very rare injury. We report the first known survivor of this injury. The patient had also sustained a 'Chance' vertebral fracture'. Case reportA 20-year-old woman was admitted to hospital following involvement in a two car head-on collision. She was a front-seat passenger wearing an inertia-reel lap and shoulder type seat belt. On arrival in the Accident and Emergency Department she was complaining of abdominal pain. Blood pressure was 130/80mmHg and pulse rate 100 per minute. Abdominal examination revealed bruising across the centre of her abdomen and at the right anterior superior iliac spine. She had generalized tenderness with guarding. While being examined she vomited a large amount of fresh blood. At laparotomy the peritoneal cavity was filled with blood and food debris. The stomach had been completely transected just proximal to the pylorus. No other abdominal injuries were discovered. Gastroduodenal continuity was restored and the peritoneal cavity was copiously irrigated. On the second postoperative day she complained of back pain. Lateral X-rays of her lumbar spine showed splitting-apart of the neural arch and posterior aspect of the body of the second lumbar vertebra. On the anteroposterior views separation of the transverse and spinous processes was visible ( Figure I ) . DiscussionShamblin* and Dajee3 have previously reported seat-belt stomach transection in young adult women, both of whom died from exsanguination. A clinical finding in both cases was central abdominal bruising; the 'seat-belt sign'4. If this sign is accompanied by evidence of peritoneal irritation, however minimal, intra-abdominal injuries should be suspected and laparotomy undertaken promptly.Seat belt injury to the stomach is very rare because of the stomach's relatively protected position. The distal part of the stomach is vulnerable in deceleration, as shearing forces come into play at the 'free-fixed' junction with resultant transection. Alternatively, when the empty stomach is suddenly and forcibly compressed against the vertebral column by a seat belt, vertical transection of the stomach may occur.Visceral and vertebral injuries frequently co-exist and one must be wary of falsely attributing signs of reflex ileus to a vertebral fracture in the presence of intra-abdominal injury. The 'Chance' fracture is a true flexion fracture typically seen in high velocity collisions5. It is surprisingly stable and after an initial period of bed-rest, a plaster jacket is fitted. The prognosis is excellent. 5.

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