The sensitivity of diagnostic serum amylase (>1000 iu/l) was assessed in 417 patients with acute pancreatitis as a r'esult of gall stones (258) The serum amylase activity rises sharply within the first 24 hours of an attack of acute pancreatitis and then declines steadily to normal levels over the following 5-7 days.' 2 Although a number of abdominal and extra-abdominal conditions can result in a high amylase activity,3 in patients with an appropriate clinical picture, the specificity and the sensitivity are well over 90%.45 With the generally available Phadebas method (normal range 70-300 iu/l), the level diagnostic of acute pancreatitis is considered to be > 1000-1200,' 56although an MRC study used a level >2000 iu/1.7 However, any value above the upper limit of normal is sometimes used by authors from Europe8 and North America.9 While it is generally stated that the amylase activity has no prognostic importance,' " precise details relating this to both aetiology and the severity of the attack are surprisingly lacking.A number of studies have challenged the primary diagnostic role of serum amylase, and a case has been made for the use of serum lipase instead,3 2 13 as it remains raised for a slightly longer period.'4 In a study in which computed tomography was used8 to assess the pancreas, a normal amylase activity (<160 iu/l) was seen in 19% of 352 attacks of acute pancreatitis;8 implicitly, a diagnostic level in this study was taken as any value above the upper limit of normal. No difference was found between patients with a normal serum amylase value and the subsequent clinical course. Most patients presented at least two days after the onset of the attack, 34% had a gall stone aetiology, and 29% had a clinically severe course.8 If the results in this study were applicable to Britain, these would strengthen the case for the routine use of lipase. The value of amylase determination as a diagnostic tool may be influenced by the prevalence of different aetiological factors, the proportion of severe attacks, and the time that patients are usually admitted to hospital after the onset ofan attack, and the present study was undertaken to assess these relations in two hospitals from the Midlands region of England.

This is the largest study to audit the impact of HIV/AIDS in general surgical practice in the UK retrospectively. Surgery for HIV patients can be safely conducted with a low complication rate for the diagnostic and anorectal procedures that comprise the vast majority of surgery in HIV/AIDS patients. Medical treatment for patients with HIV/AIDS has developed dramatically over the last two decades. In parallel, this has resulted in a heavy, new and varied workload for general surgeons, who have also had to adapt in order to deal with the challenging spectrum of this disease.

Summary The tumour vasculature is vital for the establishment, growth and metastasis of solid tumours. Its physiological properties limit the effectiveness of conventional anti-cancer strategies. Therapeutic approaches directed at the tumour vasculature are reviewed, suggesting the potential of anti-angiogenesis and the targeting of vascular proliferation antigens as cancer treatments.

Tetanus remains an important disease worldwide. In the United Kingdom, the elderly and intravenous drug users are at particular risk of acquiring clinical tetanus. Tetanus is associated with a high morbidity and mortality. Once the diagnosis of tetanus is suspected, intensive management is necessary. In this article we review the history, epidemiology, microbiology, clinical features, mode of transmission, pathogenesis, differential diagnosis, management, complications and prevention of this life threatening disease.