- Email: [email protected]
COLONOSCOPY—ESSENTIAL SERVICE IN A GENERAL HOSPITAL
1311
Court-Brownl° did
effects in malignant melanoma and renal cell carcinoma. Maybe the negative results obtained by some, groups were partly due to incorrect timing of thymic hormone treatment in relation to cytotoxic tumour
drugs. It will
clearly be a long time before thymic hormone
therapy comes of age. There must be better understanding of which cells respond to which peptides, and assays are needed that are simple enough for routine use. Meanwhile there are already a few clinical applications for the hormones which should be enough to sustain physicians’ interest in the subject.
THE practice of shaving patients’ skin preoperatively probably dates from the days of Lister and Semmelweis.’ Many surgeons still regard hair as a source of contamination and insist on extensive skin depilation, usually with a disposable razor on the day before surgery. Scanning electron micrographs have shown that any skin shave acceptable to the surgeon causes epidermal damage and permits bacterial colonisation of the skin.2 A shave on the day before surgery will increase the degree of colonisation and therefore, presumably, the chance of wound infection.3,4 Although several workers had shown that a depilatory cream is not harmful to skin,4-6 the traditional preoperative shave remained unchallenged until 1971. Seropian and Reynolds compared two matched groups of patients and showed that the postoperative wound infection rate after use ofadepilatory cream was only 0’ 6%, compared with 5’ 6% in the group having a traditional shave. The wounds were graded according to the system of the American National Research Council,8 which separates operations into clean, clean-contaminated, contaminated, or dirty according to the degree of potential infection. No wound infections were ’
found in the clean and clean-contaminated groups after use of a depilatory cream whereas in the same categories managed with a razor the infection rate was 6’4%. 155 patients were excluded from this trial because they had had no preoperative skin preparation; the overall wound infection rate in this group was only 0’6%. These findings were confirmed by Cruse and Foord9 who studied 23 649 surgical wounds prospectively. The same wound grading system was used and in the 18 090 clean wounds that were examined there was a 2’ 3% infection rate after shaving, as against 0-9% with no skin preparation. 1.
Wangensteen OH, Wangensteen SO. The rise of surgery from empiric craft to scientific discipline. Minneapolis: University of Minnesota Press, 1978. 353. 2. Hamilton HW, Hamilton KR, Lone FJ. Pre-operative hair removal. Can J Surg 1971; 20: 269-75. 3. Altemeier WA. Infection in
hospitals. Epidemiology and control. In: Williams R, Shooter RA, eds. Oxford: Blackwell, 1963: 209. 4. Prigot A, Garnes AL, Nwagbo U. Evaluation of achemical depilatory for pre-operative preparation of 515 surgical patients. Am J Surg 1962; 104: 900-06. 5. Stephens FO. The use of a depilatory cream in surgery. Med J Aust 1966; i: 886-88. 6. Almersjo O, Hulten L, Rydberg B, Wahlquist L, Amren C. Wound healing after depilation with a meratolytic cream. Acta Chir Scand 1967; 133: 355-62. 7 Seropian B, Reynolds BM. Wound infections after pre-operative depilatory versus razor preparation. Am J Surg 1971; 121: 251-54. 8. Howard JM, Barker WF, Culbertson WR, et al. Post-operative wound infections: The influence of ultraviolet irradiation of the operating room and of various other factors. Ann Surg 1964; 160 (suppl); 1-192. 9 Cruse PJE, Foord R. A five-year prospective study of 23 649 surgical wounds. Arch Surg 1973; 107:
206-10.
prospective study
on
patients
statistically significant. The role ofpreoperative hair clipping has been investigated by Alexander et al." In populations again matched according to the ANRC grading system the infection rate in the clean 4’ 0% in the shaved group and 1’ 4% in the clipped group. Despite the low infection rate with clipping, these workers felt that the method entailed some skin damage and that infection rates might be higher than those after
wounds
PREOPERATIVE DEPILATION
a
undergoing abdominal surgery, comparing the effect of shaving, cream depilation, and no preparation on the postoperative wound infection rate. The same wound grading system was used and the surgical materials and use of peroperative antibiotics were standardised. The overall infection rates were 12-4% after shaving, 7-9% after cream depilation, and 7-8% with no preparation. When only the clean and clean-contaminated wounds were compared the infection rate after shaving was 10’4%, as against 3-9% for the cream group and 2 - 9% for the no preparation group. The increase in the infection rate in the shaved group was
cream
was
depilation or no preparation.
The timing of the skin preparation affects the wound infection rate. If the interval between a preoperative shave and subsequent surgery is prolonged, the infection rate rises. 7, 10 Seropian and Reynolds showed that if the shave was done immediately before operation the infection rate was 3’1%. Extending the interval to over twenty-four hours increased the infection rate to more than 20%. This time difference is not seen with depilatory creams. 10 Since preoperative shaving increases the rate of postoperative wound infection, this traditional surgical practice should be dropped. If the surgeon wishes to have a hairless field then a depilatory cream should be used; failing that, the preoperative shave should be done immediately before surgery. A depilatory cream is particularly useful in orthopaedic or cardiothoracic surgery where shaving is difficult. Hair clippers undoubtedly lower the incidence of wound infection but probably still cause skin damage. Wound infections delay patient discharge by an average of 7’ 312 to 9. 113 days. It has been suggested that if the practice of preoperative shaving was abandoned in the USA, the annual saving could exceed$3 billion.l
COLONOSCOPY—ESSENTIAL SERVICE IN A GENERAL HOSPITAL THE first British reports of complete examination of the colon with a flexible endoscope were published about ten years ago.I,2 At the time, most clinicians were happy with rigid sigmoidoscopy and barium enema, and were less than enthusiastic about colonoscopy, because the instruments were expensive and fragile and the techniques were more exacting and time-consuming than those of fibreoptic gastroscopy. This has all changed. The ability to examine the 10. Court-Brown CM.
Pre-operative skin depilation and its effect on post-operative wound infections. J Roy Coll Surg Edinb 1981; 26: 238-41. 11. Alexander JW, Fischer JE, Boyajian M, Palmquist J, Morris MJ The influence of hairremoval methods on wound infections: Arch Surg 1983; 118: 347-52. 12. Lowenthal J. Sources and sequelae of surgical sepsis. Br Med J 1962; i: 1437-40. 13. Cruse PJE. Incidence of wound infection on the surgical services. Surg Clin N Am 1975; 55: 1269-75. CB, Muto T. Examination of the whole colon with the fibreoptic colonoscope. Br Med J 1972; iii: 278-81. Teague RH, Salmon PR, Read AE. Fibreoptic examination ofthe colon: a review of 255
1. Williams 2.
cases.
Gut 1973; 14: 139-42.
1312 an outpatient in less than 30 min,3 with endoscopy is the only real advance in the diagnosis and treatment of such polyps since the introduction of the barium scarcely any ill-effects,4 has added a new dimension to colonic enema 60 years ago. It may hold the key to earlier diagnosis diagnosis and therapy. Equivocal radiological findings can be clarified and occult bleeding exposed; most importantly, and to cure of colonic cancer. mucosal and cancers3 can be excised polypoidal polyps without colotomy. The resultant decline in formal inpatient surgery for early polypoidal neoplasms and angiomatous malformations of the colon3has led to savings in terms of inpatient investigations, theatre time, convalescent facilities, SEASONALITY, DOWN’S SYNDROME, AND and absence from work-counterbalanced, admittedly, by the S ANENCEPHALY and revenue of the unit. capital consequences endoscopy A colonoscopy service needs careful planning with good "COMING into season" is a well-known phenomenon in nursing and secretarial cover and a commitment of at least cyclically breeding animals. In man there is no clear-cut one medical session a week.5 Where money is tight, other breeding season but ample evidence of seasonal variation in endoscopic procedures may have to be included, or the birth numbers.’ The pattern is similar in most countries in service may have to be one element of a day case or outpatient Europe, is generally the opposite in the southern hemisphere, theatre facility. Every district general hospital should now and is different in the usN but varies regionally.3 Among offer full colonoscopy as a method of secondary screening and the biological factors that have been invoked are seasonal treatment. Surgeons, gastroenterologists, and clinical variation in conception frequency due to variation in female assistants have all become successful and experienced endocrinological function,4-6 in fecundability,7 in sex drive, colonoscopists after initial instruction at a teaching centre and in intercourse frequency;8variation in pregnancy loss;9 The complication rate for diagnostic examination is between and the effects of climate itself.9 Among the social have been 1 in 300 and 1 in 700, and for therapeutic procedures 1 in illegitimacy,10 poverty, class, 11,12 the distribution of holiday 200.4 These figures compare favourably with the 20% periods,2 the effect of the fiscal year, 13 migrant labour of morbidity after transabdominal colotomy and polypectomy.6 spouses,and the yearly distributions of work activity As operators gain experience and instruments become more patterns,14,15 again related to climate. versatile the complication rate of colonoscopy can be Seasonal variation in incidence of specific disorders usually expected to decline. points to environmental factors, though precise identification Most colonic disease is in the distal bowel, and the advent of may be difficult, as with the neural tube defects. 16 Changes in the flexible fibreoptic sigmoidoscope-a short colonoscopeseasonal pattern could reflect changes not in the disorder has led to re-evaluation of the role of rigid sigmoidoscopy and itself but in associated environmental conditions, just as barium enema.A complete endoscopic examination of the trends in the outbreaks of salmonella food-poisoning seem to colon is generally undertaken as a secondary procedure-after reflect changing patterns of animal husbandry. 17 Differences rigid sigmoidoscopy and double-contrast radiology-because in seasonal suggest aetiological pattern may it is time-consuming and requires cathartic bowel between omphalocele and heterogeneity-for example, preparation.Flexible fibreoptic sigmoidoscopy to 60 cm Some seasonal associations have been gastroschisis. 18 (often to the splenic flexure) is well tolerated by most patients as to hormonal interpreted responses cyclical phenomena, without sedation, requires no more than two phosphate influenced by extrinsic seasonal variables: one such is again enemas as preparation, and usually takes about 5 min. It can hypospadias, mediated by hCG fluctuations;r9 another is be done as a primary procedure in the outpatient department when a left-sided colonic lesion is suspected. Rigid 1. Cowgill UM The of birth Ecology 1966; 47: 614. sigmoidoscopy is clearly under threat, and so too perhaps, is 2. Parkes AS. Seasonal variation human sexual activity. In: Thoday JM, Parkes AS, eds Genetic and environmental influences behaviour Edinburgh Oliver & Boyd. barium enema for diagnosis of distal colonic disease, although 1968:31. the irritant effects of the enemas preliminary to endoscopy 3. Macfarlane WV, Spalding D. Seasonal conception Australia. Med J Aust 1960. 1: 121. may obscure fine abnormalities in the texture and granularity 4. Arendt J, Wirz-Justice A, Bradtke J, Kornemark M. Long-term studies of the colonic mucosa. The flexible sigmoidoscope may also, immunoreactive human melatonin. Ann Clin Biochem 1979; 16: 307 on occasion, be used instead of a long colonoscope-eg, where 5. Sundararaj J, Chern M, Gatewood L, Hickman L, McHugh R Seasonal behaviour of human menstrual cycles. biometric investigation. Hum Biol 1978; 50: 15 double-contrast radiology has identified a solitary ’polyp in 6. Tarquini B, Gheri R, Romano S, Costa A, Cagnom M, Keun Lee F, Halberg F be the descending colon-allowing the long instruments to Circadian mesor-hyperprolactinaemia fibrocystic mastopathy. Am J Med 1979. 66: 229. reserved for the more extensive procedures. At least one 7. Chen LC, Gesche MC, Moseley WH. A prospective study of birth interval dynamics in flexible sigmoidoscope should be available in each endoscopy rural Bangladesh. Population Studies 1974; 28: 277 8. Becker S. Seasonality of fertility unit to complement the long instrument and to introduce Matlab, Bangladesh. J Biosoc Sci 1981, 13: 97 9. Bernard RP, Bhatt RV, Potts DM, Rao AP. Seasonality of births India. J Biosoc Sci neophyte endoscopists to the techniques of the examination. 1978; 10: 409. 10. James WH. Social class and of birth. J Biosoc Sci 1971, 3: 309 Large bowel cancer is the second most common cause of 11. Record RG. Anencephalus Scotland. BrJ Prev Soc Med 1961, 15: 93 death from malignant disease in the Western world. It seems 12. Zelnik M. Socioeconomic and seasonal variations births Millbank Mem Fund Quar to originate at least partly in premalignant adenomatous Bull 1969; 47: 159. 13. Anon. Rush of "rebate" babies. Times 27 April, 1966, p 6. polyps,8 usually in the left side of the colon. Flexible colonic 14. Scaglion R, Condon RG. Abilam Yam beliefs and socio-rhythmicity. J Biosoc Sci 1979.
whole colon of
.
m man.
season
in
on
rates in
on
a
in
in
in
season
in
in
11: 17.
3. Hunt RH. Towards safer colonoscopy. Gut 1983; 24: 371-75. 4. Macrae FA, Tan KG, Williams CB. Towards safter colonoscopy: a report on the complications of 5000 diagnostic or therapeutic colonoscopies. Gut 1983; 24: 376-83. 5. Britton DC, Tregoning D, Bone G, McKelvey STD. Colonoscopy in surgical practice. Br Med J 1977; i: 149-51. 6. Kleinfield G, Gump FE. Complications of colotomy and polypectomy. Surg Gynecol Obstet 1960; 111: 726-28. 7. Nicholls RJ Sigmoidoscopy. Br J Hosp Med 1982; 28: 59-66. 8. Morson BC. Genesis of colorectal cancer Clin Gastroenterol 1975; 8: 505-24.
Ogum GEO, Okorafor AE. Seasonality of births in south-eastern Nigeria J Biosoc Sci 1979; 11: 209. 16. Buckley MR, Erten O. The epidemiology of anencephaly and spina bifida in Izmir; Turkey. J Epidem Commun Health 1979; 33: 186. 17. Galbraith NS, Forbes P, Clifford C. Communicable disease associated with milk and dairy products in England and Wales, 1951-80. Br MedJ 1982, 284: 1761 18. Hemminki K, Salaniemi I, Kyyronen P, Kekomaki M. Gastroschisis and omphalocele in Finland in the 1970s. J Epidem Commun Health 1982, 36: 289. 19. Neto MR, Castilla EE, Paz JE. Hypospadias, an epidemiological study Am J Med
15.
Genet 1981; 10: 5.
Court-Brownl° did
effects in malignant melanoma and renal cell carcinoma. Maybe the negative results obtained by some, groups were partly due to incorrect timing of thymic hormone treatment in relation to cytotoxic tumour
drugs. It will
clearly be a long time before thymic hormone
therapy comes of age. There must be better understanding of which cells respond to which peptides, and assays are needed that are simple enough for routine use. Meanwhile there are already a few clinical applications for the hormones which should be enough to sustain physicians’ interest in the subject.
THE practice of shaving patients’ skin preoperatively probably dates from the days of Lister and Semmelweis.’ Many surgeons still regard hair as a source of contamination and insist on extensive skin depilation, usually with a disposable razor on the day before surgery. Scanning electron micrographs have shown that any skin shave acceptable to the surgeon causes epidermal damage and permits bacterial colonisation of the skin.2 A shave on the day before surgery will increase the degree of colonisation and therefore, presumably, the chance of wound infection.3,4 Although several workers had shown that a depilatory cream is not harmful to skin,4-6 the traditional preoperative shave remained unchallenged until 1971. Seropian and Reynolds compared two matched groups of patients and showed that the postoperative wound infection rate after use ofadepilatory cream was only 0’ 6%, compared with 5’ 6% in the group having a traditional shave. The wounds were graded according to the system of the American National Research Council,8 which separates operations into clean, clean-contaminated, contaminated, or dirty according to the degree of potential infection. No wound infections were ’
found in the clean and clean-contaminated groups after use of a depilatory cream whereas in the same categories managed with a razor the infection rate was 6’4%. 155 patients were excluded from this trial because they had had no preoperative skin preparation; the overall wound infection rate in this group was only 0’6%. These findings were confirmed by Cruse and Foord9 who studied 23 649 surgical wounds prospectively. The same wound grading system was used and in the 18 090 clean wounds that were examined there was a 2’ 3% infection rate after shaving, as against 0-9% with no skin preparation. 1.
Wangensteen OH, Wangensteen SO. The rise of surgery from empiric craft to scientific discipline. Minneapolis: University of Minnesota Press, 1978. 353. 2. Hamilton HW, Hamilton KR, Lone FJ. Pre-operative hair removal. Can J Surg 1971; 20: 269-75. 3. Altemeier WA. Infection in
hospitals. Epidemiology and control. In: Williams R, Shooter RA, eds. Oxford: Blackwell, 1963: 209. 4. Prigot A, Garnes AL, Nwagbo U. Evaluation of achemical depilatory for pre-operative preparation of 515 surgical patients. Am J Surg 1962; 104: 900-06. 5. Stephens FO. The use of a depilatory cream in surgery. Med J Aust 1966; i: 886-88. 6. Almersjo O, Hulten L, Rydberg B, Wahlquist L, Amren C. Wound healing after depilation with a meratolytic cream. Acta Chir Scand 1967; 133: 355-62. 7 Seropian B, Reynolds BM. Wound infections after pre-operative depilatory versus razor preparation. Am J Surg 1971; 121: 251-54. 8. Howard JM, Barker WF, Culbertson WR, et al. Post-operative wound infections: The influence of ultraviolet irradiation of the operating room and of various other factors. Ann Surg 1964; 160 (suppl); 1-192. 9 Cruse PJE, Foord R. A five-year prospective study of 23 649 surgical wounds. Arch Surg 1973; 107:
206-10.
prospective study
on
patients
statistically significant. The role ofpreoperative hair clipping has been investigated by Alexander et al." In populations again matched according to the ANRC grading system the infection rate in the clean 4’ 0% in the shaved group and 1’ 4% in the clipped group. Despite the low infection rate with clipping, these workers felt that the method entailed some skin damage and that infection rates might be higher than those after
wounds
PREOPERATIVE DEPILATION
a
undergoing abdominal surgery, comparing the effect of shaving, cream depilation, and no preparation on the postoperative wound infection rate. The same wound grading system was used and the surgical materials and use of peroperative antibiotics were standardised. The overall infection rates were 12-4% after shaving, 7-9% after cream depilation, and 7-8% with no preparation. When only the clean and clean-contaminated wounds were compared the infection rate after shaving was 10’4%, as against 3-9% for the cream group and 2 - 9% for the no preparation group. The increase in the infection rate in the shaved group was
cream
was
depilation or no preparation.
The timing of the skin preparation affects the wound infection rate. If the interval between a preoperative shave and subsequent surgery is prolonged, the infection rate rises. 7, 10 Seropian and Reynolds showed that if the shave was done immediately before operation the infection rate was 3’1%. Extending the interval to over twenty-four hours increased the infection rate to more than 20%. This time difference is not seen with depilatory creams. 10 Since preoperative shaving increases the rate of postoperative wound infection, this traditional surgical practice should be dropped. If the surgeon wishes to have a hairless field then a depilatory cream should be used; failing that, the preoperative shave should be done immediately before surgery. A depilatory cream is particularly useful in orthopaedic or cardiothoracic surgery where shaving is difficult. Hair clippers undoubtedly lower the incidence of wound infection but probably still cause skin damage. Wound infections delay patient discharge by an average of 7’ 312 to 9. 113 days. It has been suggested that if the practice of preoperative shaving was abandoned in the USA, the annual saving could exceed$3 billion.l
COLONOSCOPY—ESSENTIAL SERVICE IN A GENERAL HOSPITAL THE first British reports of complete examination of the colon with a flexible endoscope were published about ten years ago.I,2 At the time, most clinicians were happy with rigid sigmoidoscopy and barium enema, and were less than enthusiastic about colonoscopy, because the instruments were expensive and fragile and the techniques were more exacting and time-consuming than those of fibreoptic gastroscopy. This has all changed. The ability to examine the 10. Court-Brown CM.
Pre-operative skin depilation and its effect on post-operative wound infections. J Roy Coll Surg Edinb 1981; 26: 238-41. 11. Alexander JW, Fischer JE, Boyajian M, Palmquist J, Morris MJ The influence of hairremoval methods on wound infections: Arch Surg 1983; 118: 347-52. 12. Lowenthal J. Sources and sequelae of surgical sepsis. Br Med J 1962; i: 1437-40. 13. Cruse PJE. Incidence of wound infection on the surgical services. Surg Clin N Am 1975; 55: 1269-75. CB, Muto T. Examination of the whole colon with the fibreoptic colonoscope. Br Med J 1972; iii: 278-81. Teague RH, Salmon PR, Read AE. Fibreoptic examination ofthe colon: a review of 255
1. Williams 2.
cases.
Gut 1973; 14: 139-42.
1312 an outpatient in less than 30 min,3 with endoscopy is the only real advance in the diagnosis and treatment of such polyps since the introduction of the barium scarcely any ill-effects,4 has added a new dimension to colonic enema 60 years ago. It may hold the key to earlier diagnosis diagnosis and therapy. Equivocal radiological findings can be clarified and occult bleeding exposed; most importantly, and to cure of colonic cancer. mucosal and cancers3 can be excised polypoidal polyps without colotomy. The resultant decline in formal inpatient surgery for early polypoidal neoplasms and angiomatous malformations of the colon3has led to savings in terms of inpatient investigations, theatre time, convalescent facilities, SEASONALITY, DOWN’S SYNDROME, AND and absence from work-counterbalanced, admittedly, by the S ANENCEPHALY and revenue of the unit. capital consequences endoscopy A colonoscopy service needs careful planning with good "COMING into season" is a well-known phenomenon in nursing and secretarial cover and a commitment of at least cyclically breeding animals. In man there is no clear-cut one medical session a week.5 Where money is tight, other breeding season but ample evidence of seasonal variation in endoscopic procedures may have to be included, or the birth numbers.’ The pattern is similar in most countries in service may have to be one element of a day case or outpatient Europe, is generally the opposite in the southern hemisphere, theatre facility. Every district general hospital should now and is different in the usN but varies regionally.3 Among offer full colonoscopy as a method of secondary screening and the biological factors that have been invoked are seasonal treatment. Surgeons, gastroenterologists, and clinical variation in conception frequency due to variation in female assistants have all become successful and experienced endocrinological function,4-6 in fecundability,7 in sex drive, colonoscopists after initial instruction at a teaching centre and in intercourse frequency;8variation in pregnancy loss;9 The complication rate for diagnostic examination is between and the effects of climate itself.9 Among the social have been 1 in 300 and 1 in 700, and for therapeutic procedures 1 in illegitimacy,10 poverty, class, 11,12 the distribution of holiday 200.4 These figures compare favourably with the 20% periods,2 the effect of the fiscal year, 13 migrant labour of morbidity after transabdominal colotomy and polypectomy.6 spouses,and the yearly distributions of work activity As operators gain experience and instruments become more patterns,14,15 again related to climate. versatile the complication rate of colonoscopy can be Seasonal variation in incidence of specific disorders usually expected to decline. points to environmental factors, though precise identification Most colonic disease is in the distal bowel, and the advent of may be difficult, as with the neural tube defects. 16 Changes in the flexible fibreoptic sigmoidoscope-a short colonoscopeseasonal pattern could reflect changes not in the disorder has led to re-evaluation of the role of rigid sigmoidoscopy and itself but in associated environmental conditions, just as barium enema.A complete endoscopic examination of the trends in the outbreaks of salmonella food-poisoning seem to colon is generally undertaken as a secondary procedure-after reflect changing patterns of animal husbandry. 17 Differences rigid sigmoidoscopy and double-contrast radiology-because in seasonal suggest aetiological pattern may it is time-consuming and requires cathartic bowel between omphalocele and heterogeneity-for example, preparation.Flexible fibreoptic sigmoidoscopy to 60 cm Some seasonal associations have been gastroschisis. 18 (often to the splenic flexure) is well tolerated by most patients as to hormonal interpreted responses cyclical phenomena, without sedation, requires no more than two phosphate influenced by extrinsic seasonal variables: one such is again enemas as preparation, and usually takes about 5 min. It can hypospadias, mediated by hCG fluctuations;r9 another is be done as a primary procedure in the outpatient department when a left-sided colonic lesion is suspected. Rigid 1. Cowgill UM The of birth Ecology 1966; 47: 614. sigmoidoscopy is clearly under threat, and so too perhaps, is 2. Parkes AS. Seasonal variation human sexual activity. In: Thoday JM, Parkes AS, eds Genetic and environmental influences behaviour Edinburgh Oliver & Boyd. barium enema for diagnosis of distal colonic disease, although 1968:31. the irritant effects of the enemas preliminary to endoscopy 3. Macfarlane WV, Spalding D. Seasonal conception Australia. Med J Aust 1960. 1: 121. may obscure fine abnormalities in the texture and granularity 4. Arendt J, Wirz-Justice A, Bradtke J, Kornemark M. Long-term studies of the colonic mucosa. The flexible sigmoidoscope may also, immunoreactive human melatonin. Ann Clin Biochem 1979; 16: 307 on occasion, be used instead of a long colonoscope-eg, where 5. Sundararaj J, Chern M, Gatewood L, Hickman L, McHugh R Seasonal behaviour of human menstrual cycles. biometric investigation. Hum Biol 1978; 50: 15 double-contrast radiology has identified a solitary ’polyp in 6. Tarquini B, Gheri R, Romano S, Costa A, Cagnom M, Keun Lee F, Halberg F be the descending colon-allowing the long instruments to Circadian mesor-hyperprolactinaemia fibrocystic mastopathy. Am J Med 1979. 66: 229. reserved for the more extensive procedures. At least one 7. Chen LC, Gesche MC, Moseley WH. A prospective study of birth interval dynamics in flexible sigmoidoscope should be available in each endoscopy rural Bangladesh. Population Studies 1974; 28: 277 8. Becker S. Seasonality of fertility unit to complement the long instrument and to introduce Matlab, Bangladesh. J Biosoc Sci 1981, 13: 97 9. Bernard RP, Bhatt RV, Potts DM, Rao AP. Seasonality of births India. J Biosoc Sci neophyte endoscopists to the techniques of the examination. 1978; 10: 409. 10. James WH. Social class and of birth. J Biosoc Sci 1971, 3: 309 Large bowel cancer is the second most common cause of 11. Record RG. Anencephalus Scotland. BrJ Prev Soc Med 1961, 15: 93 death from malignant disease in the Western world. It seems 12. Zelnik M. Socioeconomic and seasonal variations births Millbank Mem Fund Quar to originate at least partly in premalignant adenomatous Bull 1969; 47: 159. 13. Anon. Rush of "rebate" babies. Times 27 April, 1966, p 6. polyps,8 usually in the left side of the colon. Flexible colonic 14. Scaglion R, Condon RG. Abilam Yam beliefs and socio-rhythmicity. J Biosoc Sci 1979.
whole colon of
.
m man.
season
in
on
rates in
on
a
in
in
in
season
in
in
11: 17.
3. Hunt RH. Towards safer colonoscopy. Gut 1983; 24: 371-75. 4. Macrae FA, Tan KG, Williams CB. Towards safter colonoscopy: a report on the complications of 5000 diagnostic or therapeutic colonoscopies. Gut 1983; 24: 376-83. 5. Britton DC, Tregoning D, Bone G, McKelvey STD. Colonoscopy in surgical practice. Br Med J 1977; i: 149-51. 6. Kleinfield G, Gump FE. Complications of colotomy and polypectomy. Surg Gynecol Obstet 1960; 111: 726-28. 7. Nicholls RJ Sigmoidoscopy. Br J Hosp Med 1982; 28: 59-66. 8. Morson BC. Genesis of colorectal cancer Clin Gastroenterol 1975; 8: 505-24.
Ogum GEO, Okorafor AE. Seasonality of births in south-eastern Nigeria J Biosoc Sci 1979; 11: 209. 16. Buckley MR, Erten O. The epidemiology of anencephaly and spina bifida in Izmir; Turkey. J Epidem Commun Health 1979; 33: 186. 17. Galbraith NS, Forbes P, Clifford C. Communicable disease associated with milk and dairy products in England and Wales, 1951-80. Br MedJ 1982, 284: 1761 18. Hemminki K, Salaniemi I, Kyyronen P, Kekomaki M. Gastroschisis and omphalocele in Finland in the 1970s. J Epidem Commun Health 1982, 36: 289. 19. Neto MR, Castilla EE, Paz JE. Hypospadias, an epidemiological study Am J Med
15.
Genet 1981; 10: 5.