Fifty-eight patients with uncomplicated diverticular disease of the colon took bran crispbread, ispaghula drink, and placebo for four months each in a randomised, cross-over, double-blind controlled trial. Assessments were made subjectively, using a monthly self-administered questionnaire, and objectively, by examining a seven-day stool collection at the end of each treatment period. In terms of a pain score, lower bowel symptom score (the pain score and sensation of incomplete emptying, straining, stool consistency, flatus, and aperients taken), and total symptom score (belching, nausea, vomiting, dyspepsia, and abdominal distension) fibre supplementation conferred no benefit. Symptoms of constipation, however, when assessed alone, were significantly relieved. Both fibre regimens produced the expected changes in stool weight, consistency, and frequency.It is concluded that dietary fibre supplements in the commonly used doses do no more than relieve constipation. Perhaps the impression that fibre helps diverticular disease is simply a manifestation of Western civilisation's obsession with the need for regular frequent defecation.

Non-operative management of acute necrotizing pancreatitis carries a mortality of up to 80 per cent. Over the last 6 years we have pursued an aggressive policy of intensive supportive therapy followed by pancreatic resection in those patients with this severe form of the disease. We have managed 15 patients in this way, 14 by subtotal pancreatic resection (usually body and tail of the gland) and one by total pancreatectomy; 7 had early overwhelming multi-system failure with a median of 4 positive prognostic factors whilst 8 were operated on later between 3 and 8 weeks (plus one at 32 weeks) and had varying clinical pictures. Eight patients had ischaemia of the transverse colon which was noted at operation in four, and presented postoperatively in the remainder. Re-operation was necessary in 13 patients to remove further slough or resect ischaemic bowel. Five patients (33 per cent) died between 10 days and 4 weeks postoperatively, death being due to sepsis and multi-system failure in four and a massive retroperitoneal haemorrhage in one. Of the ten survivors, four require insulin. Timely excision of necrotic pancreatic tissue combined with intensive supportive therapy may help reduce the high mortality in this condition.

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globulin have a strong but not exclusive influence.' Changes in albumin have only a minor effect, but paraproteins2 and lipoproteins3 also increase plasma and serum viscosity. For these reasons estimations of plasma fibrinogen from the difference of plasma and serum viscosity are unreliable and can be wrong by as much as 100",.1 According to the authors' own reasoning a quantitative plasma protein determination (electrophoresis) therefore should be more reliable as a predictor of early rheumatic conditions.

Ductal carcinoma in situ (DCIS) now represents up to 20% of breast cancer cases, yet its behaviour is still poorly understood. Morphological classifications go some way to predicting prognosis, but more sophisticated approaches are required to better tailor therapy to the individual. A number of biological molecules have been identified that appear to relate to prognosis and, in model systems, promote progression to invasive disease. Some of these, such as COX-2, provide real therapeutic opportunities, whilst other marker combinations are showing promise in categorising women according to risk. Gene expression studies have led to an emerging molecular classification of invasive breast cancer, and it is now evident that at least some of these molecular subtypes can be identified at the pre-invasive stage. The difference in frequency of these subtypes between DCIS and invasive cancer may hold clues as to the biological mechanisms underpinning disease transition. It is increasingly clear that the host microenvironment can have a major impact on disease behaviour, and as well as acting as potential predictive factors, the altered microenvironment phenotype also offers novel therapeutic opportunities.

This paper is based upon findings from the qualitative element of a mixed-methods study on the response of Black women aged 25-50 to a public health intervention related to breast cancer. The focus groups were conducted in the London Borough of Hackney, UK between 2013 and 2016, and were part of an evaluation of the effectiveness of a breast awareness DVD. While the content of the DVD was generally well-received by the participants, the focus group discussions revealed a complex and, at times, contradictory response to the women's construction as an 'at risk' community. As the paper highlights, for many of the women, breast cancer remains a disease of whiteness and the information provided in the DVD prompted a range of emotional responses; from anxiety and fear to a desire to become more knowledgeable and active in the promotion of self-care. As the paper argues, of particular importance to the women was the need to feel a much stronger emotional connection to the information presented in the DVD. The paper concludes by arguing that placing greater emphasis on feeling and emotion is an important dimension of future research in this area.

A 59-year-old lady presented with malaise, abdominal pain and a low grade pyrexia. After investigation, polymyalgia rheumatica was dmgnosed and she was treated with steroids.However, her condition deteriorated and at diagnostic laparotom a lower pole tumour of the right kidney was found. After conlrming normal function and anatomy of the left kidney by an on-table intravenous pyelogram, she had a right nephrectomy. The renal vein was not involved and the regional lymph nodes were normal. Histology showed a moderately well-differentiated clear cell adenocarcinoma of the kidne After 3 years of excellent health she presented with painress haematuria. Cytoscopy was normal but an IVP and a left retrograde pyelogram showed a filling defect in the mid-ureter, with proximal dilatation of the renal pelvis and calyces (Fig. 1).The left ureter was explored and a soft 2-cm swelling was found in the mid-ureter. She had a wedge resection of the ureter, including the twnour with its pedicle. Histology of the lesion showed secondary adenocarcinoma of the kidney. Later, angiography of her remaining left kidney showed a small tumour at the upper pole and a separate smaller one on the medial aspect.The left kidney was explored and these two well-demarcated and almost encapsulated tumours were excised locally. The renal vein and the para-aortic nodes felt normal. Histology of each tumour showed primary clear cell adenocarcinoma.The patient made an excellent recovery and at 1 year followup remains in good health with no residual symptoms or evidence of recurrence.

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