AimTo compare the treatment outcomes of a clinical pharmacist-managed anticoagulation service with physician-managed service in Chinese patients. MethodsA prospective, randomized clinical trial was conducted at the anticoagulation clinic of a teaching hospital in Hong Kong. Patients aged ≥ 18 years who would required warfarin therapy for at least 3 months were recruited. Patients were randomized to the pharmacist-managed or physician-managed group. Primary clinical outcome was assessed by the percentage of patient time spent within the target international normalized ratio (INR) range. The incidence of major thromboembolic events (TEs) and major bleeding was assessed as secondary clinical outcomes. The cost per patient per month (cPPPM) was calculated and patient satisfaction was assessed by patient satisfaction questionnaire (PSQ)-18. ResultsOne hundred and forty-one patients were recruited at the anticoagulation clinic and 137 patients completed the study. Patients in the pharmacist-managed group ( n = 68) were in the target INR 64% of patient time vs. 59% in the physicianmanaged group ( n = 69) ( P < 0.001). There was no significant difference in incidence of major TEs or bleeding. The cPPPM in the pharmacist-managed group (US$76 ± 95) (£43 ± 53) was lower than in the physician-managed group (US$98 ± 158) (£55 ± 89) ( P < 0.001). The PSQ-18 score of the pharmacist-managed group (3.8 ± 0.2) was higher than that of the physician-managed group (3.6 ± 0.3) ( P < 0.001). ConclusionThe pharmacist-managed anticoagulation service was more effective and less costly than the physician-managed service in achieving target anticoagulation control for Chinese patients on warfarin therapy.

Background: The purpose of this prospective study was to determine the value of water‐soluble contrast follow‐through radiology in predicting the outcome in patients with small bowel obstruction.Methods: Patients with clinical and radiological evidence of small bowel obstruction were selected according to pre‐set criteria. A water‐soluble contrast follow‐through examination using 76% urografin was carried out within 24 h of hospital admission. The result was interpreted as ‘significant obstruction’ if the contrast failed to reach the caecum in 4 h or if there was a clear cut‐off in the gastrointestinal tract. The result was interpreted as ‘insignificant obstruction’ if the contrast reached the caecum within 4 h. The surgeon was blinded to the result of the contrast examination in the patient management, and the decision to operate was based entirely on conventional clinical grounds.Results: Fifty‐one patients in an 18 month period underwent the contrast examinations. Thirty‐four patients (67%) had had previous abdominal operations. The results showed that significantly more patients who had ‘significant obstruction’ on contrast radiology required surgery to relieve the intestinal obstruction (17/19) than those who had ‘insignificant obstruction’ (1/32; Fisher's exact test, P < 0.0001). This difference was found to be significant in both patient subgroups: patients with or without previous abdominal operation. There was no major morbidity or mortality related to the contrast radiology procedure.Conclusions: Urografin follow‐through examination is a safe procedure; using 4 h as the cut‐off it is highly predictive of the outcome in small bowel obstruction in patients with or without previous abdominal operation.

Case reportsintermingled with normal pancreatic acini. Tubercle follicles were also seen in the rest of the pancreas. The serosal surface of the stomach was also coated with tuberculous nodules. Multiple tuberculous nodules were seen in the lungs.

SUMMARYIn the past six years, 37 patients with gastrointestinal bleeding of obscure origin had their bleeding sites localised preoperatively or intraoperatively. Preoperative investigations followed a regime consisting of endoscopy, barium meal and follow through, small bowel enema, 9mTc pertechnetate scan, 'mTc-labelled red blood cell scan and selective coeliac and mesenteric angiography. Bleeding lesions were localised preoperatively in 36 patients. In one patient, diagnostic laparotomy had to be carried out immediately before any investigation because the bleeding was severe. At operation, angiosarcoma of ileum was found. Unless preoperative investigations showed the lesions to be in anatomically fixed organs like the duodenum or colon, the lesions had still to be found at operation. Palpation and transillumination detected the lesion intraoperatively in 21 patients while only some lesions were found in three patients with multiple lesions. Sigmoidoscopy through enterotomies was required in one patient. Intraoperative enteroscopy was done for small lesions not found grossly at operation in nine patients, to detect additional lesions in three patients or to rule out suspicious lesion shown on preoperative tests in one patient. In another patient with diffuse lymphoma of small bowel with bleeding from only a small segment of jejunum, injection of methylene blue intraoperatively through a previously placed angiographic catheter stained the bleeding segment of jejunum blue. This segment was identified easily and resected. These preoperative and intraoperative localisation procedures were simple and effective and we recommend them to be used more freely.

A 22-year-old man with blue rubber-bleb nevus syndrome is reported on. This is a rare syndrome. This patient is of particular interest because he had a combination of rare features: (1) five ileo-ileal intussusceptions each with a hemangioma acting as the lead point, were present during operation; (2) there was an angiomatous lesion of the glans penis; (3) this is the first case reported in a Chinese person. An aggressive surgical approach was used with success. Preoperative and perioperative investigations, including operative colonoscopy, were used to localize the gastrointestinal hemangiomas.

Objective: Postoperative adhesive intestinal obstruction is the most common cause of small bowel obstructions in adults. The use of water-soluble contrast follow-through has been shown to be safe with a high predictive value for surgery. This study aims to evaluate the impact of contrast follow-through on clinical outcomes of patients with adhesive small bowel obstructions. Methods: From July 1994 to June 1998, 150 patients were recruited into the study and randomized into two groups. One group ( n = 75) received water-soluble contrast follow-through within 24 h of admission, whereas the control group ( n = 75) did not. Both groups were put on conservative management and the outcomes measured included operative rate, postoperative morbidities, length of hospital stay and mortality. Results: The operative rate of both groups was similar (33.3 vs 38.7%, P = 0.496). The preoperative observation period (42 vs 65 h. P = 0.014) and the total median hospital stay (5 vs 7 days, P = 0.025) of the contrast group were significantly shorter than those of the control group. No significant difference could be found between the two groups in terms of postoperative morbidities and mortalities. Conclusions: In managing patients suspected to have adhesive small bowel obstruction, water-soluble contrast follow-through expedites the decision process for surgical intervention, which translates into a shorter hospital stay.

enteroscopy for bleeding lesions in the small intestineTwenty-five patients with gastrointestinal bleeding proved to have lesions in the small intestine. Intra-operative fibreoptic enteroscopy was performed on seven patients, in six patients through the anus and in one patient through an enterotomy and the anus. The indications for fibreoptic enteroscopy were inability tofind the lesions in the 3 patients, multiple small lesions in 3 patients and to rule out suspicious pathology in the jejunum shown on a small bowel enema in a patient with ileal ulcers. In all instances, thefibreoptic enteroscopy was useful in localizing lesions, in detecting additional lesions and in ruling out the suspicious lesions. I t can be performed easily and is safe. N o complication developed from its use in this series.

In the past 9 years, we have operated on 56 patients with gastrointestinal bleeding of obscure origin. Selective visceral angiography demonstrated the bleeding lesions in 24 of the 30 patients who underwent this investigation. Six of these 24 patients, however, had a negative angiogram initially and the lesions were only demonstrated on a repeat angiogram. The negative initial angiograms were due to: (1) slow bleeding from lesions in two patients; (2) a small bleeding tumour that caused only intermittent jejunojejunal intussusception in one patient; (3) technical fault in one patient; and (4) spasm of the bleeding vascular lesions and their feeding arteries in two patients. We advocate repeat angiography the following day in all patients in whom profuse bleeding continues, and during the next intestinal bleeding in those whose bleeding stops after the initial negative angiography. In patients who have repeated episodes of massive bleeding, and in whom full investigations fail to reveal the bleeding source, repeat angiography carried out 4 weeks after the bleeding has stopped can sometimes demonstrate the vascular lesions.