Patient-reported outcomes in young patients with isolated fracture of the hip.

AIMS: Hip fractures in patients < 60 years old currently account for only 3% to 4% of all hip fractures in England, but this proportion is increasing. Little is known about the longer-term patient-reported outcomes in this potentially more active population. The primary aim is to examine patient-reported outcomes following isolated hip fracture in patients aged < 60 years. The secondary aim is to determine an association between outcomes and different types of fracture pattern and/or treatment implants. METHODS: All hip fracture patients aged 18 to 60 years admitted to a single centre over a 15-year period were used to identify the study group. Fracture pattern (undisplaced intracapsular, displaced intracapsular, and extracapsular) and type of operation (multiple cannulated hip screws, angular stable fixation, hemiarthroplasty, and total hip replacement) were recorded. The primary outcome measures were the Oxford Hip Score (OHS), the EuroQol five-dimension questionnaire (EQ-5D-3L), and EQ-visual analogue scale (VAS) scores. Preinjury scores were recorded by patient recall and postinjury scores were collected at a mean of 57 months (9 to 118) postinjury. Ethics approval was obtained prior to study commencement. RESULTS: A total of 72 patients were included. There was a significant difference in pre- and post-injury OHS (mean 9.8 point reduction (38 to -20; p < 0.001)), EQ-5D (mean 0.208 reduction in index (0.897 to -0.630; p < 0.001)), and VAS , and VAS (mean 11.6 point reduction (70 to -55; p < 0.001)) Fracture pattern had a significant influence on OHS (p < 0.001) with extracapsular fractures showing the least favourable long-term outcome. Fixation type also impacted significantly on OHS (p = 0.011) with the worst outcomes in patients treated by hemiarthroplasty or angular stable fixation. CONCLUSION: There is a significant reduction in function and quality of life following injury, with all three patient-reported outcome measures used, indicating that this is a substantial injury in younger patients. Treatment with hemiarthroplasty or angular stable devices in this cohort were associated with a less favourable hip score outcome. Cite this article: Bone Joint J 2020;102-B(6):766-771.

The academic radiography workforce: Age profile, succession planning and academic development.

INTRODUCTION: Academia is one area of practice in which radiographers can specialise; they compile approximately 2% of the total radiography profession in the UK, but are highly influential and essential for the education and development of the workforce in addition to undertaking research. However, the academic environment is very different to clinical practice and a period of transition is required. METHODS: Data were collated to explore the age and retirement profile of the academic radiography workforce in the UK; to understand the research time allocated to this workforce; the time required to develop a clinical radiographer into an academic and the mentorship and succession planning provisions nationally. An online UK wide survey was conducted and sent to all 24 Universities delivering radiography education within the UK. RESULTS: Eighteen out of 24 Universities in the UK responded to the survey. Approximately 30% of radiography academics are due to retire over the next 10 years, with over 25% of radiographers who currently hold a doctorate qualification included within this figure. Those entering academia have notably lower qualifications as a group than those who are due to retire. Developing clinical radiographers into academics was thought to take 1-3 years on average, or longer if they are required to undertake research. CONCLUSION: There is vulnerability in the academic radiography workforce. Higher education institutions need to invest in developing the academic workforce to maintain research and educational expertise, which is underpinned by master's and doctorate level qualifications.

A qualitative analysis of staff-client interactions within a breast cancer assessment clinic.

OBJECTIVES: Breast screening clients recalled to an assessment clinic experience high levels of anxiety. The culture of the assessment clinic may impact upon client experience, which may influence their future re-engagement in screening. This study aimed to explore the culture of staff-client interactions within a breast cancer assessment clinic. MATERIALS AND METHODS: Following an ethnographic approach, twenty-three client journeys were observed, followed by semi-structured interviews with the clients. The observation and interview data were analysed to produce research themes, which were then explored within two focus groups to add a practitioner perspective. RESULTS: Multiple staff-client interaction events were observed over a period of several weeks. Client interview feedback was overwhelmingly positive. Three recurrent and sequential themes emerged: breaking down barriers, preparing the ground and sign-posting. These themes outline the changing focus of staff-client interactions during the client's clinic journey, encompassing how anxieties were expressed by clients, and responded to by practitioners. CONCLUSION: This study was the first to explore in depth the staff-client interaction culture within a breast assessment clinic using an ethnographic approach. A new perspective on professional values and behaviours has been demonstrated via a model of staff-client interaction. The model documents the process of guiding the client from initial confusion and distress to an enhanced clarity of understanding. A recommendation most likely to have a positive impact on the client experience is the introduction of a client navigator role to guide the clients through what is often a lengthy, stressful and confusing process.

Chronic cholestasis in patients on parenteral nutrition: the influence of restoring bowel continuity after mesenteric infarction.

BACKGROUND/OBJECTIVES: Patients with a short bowel and receiving parenteral nutrition (PN) have an increased risk of chronic cholestasis (CC). Restoration of bowel continuity after a mesenteric infarction results in PN requirements being reduced or stopped. This study aimed to determine the prevalence of CC and whether restoring bowel continuity reduced the risk of CC. SUBJECTS/METHODS: A retrospective review of patients with a short bowel owing to mesenteric infarction from 2000 to 2012. CC was defined as two of bilirubin, alkaline phosphatase and gamma-glutamyl transferase being 1.5 times the upper limit of normal for >6 months. RESULTS: We identified 104 (55 females, median age 54 years) patients. Seventy-three (70%) patients had restoration of bowel continuity; of these, 25 (34%) had abnormal liver biochemistry (liver function test (LFT)), with 15 (21%) having CC. Following restoration of bowel continuity, 8 (53%) of 15 patients with CC and 10 (100%) of 10 patients with abnormal LFT but not CC had a return of liver function within normal range within a year. Univariate analysis showed restoring bowel continuity (P=0.002) and cessation of PN (P=0.006) were associated with a reduction in prevalence of CC. Multivariate analysis showed that cessation of PN was a significant factor in reducing CC (P=0.02). CONCLUSIONS: The prevalence of CC is 29% for patients with a short bowel receiving PN following a mesenteric infarction. CC resolves in 53% after continuity is restored, and this is most likely due to stopping or reducing the PN.

Mortality after acute primary mesenteric infarction: a systematic review and meta-analysis of observational studies.

AIM: The primary aim of this study was to determine whether the in-hospital mortality for acute mesenteric infarction has reduced in the last decade. The secondary aim was to determine if there was a statistical difference in mortality between patients having acute primary mesenteric infarction due to different causes. METHOD: A literature search was performed of PubMed, Ovid (Embase) and Google Scholar databases. Studies on acute mesenteric infarction of primary vascular pathology were included for pooled analyses while studies that had reported comparative mortality between arterial, venous and non-occlusive mesenteric infarction (NOMI) were included in meta-analyses. Their quality was assessed using the National Institute for Health and Care Excellence assessment scale. Odds ratios (ORs) of mortality were calculated using a Mantel-Haenszel random effect model. RESULTS: The total number of patients was 4527 and the male/female ratio was 1912/2247. The pooled in-hospital mortality was 63%. There was no significant reduction of in-hospital mortality rate in the last decade (P = 0.78). There was a significant difference in in-hospital mortality between acute arterial mesenteric infarction (73.9%) compared with acute venous mesenteric infarction (41.7%) [OR 3.47, confidence interval (CI) 2.43-4.96, P < 0.001] and NOMI (68.5%) compared with acute venous mesenteric infarction (44.2%) (OR 3.2, CI 1.83-5.6, P < 0.001). There was no difference in mortality between acute arterial mesenteric infarction and NOMI (OR 1.08, CI 0.57-2.03, P = 0.82). CONCLUSION: In-hospital mortality rate has not changed in the last decade. Patients with arterial mesenteric infarction or with NOMI are over three times more likely to die during the first hospital admission compared with those with venous mesenteric infarction.

Intestinal failure and home parenteral nutrition: implications for oral health and dental care.

BACKGROUND & AIMS: Background disease processes, medication and therapies in people with intestinal failure receiving home parenteral nutrition may affect their oral health. To inform oral health advice for this group a study of their oral health status was carried out. METHODS: Fifty-two HPN outpatients recruited from specialised nutrition clinics at a national referral centre listed their medical and medication history, perceived oral health and dental treatment experience in a structured interview and underwent an oral health examination. Findings were compared with 2009 UK Adult Dental Health Survey data, using one-sample t tests. RESULTS: Oral health of the HPN cohort was poorer than the UK norm; patients had more decay (p<0.001), fewer teeth (p<0.001) and fewer sound and untreated teeth (p=0.023) despite similar dental attendance. Hyperphagia, sip feeds, oral rehydration fluids and polypharmacy (in 96%) are identifiable risk factors for caries, xerostomia (in 81%) and thus oral infection risk (including oral candidiasis). Patients were experiencing current problems (60%) and psychological discomfort (56%) from poor oral health. The patient pathway does not include oral health information. CONCLUSION: Dental teams should be aware of the management and prevention of HPN related complications with bisphosphonates, anticoagulant therapy, and parenteral antibiotic prophylaxis. HPN patients may benefit from increased awareness of their oral health risk factors.

Oral health, dental prophylaxis and catheter related bloodstream infections in home parenteral nutrition patients: results of a UK survey and cohort study.

BACKGROUND: Concern that some catheter related bloodstream infections (CRBSI) arise from dental treatment in home parenteral nutrition (HPN) patients results in recommendation of antibiotic prophylaxis. Clinical guideline 64 is widely recognised and observed. There is a lack of consistent guidance for other patient groups viewed at risk from procedural bacteraemia. METHODS: 1. An email survey of the British Association for Parenteral and Enteral Nutrition (BAPEN) HPN group, requesting physicians' opinions, observations and practises relating to oral health and CRBSI prevention; 2. Comparison of oral health parameters and dental treatment in relation to patient reported 12 month CVC infection history, using chi-square analysis to assess associations in 52 HPN patients. RESULTS: 1. Sixty-eight percent of the UK HPN Group responded. Fifty percent linked oral health/dental treatment with the possibility of CRBSI, 39% were unsure. Sixty-one percent had recommended parenteral prophylactic antibiotics (82% IV, 18% IM), mainly following the historic infective endocarditis (IE) dental prophylaxis guidelines. Infection with streptococci, prevotella and fusobacteria caused most concern. Amoxicillin, metronidazole, co-amoxyclav and gentamycin were the most prescribed antibiotics. Thirty-six percent might delay HPN if oral health was poor; 57% had recommended dental examination and 25% dental extractions, to prevent or treat CRBSI. 2. Associations between patient recalled CVC infection and their current dental status, the interval since dental treatment or the prophylaxis received over the previous 12 months did not achieve significance. CONCLUSIONS: Opinion varies among UK HPN providers on the role of dental treatment and oral health in CRBSI and on prescribing prophylactic antibiotics for dental treatment. Prophylaxis guidance specific to this patient group is required.

Causes and management of a high-output stoma.

AIM: Patients with a high-output stoma (HOS) (> 2000 ml/day) suffer from dehydration, hypomagnesaemia and under-nutrition. This study aimed to determine the incidence, aetiology and outcome of HOS. METHOD: The number of stomas fashioned between 2002 and 2006 was determined. An early HOS was defined as occurring in hospital within 3 weeks of stoma formation and a late HOS was defined as occurring after discharge. RESULTS: Six-hundred and eighty seven stomas were fashioned (456 ileostomy/jejunostomy and 231 colostomy). An early HOS occurred in 75 (16%) ileostomies/jejunostomies. Formation of a jejunostomy (defined as having less than 200 cm remaining of proximal small bowel; n = 20) and intra-abdominal sepsis? obstruction (n = 14) were the commonest causes identified for early HOS. It was possible to stop parenteral infusions in 53 (71%) patients treated with oral hypotonic fluid restriction, glucose-saline solution and anti diarrhoeal medication. In 46 (61%) patients, the HOS resolved and no drug treatment was needed, 20 (27%) patients continued treatment, six (8%) of whom went home and continued to receive parenteral or subcutaneous saline, and nine died. Twenty-six patients had late HOS. Eleven were admitted with renal impairment and four had intermittent small-bowel obstruction. Eight patients were given long-term subcutaneous or parenteral saline and two also received parenteral nutrition. All had hypomagnesaemia. CONCLUSION: Early high output from an ileostomy is common and although 49% resolved spontaneously, 51% needed ongoing medical treatment, usually because of a short small-bowel remnant.

An evaluation of radiographer performed and interpreted barium swallows and meals.

AIM: To determine whether radiographers are able to perform and interpret barium swallows and meals (BSM) to an acceptable standard. MATERIALS AND METHODS: A retrospective audit was performed of all radiographer-managed BSMs over a 4-year period in an acute hospital. Descriptive statistics were used to analyse patient demographics, radiation doses, referral sources, and imaging findings. Radiographer reports were compared with radiologist reports assumed to be the reference standard, and correlated with patient outcomes via electronic record searches and case note scrutiny. Reporting accuracy, sensitivity, and specificity were calculated. RESULTS: Three radiographers performed a total of 962 BSMs in the 4-year audit period, including a varied and complex case-mix. Only 13 (0.01%) cases were abandoned due to technical reasons, with all other examinations of diagnostic quality. Although radiation dose levels were initially variable, following the installation of modern fluoroscopy equipment they remained comfortably within the national and regional diagnostic reference levels. Consultant radiologists verified the majority of the radiographer reports, with the most experienced radiographer independently reporting 230 cases (24%). Follow-up of patient outcome was possible in 935 cases. The overall radiographer accuracy based on the 935 cases was 98.9%, sensitivity 98%, and specificity 98.9%. CONCLUSIONS: Appropriately trained radiographers are able to perform and interpret BSM examinations to a very high standard.

Muscle cramps are the commonest side effect of home parenteral nutrition.

BACKGROUND & AIMS: Complications resulting from home parenteral nutrition (HPN) reduce a patient's quality of life. The major complications of catheter-related sepsis, venous thrombosis and chronic liver disease are well recognised. This study aimed to determine if there were other minor, but common complications that caused patient distress. METHODS: All patients (45) from four HPN centres were asked if they had suffered any side effects of parenteral nutrition and whether these side effects related to the timings of the feed or required specific intervention. RESULTS: Muscle cramps were the most common minor side effect [12/45 (27%)]. A greater proportion of HPN patients (51%) suffered from muscle cramps than did a control group of patients with inflammatory bowel disease (24%) [p=0.0001]. In the HPN patients, no significant difference in serum electrolyte concentration or in feed composition was noted between those patients with and those without cramps in relation to feeds. Cramps were of sufficient severity to warrant pharmacological intervention in 9 of 12 patients who had cramps in relation to feeds, and parenteral nutrition administration was slowed in 2 of the 12. CONCLUSION: Muscle cramps have a high prevalence in patients receiving home parenteral nutrition.

Dysphagia and thoracoabdominal aneurysm.

Two elderly patients who presented with gradually progressive dysphagia are described. Investigations excluded an intraluminal obstruction and showed extrinsic compression of the oesophagus by an aneurysmal aorta. Surgery was not performed and they were successfully managed with a liquid diet.

Management of patients with a short bowel.

There are two common types of adult patient with a short bowel, those with jejunum in continuity with a functioning colon and those with a jejunostomy. Both groups have potential problems of undernutrition, but this is a greater problem in those without a colon, as they do not derive energy from anaerobic bacterial fermentation of carbohydrate to short chain fatty acids in the colon. Patients with a jejunostomy have major problems of dehydration, sodium and magnesium depletion all due to a large volume of stomal output. Both types of patient have lost at least 60 cm of terminal ileum and so will become deficient of vitamin B(12). Both groups have a high prevalence of gallstones (45%) resulting from periods of biliary stasis. Patients with a retained colon have a 25% chance of developing calcium oxalate renal stones and they may have problems with D(-) lactic acidosis. The survival of patients with a short bowel, even if they need long-term parenteral nutrition, is good.

Knowledge about the assessment and management of undernutrition: a pilot questionnaire in a UK teaching hospital.

BACKGROUND & AIMS: The detection, prevention and treatment of undernutrition in hospitals is often poor. This study assesses the knowledge about undernutrition of staff in a UK teaching hospital. METHODS: Twenty nine doctors, 65 final year medical students, 45 nurses, 11 dietitians, and 11 pharmacists anonymously completed a questionnaire of 20 multiple choice questions. One of five possible answers was considered correct. Twelve questions were about adult nutritional assessment and requirements, five about oral/enteral nutrition and three about parenteral nutrition. RESULTS: Dietitians scored significantly more (median 16) than the other groups (doctors: seven, medical students: eight, nurses: seven and pharmacists: nine) (P < 0.0001). Medical students scored more than doctors (P < 0.001). Examples of areas in which knowledge could be improved are: 67% respondents thought the prevalence of hospital undernutrition to be less than 30%. While 91% of respondents correctly chose a well 70 kg man to need about 2000 kcal/day, only 23% knew that approximately the same amount was needed for a febrile post-operative patient. Sixteen percent knew antibiotic treatment to be the most common reason for enteral feeding-related diarrhoea. CONCLUSIONS: Knowledge about the assessment and management of undernutrition among doctors, medical students, nurses and pharmacists was poor. This questionnaire provides a framework for teaching and auditing the effectiveness of an educational program.

Management of patients with a short bowel.

Short bowel syndrome most commonly results after bowel resections for Crohn's disease. The normal human small intestinal length ranges from about 3 to 8 m, thus if the initial small intestinal length is short, a relatively small resection of the intestine may result in the problems of a short bowel. Two types of patient with a short bowel are encountered in clinical practice: those with their jejunum anastomosed to a functioning colon, and those with a jejunostomy. Both types of patient have problems absorbing adequate macronutrients, and both need long-term vitamin B12 therapy. Patients with a jejunostomy also have major problems with large stomal losses of water, sodium, and magnesium. This high-volume jejunostomy output is treated by restricting oral fluids, giving a glucose-saline solution to drink, and using drugs that either reduce gastrointestinal motility (loperamide or codeine phosphate) or secretions (H2 antagonists, proton pump inhibitors, or octreotide). Patients whose jejunal length is less than 100 cm, and whose stomal output is greater than their oral intake, benefit most from antisecretory drugs. In patients with a retained colon, bacterial fermentation of unabsorbed carbohydrate in the colon results in energy being salvaged. However, they have increased oxalate absorption and a 25% chance of developing calcium oxalate renal stones. Thus patients with a colon are advised to eat a high-energy diet rich in carbohydrate but low in oxalate. Patients with a jejunostomy need a high-energy iso-osmolar diet with added salt. Both patient types have a 45% prevalence of gallstones. With current therapy most patients with a short bowel have a normal body mass index and a good quality of life.

Circulating gastrointestinal hormone abnormalities in patients with severe idiopathic constipation.

OBJECTIVE: This study aimed to determine if there is an abnormality of circulating gastrointestinal hormones in patients with severe idiopathic constipation. METHODS: Twelve patients, all female (median age 34 yr) and 12 healthy controls (eight female, median age 32 yr) were studied. A radioisotope-labeled solid/liquid meal was ingested, and the serum hormone response, as well as the relationship between serum hormones and rates of gastric emptying and small intestinal transit, were studied for 180 min postprandially. RESULTS: Somatostatin levels were higher in patients with constipation (basal level, controls vs patients, 31 vs 57 pmol/L, p < 0.05, median values; peak level, 48 vs 60, p < 0.05). Patients showed a significantly lower somatostatin integrated incremental meal response (2182 vs 104, p < 0.05). No correlation was found between the somatostatin levels and rates of upper gastrointestinal transit in patients. Pancreatic glucagon was significantly decreased (p=0.04). Enteroglucagon levels were significantly lower (p > 0.05) in patients between 30 and 60 min after the meal. The peak found after the meal in normal subjects was absent. Basal levels of pancreatic glucagon correlated with small bowel transit by two different measures: head of meal (r=0.69, p=0.03) and cecal filling at the time of 50% gastric emptying (r=0.84, p=0.002). No significant differences between the two groups could be found for basal and peak levels at different times and integrated incremental response to the meal for insulin, gastric inhibitory polypeptide (GIP), glucagon-like peptide-1 (GLP-1), cholecystokinin (CCK), gastrin, pancreatic polypeptide (PP), motilin, neurotensin, and peptide tyrosine tyrosine (PYY). CONCLUSION: Patients with severe idiopathic constipation have specific abnormalities of circulating gut hormones that most likely play a role in gastrointestinal motility and that may be of pathophysiological significance.

Gastrointestinal hormones in short bowel syndrome. Peptide YY may be the 'colonic brake' to gastric emptying.

BACKGROUND: Short bowel patients with a jejunostomy have large volume stomal outputs, which may in part be due to rapid gastric emptying of liquid. Short bowel patients with a preserved colon do not have such a high stool output and gastric emptying of liquid is normal. AIMS: To determine if differences in the gastric emptying rate between short bowel patients with and without a colon can be related to gastrointestinal hormone changes after a meal. SUBJECTS: Seven short bowel patients with no remaining colon (jejunal length 30-160 cm) and six with jejunum in continuity with a colon (jejunal length 25-75 cm), and 12 normal subjects. METHODS: The subjects all consumed a 640 kcal meal; blood samples were taken for 180 minutes for measurement of gastrointestinal hormones. RESULTS: Patients with a colon had high fasting peptide YY values (median 71 pmol/l with a colon; 11 pmol/l normal subjects, p < 0.005) with a normal postprandial rise, but those without a colon had a low fasting (median 7 pmol/l, p = 0.076) and a reduced postprandial peptide YY response (p < 0.050). Motilin values were high in some patients without a colon. In both patient groups fasting and postprandial gastrin and cholecystokinin values were high while neurotensin values were low. There were no differences between patient groups and normal subjects in enteroglucagon, pancreatic polypeptide, or somatostatin values. CONCLUSIONS: Low peptide YY values in short bowel patients without a colon may cause rapid gastric emptying of liquid. High values of peptide YY in short bowel patients with a retained colon may slow gastric emptying of liquid and contribute to the "colonic brake'.

Three simple methods of detecting malnutrition on medical wards.

Malnutrition in hospital is often unrecognized. A nutrition team aims to teach simple methods of detecting malnutrition. On a single day all medical in-patients underwent a nutritional assessment. Eighty-four patients (43 men), median age 71 years (range 28-97), were assessed. The most common diagnoses were cardiac disease (26), stroke/dementia (12), non-malignant lung disease (9) and malignancy (6). A weight loss of more than 10% (%WL) was found in 17/65 (26%) and a body mass index (BMI) of less than 19 kg/m2 in 13/69 (19%). A mid-arm muscle circumference (MAMC) less than the fifth percentile occurred in 16/83 (19%) patients. Percentage weight loss alone detected seven patients of whom four were overweight (BMI > 25 kg/m2), BMI alone detected three patients, and MAMC alone eight patients of whom three could not be weighed and three had fluid retention. There was fluid retention in 35/84 (42%) patients of whom nine were malnourished (six detected by BMI and/or %WL, and three by MAMC alone). All three measurements were made in 64 patients, six (9%) of whom were detected as malnourished by all three methods. Combining the three measurements 29/84 (35%) of patients were malnourished and only 28% of these patients had been assessed by a dietitian. BMI and %WL detect most patients but fluid retention may limit their accuracy. MAMC is useful in those who cannot be weighed or who have fluid retention.

Adult patients with a short bowel due to Crohn's disease often start with a short normal bowel.

OBJECTIVE: The normal adult human small intestinal length, measured surgically or at autopsy from the duodeno-jejunal flexure, ranges from 275 to 850 cm. The length is generally shorter in women than in men. Patients with a short bowel have often had relatively little bowel resected and the majority of patients are women. We aimed to determine whether patients with a short bowel had a short small intestinal length before any resections. PATIENTS AND METHODS: In 11 patients (six men and five women) with Crohn's disease and less than 200 cm residual small intestine, both the residual length of small intestine and the amount resected were measured. RESULTS: Patients had a median of four resections (range 1-5). The median length of small bowel resected was 120 cm (range 60-165 cm) and the medium length of small bowel remaining was 125 cm (range 90-185 cm). Thus, the calculated median original small intestinal length was 240 cm (range 205-315 cm). CONCLUSION: Although there may have been some bowel shortening as a result of Crohn's disease, the original small intestinal length before any resections was short. It is therefore more important, after performing a bowel resection, to measure the remaining than the resected bowel length. Patients with Crohn's disease and a short bowel may have had a short but 'normal' small intestinal length before any bowel was resected.

The short-bowel syndrome.

Patients with a short bowel have usually had a bowel resection for Crohn's disease. Two types of short-bowel patient can be distinguished: those with a jejunostomy and those with their jejunum anastomosed to a functioning colon. Both types of patient have problems with macronutrient absorption, although those with a colon experience fewer problems because some energy from unabsorbed carbohydrate is salvaged in the colon. Patients with a jejunostomy have problems with large stomal losses of water, sodium and magnesium, whereas those with a jejuno-colic anastomosis rarely have problems with water and electrolyte absorption. Patients with a jejunostomy 100-200 cm from the duodeno-jejunal flexure ('absorbers') usually absorb more from the diet than they pass through the stoma and therefore require oral electrolyte or nutrient supplements. Those with a residual jejunal length of less than 100 cm usually secrete more from the stoma than they take in orally ('secretors') and therefore require long-term parenteral fluid or nutrient supplements. A high output resulting from a jejunostomy is treated by reducing the oral intake of hypotonic fluid, administering a sipped glucose-saline solution and, often, by giving drugs that reduce intestinal motility (most effective in absorbers) or gastrointestinal secretions (most effective in secretors). Gallstones are common both in short-bowel patients with and in those without a colon (45%), and calcium oxalate renal stones occur in the former (25%). However, it is now possible to provide adequate nutrition and fluid supplements for most patients with a short bowel, and the prospects for the rehabilitation of such patients are good.