SUMMARY The possibility that malabsorbed fat passing through the human ileum exerts an inhibitory feedback control on jejunal motility has been investigated in 24 normal subjects by perfusing the ileum with a fat containing solution designed to produce ileal luminal fat concentrations similar to those in steatorrhoea (30-40 mg/ml). Mean transit times through a 30 cm saline perfused jejunal segment were measured by a dye dilution technique. Thirty minutes after ileal fat perfusion, mean transit times rose markedly to 18 9±2 5 minutes from a control value of 7*5±0-9 minutes (n=5; p<005). This was associated with an increase in volume of the perfused segment which rose to 17541±229 ml (control 976±103 ml, n=5; p<005). Transit times and segmental volumes had returned towards basal values 90 minutes after completing the fat perfusion. Further studies showed that ileal fat perfusion produced a pronounced inhibition of jejunal pressure wave activity, percentage duration of activity falling from a control level of 40 3±5 0% to 14 9±2 8% in the hour after ileal perfusion (p<001). Ileal fat perfusion was associated with marked rises in plasma enteroglucagon and neurotensin, the peak values (218±37 and 68±13 1 pmol/l) being comparable with those observed postprandially in coeliac disease. These observations show the existence in man of an inhibitory intestinal control mechanism, whereby ileal fat perfusion inhibits jejunal motility and delays caudal transit of jejunal contents.

SUMMARY Previous studies have shown that ileal infusion of partially digested triglyceride inhibits jejunal motility. The partial digest used in those studies contained a mixture of glycerol, free fatty acid, mono-, di-, and triglycerides. In Part I of the present study we have separately infused emulsions containing either glycerol 3.1 g (n=6), oleic acid 9-6 g (n=6), triolein 10 g (n=12), or medium chain triglycerides 10 g (n=6) into the ileum and have recorded the effect this has on jejunal motility. Five further subjects received infusions of partial hydrolysates of corn starch 10 g and lactalbumin 7 g. Marked inhibition of jejunal pressure wave activity was seen after all three lipid infusions, per cent activity falling from a control of 37-7 (7.7) to 6-2 (2 1) and 22.4 (8.2)% 30 min after completing the oleic acid and triolein infusions respectively, and from a control value of 39.5 (4.1) to 17.7 (4.7) after MCTs (all p<005). No significant fall occurred after infusion of glycerol, protein or carbohydrate. All three lipid infusions raised plasma concentrations of neurotensin, enteroglucagon and peptide YY equally effectively, although only the rise in peptide YY correlated significantly with the inihibition ofjejunal pressure wave activity (r=0 80, n=6, p

Measurements of motility of the alimentary tract are important in the understanding of gut physiology and the mechanism of symptoms. While the oesophagus, stomach and small intestine are readily accessible by oral transtubation, this does not apply to the colon. Most of the published data on colonic intraluminal pressures (IP's) derive from tube assemblies, positioned in the bowel through a rigid sigmoidoscope. Consequently the more proximal parts of the large intestine, including the potentially very interesting sigmoid, have remained unexplored. In this study we report a method for placing pressure sensitive tube assemblies in the more proximal colon at colonoscopy. Results of intraluminal pressure measurements in the sigmoid colon in controls, patients with the irritable bowel syndrome (IBS), or with diverticular disease (DD) are described. residue diet for 48 h previously. Bowel cleansing was done with 1 1 oral mannitol 10% on the morning of colonoscopy, under sedation with pethidine 50 mg and diazepam 10-20 mg iv. After routine examination of the bowel to the caecum the colonoscope was withdrawn to the transverse colon and any loops present were straightened. Four angiology guide wires (Kimal Scientific 5SU400, length 4 m) were introduced into the bowel lumen through the biopsy channel; the colonoscope was then withdrawn, leaving the guide wires in situ. Radio-opaque open ended PVC tubes (OET's, length 1-7 m, id 1-2 mm) marked at intervals of 10 cm were threaded over each guide wire for approximately 1 m of their length. The guide wires were then withdrawn and the four OET's taped securely to the buttock.After a normal supper and the night spent in the ward, the patients returned to the laboratory, having fasted since midnight. The position of the OET's was adjusted under fluoroscopic control and with reference to the external markings, so, that the tips were at 25, 35, 45, and 55 cm from the anal margin (Fig.

The purpose of this paper is to identify the treatment patterns and corresponding costs of healthcare resource use associated with palliative care for different types of advanced cancer patients, from the time they started strong opioid treatment until death. This was a modelling study performed from the perspective of the UK's National Health Service (NHS). A data set was created comprising 547 patients in the DIN-Link database who had a Read code for malignant neoplasms with a specific tumour-type diagnosis and who received their first strong opioid between 1 January 1998 and 30 September 2000 and died during that period. Palliative care-related resource utilization data were obtained from the DIN-Link database. Unit costs at 2000/2001 prices were applied to the resource use estimates to determine the mean cost of palliative care from the start of treatment until death. There were significant differences in age between patients with different cancer types and in patients' survival from diagnosis, time to the start of palliative care and duration of palliative care. The mean duration from cancer diagnosis to the start of strong opioid treatment ranged from 0.7 to 5.4 years in patients with lung and breast cancer respectively. Moreover, the length of palliative care ranged from 180 to 372 days in patients with these cancer types respectively. There were also statistically significant differences in resource use between patients with different cancer types, but this reflected, in part, the varying durations of palliative care. Nevertheless, there were also differences in the monthly number of primary care visits reflecting the different number of monthly prescriptions. There was no apparent relationship between the length and corresponding cost of palliative care which ranged from 1816 pounds sterling for colon cancer to 4789 pounds sterling for ovarian cancer. Additionally, on average, only a third of all patients also received 4-hourly morphine as part of their initial strong opioid treatment. The total cost of palliative care varied between cancer type and reflects, at least in part, the distinct clinical features associated with different tumours and the varying lengths of survival following the start of strong opioid treatment. Nevertheless, no apparent relationship was found between length of palliative care and corresponding costs. This analysis provides data on palliative care resource use for a variety of cancers and could provide useful input when planning local healthcare strategies and building service commissioning models.

Summary:Ketorolac tromethamine is a newly available non-steroidal anti-inflammatory drug which is suitable for parenteral administration. We have given it by continuous subcutaneous infusion to 36 patients with pain due to advanced cancer. Improvement in pain control occurred in 29 (80%). A reduction in the dose of concomitant opioid analgesia was possible in 22 (76%) and a reduction in opioid-related adverse effects occurred in 16 (73%) of these. Ketorolac was most effective in patients who had bone or visceral pain. It was mixed safely with diamorphine in a syringe driver at concentrations up to 4 g diamorphine/10 ml and 120 mg ketorolac/10 ml. Infusion was well tolerated for periods of up to 115 days (mean 21 days; median 15 days; range 3-115 days). Four patients experienced gastrointestinal bleeding and one colonic perforation to which treatment with ketorolac may have been a contributory factor. No other clinically significant adverse effects were observed.

Little has been published on the use of imaging in palliative care. This paper discusses the use of 'in-house' ultrasound at the bedside in a specialist palliative care unit. The aim of this paper is to evaluate the potential uses of bedside ultrasound in the hospice population with consideration of length of stay and cost. A single operator scanned inpatients using ultrasound in the specialist palliative care unit. The majority of these scans were done to evaluate and mark complex ascites prior to paracentesis. Other indications included marking pleural fluid prior to chest drain insertion, evaluating renal appearances and imaging bladders. Scans were done in 40 patients over a 17-month period enabling subsequent successful paracentesis in 25. The reasons for other scans included renal failure, urinary obstruction and confirmation of clinical diagnosis of liver metastases. All scans were done on the day of admission. This paper provides an anecdotal experience in improving clinical care and convenience to patients and offers a potential tool for future evaluation as a bedside aid to clinical management. The results indicate a potential for a reduction in length of inpatient stay.

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Pain due to advanced malignant disease does not always respond to opioids, or the possible use of opioids may be limited by the occurrence of adverse effects. This paper describes the successful use of ketorolac, a new nonsteroidal anti-inflammatory drug, given by continuous subcutaneous infusion. Seven patients with pain due to advanced malignant disease taking opioid analgesia were considered to have inadequate symptom control because of opioid unresponsiveness (n = 1), opioid-related adverse effects (n = 2) or both (n = 4). All patients became symptom-free with the introduction of ketorolac by subcutaneous infusion and the total daily opioid requirement was substantially reduced in three and reduced to zero in four patients.