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Thirty hospitalized patients (23 men and 7 women), aged 42 to 78 years, with impaired host defences for malignant underlying diseases and affected by life-threatening infections, were treated with the imipenem/cilastatin combination at a dosage ranging between 2 and 4 g daily i.v. at 8 or 12 h intervals. The average length of therapy was 9.6 +/- 2.09 days. The isolated organisms were as follows: Pseudomonas aeruginosa [12], Escherichia coli [10], Klebsiella pneumoniae [5], Proteus mirabilis [3], P. vulgaris [2], Serratia marcescens [1], Staphylococcus aureus [3], Streptococcus faecalis [3], Bacteroides fragilis [5]. In fourteen patients a mixed infection was observed. Twenty-three patients (76.66%) were completely cured of infection and 35 out of 44 isolated organisms (79.54%) were eradicated. No important side-effects were observed.

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In a 6 to 12-week double-blind trial, the effect of cisapride (10 mg q.i.d.) was compared with that of placebo in 63 patients with esophagitis confirmed by endoscopy and/or biopsy. In only one patient (3%) in the cisapride group but in 43% of the placebo patients (p = 0.001), symptoms had not improved after 6 weeks. Forty patients continued treatment until week 12. At that time, control endoscopy showed a significantly (p = 0.005) higher rate of healing (no erosions, ulcers, or bleeding mucosa) in the cisapride patients (63%) than in the placebo patients (12%). At week 12, only three of the 21 cisapride patients still had moderate reflux symptoms, whereas eight of the 19 placebo patients had moderate or severe symptoms (p less than 0.05). Cisapride patients also took significantly (p less than 0.001) less antacids during the trial. These results show that cisapride, 10 mg q.i.d., heals esophagitis lesions and greatly reduces associated symptoms. The treatment was well tolerated.

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Twelve hospitalised patients, affected by biliary tract infections, were treated with cefotetan at dosages ranging between 4 and 6 g daily i.v. In only 11 patients was the aetiological agent identified. Eleven patients (91.67%) completely recovered from their infections and the pathogens were eradicated; the treatment failed in only 1 patient (8.33%). Furthermore, determinations were made of cefotetan concentrations in serum, gallbladder bile, gallbladder wall and gallstones of 14 patients undergoing cholecystectomy: in 7 patients after only 1 injection i.v. of 2 g and in 7 patients after 7 injections i.v. of 2 g at intervals of 12 h. The levels recorded were several times higher than the minimum inhibitory concentrations against bacteria that are most often responsible for biliary infections. Cefotetan is a promising and effective antimicrobial agent in the therapy of biliary tract infections.

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In the light of recent publications where common hernia repair techniques are defined as unanatomical and unphysiological, a study of the anatomy of the inguinal region has been undertaken layer by layer on cadavers. The first note analyses the most superficial layer of the inguinal region, namely the external oblique muscle. Having described the dissection technique, the most significant data regarding this formation are examined. Although the correctness of the data given in anatomy textbooks is confirmed in the majority of cases, study of necroptic findings highlights a number of factors which are misunderstood or have been insufficiently analysed. Findings included vibices of the external oblique aponeurosis, to which no pathogenetic importance is attributed with respect to inguinal hernia, as well as the presence of an internal tunic of Lauth's ligament which was not easy to strip away from the posterior surface of the external oblique muscle and, finally, localization variations of the external inguinal ring. The secondary involvement of the aponeurosis of the external oblique muscle in the genesis of inguinal hernia is confirmed along with its importance as a reinforcement in hernia repair operations, the containment function proper being performed by the posterior wall. A subsequent note will deal with this.

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Following a previous note on the musculus obliquus externus, attention is now directed to the obliques internus and the transversus in an assessment of the anatomical formations of the groin, in the light of doubts concerning their constitution expressed in the recent literature, and in a critical appraisal of the hernioplasty techniques proposed. Data from the cadaver, which appear to be of particular interest, show muscle-aponeurosis fissures in both the obliquus parvus and the obliquus externus; these may be the cause of recurrent hernias. The differences in the extent of the muscle and aponeurosis portions of the obliquus internus and the greater or lesser area of the trigonum inguinale, which is covered by aponeurotic fibres of the transversus, are regarded as important factors in the genesis of inguinal hernia.

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Only 18 or 83 patients who had had a cardiomyotomy for achalasia could be induced to reflux barium. Mucosal herniation through the myotomy was shown in most by radiography. Perfusion manometry showed a higher pressure zone in the oesophagogastric junction region in 22 of 24 patients studied. This high pressure zone responded to an increment in abdominal pressure by a greater increment. The same response was seen in a patient with a small hiatal hernia and myotomy. We concluded that the persisting high pressure zone seen by perfusion manometry is likely to be caused by the hiatus, and that the hiatus rather than the sphincter is likely to be responsible for the incremental response of the high pressure zone to increased abdominal pressure. The anti-reflux mechanism after cardiomyotomy is more likely to be the hiatal mechanism than persisting sphincter fibres.

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Radiographic studies of 161 patients with a stricture within the cardiac sphincter segment showed that in appropriate circumstances all patients could herniate stomach and reflux barium freely, but that the sphincter could obliterate the lumen and sustain this contraction by its basal tone in at least 122. The sphincter could also relax and contract in response to a swallow. The capacity to remain closed depended on the position of the patient and on circumstances in which hiatal flow and reflux did not occur. Manometric studies of the cardiac sphincter were made in a further 14 patients with a stricture in the sphincter segment, and appropriate circumstances the "basal tone" of the sphincter was found to be within our range of normal.

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Carcinoma of the gastric stump in patients who have undergone resection for duodenal and gastric ulcer represents a rare event which poses considerable diagnostic and therapeutic problems. 7 personal cases are examined, particular attention being paid to the utility of endoscopy, together with sampling for cytological and histological examinations, by comparison with radiology. Endoscopy in the present cases have confirmed the high positivity obtainable with transendoscopic cytological sampling using the brushing technique. The technique should therefore become routine in the study of patients undergoing gastric resection.

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