Pyogenic granuloma of the penis--don't squeeze them

We report the case of a pyogenic granuloma on the shaft of the penis presenting with active bleeding secondary to attempted expression. Previously reported cases have documented such lesions on the prepuce and glans.

Reviewing audit: barriers and facilitating factors for effective clinical audit

OBJECTIVE

To review the literature on the benefits and disadvantages of clinical and medical audit, and to assess the main facilitators and barriers to conducting the audit process.

DESIGN

A comprehensive literature review was undertaken through a thorough review of Medline and CINAHL databases using the keywords of "audit", "audit of audits", and "evaluation of audits" and a handsearch of the indexes of relevant journals for key papers.

RESULTS

Findings from 93 publications were reviewed. These ranged from single case studies of individual audit projects through retrospective reviews of departmental audit programmes to studies of interface projects between primary and secondary care. The studies reviewed incorporated the experiences of a wide variety of clinicians, from medical consultants to professionals allied to medicine and from those involved in unidisciplinary and multidisciplinary ventures. Perceived benefits of audit included improved communication among colleagues and other professional groups, improved patient care, increased professional satisfaction, and better administration. Some disadvantages of audit were perceived as diminished clinical ownership, fear of litigation, hierarchical and territorial suspicions, and professional isolation. The main barriers to clinical audit can be classified under five main headings. These are lack of resources, lack of expertise or advice in project design and analysis, problems between groups and group members, lack of an overall plan for audit, and organisational impediments. Key facilitating factors to audit were also identified: they included modern medical records systems, effective training, dedicated staff, protected time, structured programmes, and a shared dialogue between purchasers and providers.

CONCLUSIONS

Clinical audit can be a valuable assistance to any programme which aims to improve the quality of health care and its delivery. Yet without a coherent strategy aimed at nurturing effective audits, valuable opportunities will be lost. Paying careful attention to the professional attitudes highlighted in this review may help audit to deliver on some of its promise.

Neurotrophic role of interleukin-6 and soluble interleukin-6 receptors in N1E-115 neuroblastoma cells

Interleukin 6 (IL-6) plays a role in physiological and pathophysiological processes in neuronal cells. We studied whether IL-6 plays a role in neuroblastoma cells in culture. These studies demonstrate that N1E-115 cells constitutively express IL-6 but not IL-6R. Exogenous IL-6 stimulated neuronal proliferation in a dose-dependent manner. Under serum-free conditions soluble IL-6 receptors (sIL-6R) alone or in combination with IL-6 exerted significant proliferative effects, while IL-6 alone failed to promote cell proliferation. Neutralizing anti-IL-6 antibody caused a 30-40% reduction in IL-6 mediated proliferation. Our results suggest the importance of IL-6/sIL-6R for proliferation and survival of N1E-115 adrenergic neuroblastoma cells.

Raising the "glass ceiling" for ethnic minority women in health care management

Ethnic minority women are well represented in the work force and in the health care system in general, but do not have a similar level of representation in the management sector. This paper explores three strategies for schools of health administration to consider to lessen the effect of a "glass ceiling" that may be encountered by ethnic minority women aspiring to positions of leadership in health services agencies. These strategies are advancing affirmative action, valuing ethnic women in health administration education, and investigating diversity management. Inherent in each of the three strategies is the need for acknowledgment and more open discussion of the "glass ceiling." Problem-solving in relation to the potential for systemic discrimination adversely affecting ethnic minority women in senior health care management positions, and greater study of the three strategies using both qualitative and quantitative methodologies is also needed.

Guidelines for management of hypertension: report of the third working party of the British Hypertension Society

Use non-pharmacological measures in all hypertensive and borderline hypertensive people. Initiate antihypertensive drug therapy in people with sustained systolic blood pressures (BP) >/=160 mm Hg or sustained diastolic BP >/=100 mm Hg. Decide on treatment in people with sustained systolic BP between 140 and 159 mm Hg or sustained diastolic BP between 90 and 99 mm Hg according to the presence or absence of target organ damage, cardiovascular disease or a 10-year coronary heart disease (CHD) risk of >/=15% according to the Joint British Societies CHD risk assessment programme/risk chart. In people with diabetes mellitus, initiate antihypertensive drug therapy if systolic BP is sustained >/=140 mm Hg or diastolic BP is sustained >/=90 mm Hg. In non-diabetic hypertensive people, optimal BP treatment targets are: systolic BP <140 mm Hg and diastolic BP <85 mm Hg. The minimum acceptable level of control (Audit Standard) recommended is <150/<90 mm Hg. Despite best practice, these levels will be difficult to achieve in some hypertensive people. In diabetic hypertensive people, optimal BP targets are; systolic BP <140 mm Hg and diastolic BP <80 mm Hg. The minimum acceptable level of control (Audit Standard) recommended is <140/<90 mm Hg. Despite best practice, these levels will be difficult to achieve in some people with diabetes and hypertension. In the absence of contraindications or compelling indications for other antihypertensive agents, low dose thiazide diuretics or beta-blockers are preferred as first-line therapy for the majority of hypertensive people. In the absence of compelling indications for beta-blockade, diuretics or long acting dihydropyridine calcium antagonists are preferred to beta-blockers in older subjects. Compelling indications and contraindications for all antihypertensive drug classes are specified. For most hypertensives, a combination of antihypertensive drugs will be required to achieve the recommended targets for blood pressure control. Other drugs that reduce cardiovascular risk must also be considered. These include aspirin for secondary prevention of cardiovascular disease, and primary prevention in treated hypertensive subjects over the age of 50 years who have a 10-year CHD risk >/=15% and in whom blood pressure is controlled to the audit standard. In accordance with existing British recommendations, statin therapy is recommended for hypertensive people with a total cholesterol >/=5 mmol/L and established vascular disease, or 10-year CHD risk >/=30% estimated from the Joint British Societies CHD risk chart. Glycaemic control should also be optimised in diabetic subjects. Specific advice is given on the management of hypertension in specific patient groups, ie, the elderly, ethnic subgroups, diabetes mellitus, chronic renal disease and in women (pregnancy, oral contraceptive use and hormone replacement therapy). Suggestions for the implementation and audit of these guidelines in primary care are provided.

Rib biopsy technique for cortical bone evaluation in rhesus monkeys (Macaca mulatta)

Old World primates are often studied to model human skeletal physiology. An important advantage of monkeys over other animal models (i.e., rodents) is the presence of cortical bone Haversian remodeling. Seventy-five female rhesus monkeys (Macaca mulatta) were subjected to bone biopsy. With monkeys in lateral decubitus position, the tenth rib was surgically exposed and freed from periosteum by use of careful sharp and blunt dissection. The rib section was resected, using bone cutters, and the surgical wound was closed. This procedure was repeated for the contralateral rib at a later time point in 65 monkeys. There was no mortality or appreciable morbidity. The bone specimens were (mean +/- SD) 2.50 +/- 0.25 cm long, with 5.5 +/- 1.0 mm2 total cross-sectional area. They were adequate for histologic, immunohistochemical, and quantitative histomorphometric examinations. Prevalence of pneumothorax was approximately 8.0% for the 140 procedures. This complication was immediately and successfully corrected by insertion of a small thoracic tube, evacuation of pneumothorax, and closure of the incision. This well-tolerated, repeatable procedure yields excellent specimens for performance of cortical bone histologic examination without euthanasia, allowing longitudinal evaluation.

Parental anxiety before elective surgery in children. A British perspective

This study measures the anxiety levels in 100 parents of children scheduled for elective surgery at the Royal Aberdeen Children's Hospital. Anxiety levels were quantified using the Leeds scale for self-assessment of anxiety. Forty-two per cent of parents were significantly anxious. Mothers were identified as being more pathologically anxious than fathers. The 'anxious' parents were specifically more anxious about the surgery, anaesthesia, postoperative pain and treatment, and hospitalisation in general. All parents, whether identified as anxious or not, agreed on factors likely to reduce anxiety: pre-operative information from staff, being able to accompany their child to the operating theatre and being present at induction of anaesthesia.

Diagnostic imaging of osteochondrosis

This article includes imaging of the glenohumeral (shoulder), elbow, stifle, and tarsal joints. The imaging modalities discussed are survey radiography, contrast arthrography, linear tomography, ultrasound, computed tomography, scintigraphy and magnetic resonance. Survey radiography is the first choice imaging modality for diagnosing osteochondrosis dissecans in dogs. In cases where survey radiography fail to demonstrate a lesion other modalities such as scintigraphy, linear tomography, computed tomography, and magnetic resonance may be helpful. Survey radiography, contrast arthrography, computed tomography, and magnetic resonance may also provide additional information contributing to early diagnosis and treatment.

Disadvantaged women and smoking

High rates of smoking are found among disadvantaged women, and there is a demand for cessation interventions specifically targeted to meet their needs. This project used a number of information sources to examine the factors associated with these women's smoking behaviours and the potential barriers and supports to cessation. Few of the women-centred cessation programs whose representatives were contacted were appropriate for, or available to, disadvantaged women in Canada. Interviews with 386 disadvantaged women revealed that their smoking was intimately linked with their life situation of poverty, isolation and caregiving; smoking was a mechanism for coping with the stress of their lives. Agencies outside traditional tobacco control organizations, such as women's centres, were well positioned to initiate or expand services that support smoking cessation for these women and were trusted by the women who used their services. The findings have implications for programs, research and policy.

Effects of prochloraz and malathion on the red-legged partridge: a semi-natural field study

A semi-natural field study was carried out to assess the likelihood of a potentiation of toxicity between the ergosterol biosynthesis inhibiting (EBI) fungicide, prochloraz, and the organophosphorus (OP) insecticide, malathion, in the red-legged partridge (Alectoris rufa). Groups of partridges kept in four large grassland enclosures were exposed to either prochloraz-treated or control wheat for 7 days after which two of the enclosures were sprayed with malathion whilst the remaining two were sham-sprayed. Cytochrome P-450, aldrin epoxidase and 7-ethoxyresorufin-O-deethylase (EROD) activities were found to be significantly higher in the group exposed to prochloraz alone compared to controls, suggesting that induction of the hepatic microsomal monooxygenase system had occurred by ingestion of prochloraz-treated wheat. However, the level of induction produced was not sufficient to cause a potentiation of malathion toxicity. There was evidence for induction of several forms of P-450 recognised by antibodies raised against 1A1, 2C6 and 4A1 in the prochloraz-exposed partridges.

The study of interactive effects of pollutants: a biomarker approach

Biochemical biomarkers, such as inhibition of serum butyryl cholinesterase (BuChE) and brain acetyl cholinesterase (AChE), have been useful in studies of interactive effects of pesticides in birds. Examples of interactions due to increased activation or decreased detoxication are reviewed. Studies have shown that hybrid red-legged partridges (Alectoris rufa cross) pretreated with the inducing ergosterol biosynthesis inhibiting (EBI) fungicide, prochloraz, were more sensitive to the toxic effects of the organophosphorous (OP) insecticide, malathion, than controls. A dose of 90 mg/kg prochloraz produced greater inhibition at 1, 4 and 24 h following oral administration of 50 mg/kg malathion, compared to corn oil controls. Pigeons (Columba livia) given 180 or 90 mg/kg prochloraz showed greater inhibition of BuChE activity following malathion administration than did control birds. Starlings (Stumus vulgaris), however, appeared not to be induced by 180 or 300 mg/kg prochloraz, and no difference in BuChE activity following dosing with malathion was apparent in comparison with controls. Other EBIs and OP combinations have been investigated in the partridge. Birds pretreated with prochloraz showed a trend towards greater inhibition of serum BuChE activity at most time points following dosing with the OPs dimethoate and chlorpyriphos. Birds pretreated with the EBI penconazole showed significantly greater inhibition of serum BuChE activity at 1, 4 and 24 h after malathion administration than did controls. The mechanism of increased activation of malathion due to induction of cytochrome P-450 by prochloraz is reviewed. In the case of interactions due to inhibition of detoxication, inhibition of brain AChE activity was a useful biochemical biomarker.(ABSTRACT TRUNCATED AT 250 WORDS)

Prothrombotic events in the prodromal stages of acute laminitis in horses

Prothrombotic changes occurring in the prodromal stages of carbohydrate-induced laminitis were investigated. Hemostatic alterations were evaluated by determining platelet counts, platelet survival, activated partial thromboplastin time, one-stage prothrombin time, and monocyte procoagulant activity. Thrombosis of vessels in the hoof wall was evaluated by contrast arteriography and histologic examination. Of 5 horses, 4 became lame between 28 and 52 hours after carbohydrate administration. Mean platelet count in laminitis-affected horses was lower throughout the prodromal stages of laminitis, compared with that in control horses, but differences were not statistically significant. However, survival of indium-111-labeled platelets was less than the value in control horses by 6 hours after carbohydrate administration. Arteriography of disarticulated feet revealed marked reduction in blood supply to hooves in laminitis-affected horses. Histologic examination of the laminar dermis disclosed microthrombi in venules of the laminar dermis in 2 of 4 affected horses. Statistically significant changes in prothrombin time were not observed, and changes in activated partial thromboplastin time were slight and occurred only at the onset of lameness. Statistically significant changes in monocyte procoagulant activity were not observed. Plasma endotoxin-like activity was not detected in laminitis-affected horses. These data indicate that platelet survival was decreased within the first 6 hours after induction of carbohydrate-induced laminitis, but systemic activation of the coagulation system was not detected.

Assessing the effectiveness of a screening campaign: who is missed by 80% cervical screening coverage?

A case-control study was conducted to assess the effectiveness of a regional call programme in reaching women at risk of cervical cancer. Home interviews were conducted with a random sample of 614 women aged 20-64 who were identified from a computerized register as either having had a smear test within the previous 3 years or not having an up-to-date smear history. Unscreened women fell principally into two age cohorts: under 35 years and over 50 years. A small social class differential was found to persist following the campaign. Overall, unscreened women were not at epidemiologically higher risk than the screened population. Thirty-five per cent of unscreened women reported never having had sexual intercourse compared to 3% of screened women: 17% of the unscreened and 38% of screened women reported two or more lifetime sexual partners. No difference was observed between screened and unscreened women in the frequency of current cigarette smoking (37% unscreened, 38% screened). Cigarette smoking was, however, associated with social class (31% classes 1 or 2 compared with 50% classes 4 and 5). Level of practical difficulties did not differentiate those who attended from those who did not, suggesting that recent changes to delivery or screening services have been effective in ensuring equity of access. Non-attenders and lower class women held more negative attitudes towards the test procedure and were less likely to believe that they were at risk of cervical cancer. Perceived personal risk was not associated with cigarette smoking, suggesting that further attention might be given to this factor in educational campaigns.

Women's experiences at cervical screening

Concerns about attendance for cervical screening has focussed on determining the reasons why some women never attend. Less attention has been paid to whether women continue to attend for further smears, although this is essential for further screening. This study investigated women's experiences of cervical screening and their views on subsequent attendance. Three hundred and thirty nine women aged 20-64 were identified from a computerised register of cervical smears as having had a smear test within the previous three years. They were interviewed at home about their most recent experience of screening. Just over half of the women (53%) recalled being anxious before the test, and about one fifth reported embarrassment (19%) or pain (20%) during it. The frequencies of discomfort were higher amongst those who were anxious about the test, although 24% of those who were embarrassed and 28% who had pain reported being unconcerned beforehand. The frequencies of pain and embarrassment were only slightly higher when the smear taker was male. Many women (22%) reported being concerned about the test result although only 10% of those who were concerned were recalled for further assessment. Although a number of women had unpleasant experiences, almost all (95%) who were under 60 years of age said they were likely to attend for a subsequent smear. Taking cervical smears is often an unpleasant experience for women, although some of the distressing events could easily have been avoided. Attention to technique and to the concerns of individual patients, especially ensuring privacy, could reduce the extent of the problem. The uptake of subsequent smears should be monitored to ensure that women are not being discouraged from attendance.

Transplantation of the canine distal ulna as a free vascularized bone graft

An autogenous free vascular bone graft of the canine distal ulna was evaluated. The vascularity of the graft was based on a musculoperiosteal sheath supplied solely by the caudal interosseous artery and vein. Four autogenous heterotopic (ulna to tibia) vascular transfers were performed. Two avascular transfers were performed to provide baseline criteria from which the success of vascularized transfers could be assessed. Clinical lameness evaluation, serial radiographs, bone scintigraphy, and sequential fluorochrome bone labeling were performed after surgery in both vascular and avascular transfers. All dogs were free of lameness in the donor limb by the 26th postoperative day. Serial radiographs revealed rapid graft incorporation and hypertrophy in all vascularized grafts and severe bone resorption in nonvascularized grafts. Histology, microangiography, and evaluation of fluorochrome bone labels were performed 90 days after surgery to determine graft viability, incorporation and temporal remodeling patterns. Microangiography and fluorochrome assessment complemented the histological findings. Based on these findings the distal ulnar bone graft was determined to be both viable and structurally adequate for selected cases of long bone reconstruction.

The WHO objectives for palliative care: to what extent are we achieving them?

This paper examines recent research in palliative care in the light of the guiding principles set out by the World Health Organization. It outlines the gaps in the literature and suggests priorities for future research. Areas of unmet need are documented and it is argued that research comparing outcomes across care settings and relating particular care practices to outcome measures would help to set care targets. Further definition of the expected outcomes of psychological and spiritual care, as well as care for carers, is recommended. Available measures are reviewed and suggestions made for the development of additional measures. Finally, some key methodological problems are discussed, including making cross-setting comparisons, identifying appropriate outcome measures, prioritizing patients' own identification of outcomes, using different methodologies as death approaches, and combining different perspectives offered by patients, lay carers and professional carers. The role of qualitative data as an indicator of rating scale validity is discussed in this context.

A comparison between ilioinguinal-iliohypogastric nerve block performed by anaesthetist or surgeon for postoperative analgesia following groin surgery in children

A study was performed to compare postoperative analgesia in children undergoing groin surgery. Patients were randomly allocated to receive ilioinguinal-iliohypogastric (I-I) nerve blocks using 0.25% plain bupivicaine (0.5 ml.kg-1) performed either percutaneously by the anaesthetist after the induction of general anaesthesia, before surgery commenced, or intraoperatively, under direct vision, by the surgeon. Analgesia was assessed by pain scoring in the recovery room and at hourly intervals for eight h postoperatively. Analgesic requirement was also noted. Statistical analysis of the results revealed no difference in pain score between groups treated either by anaesthetist or surgeon. However, children under two years of age had significantly higher pain scores than those over two.

Cervical screening: the optimum visit plan for contacting users and non-users in Scotland

OBJECTIVE

To investigate the numbers of visits required to obtain interviews with users and non-users of cervical screening, and to determine the workload involved to enable an optimum visit plan to be developed.

DESIGN

Case-control study of users and non-users of cervical screening using a flexible visit plan that involved up to eight attempts at contact. Visits were made in mornings, afternoons, and evenings, the visit pattern being determined by information gained from local sources.

PATIENTS

Altogether 660 non-users of cervical screening (cases), aged 20-64 and registered with 23 randomly selected general practitioners (GPs), were identified from the Tayside computerised register of cervical smears. These women were selected from the computerised lists of 18 GPs in Dundee and five in Perth. A total of 417 women recorded as having a smear within the previous three years (controls), matched by age and GP, were also identified from the computerised register.

RESULTS

Altogether 1834 attempts were made to contact the cases, of whom 339 were interviewed, giving a workload of 18 interviews per 100 attempts. For the controls 1359 attempts were made at contact to yield 339 interviews, a workload of 25 interviews per 100 attempts. Refusals (19%) and incorrect addresses (23%) were the two major reasons for failing to achieve interview. Only for four (0.6%) of the cases and one (0.2%) of the controls was no information gained. The proportion of attempts which led to interview remained constant with increasing numbers of call-backs (up to six for the cases and eight for the controls).

CONCLUSIONS

A flexible approach to visit scheduling that takes account of local knowledge can lead to interviews with 66% of non-users of health screening, when incorrect addresses are removed. It is preferable to plan for many (up to six) visits to achieve interview. This will minimise non-response bias without increasing the workload per successful interview.

Prevalence of high risk sexual behaviour in adolescents attending school in a county in Nova Scotia

High school students ina county in Nova Scotia were asked about sexual activity, including high risk practices. Fifty-five per cent had had intercourse, including 82% of those 18 and 19 years of age. Being sexually active was associated with poorer school performance, having parents with less than a university education, being female, and living with other than both parents. Forty per cent of sexually active students had more than one partner in the year before the survey. Thirty-five per cent always used condoms for vaginal intercourse. Students having regular intercourse used condoms less, but less frequent condom use was not associated with having fewer sexually partners. Twenty per cent of sexually active students engaged in anal intercourse; 18% of females and 35% of males reporting this practice used condoms for all sexual encounters. Students in this high school population are highly sexually active, and report high risk sexual activities at levels which should be of concern to both public health practitioners and educators.

Microvascular thrombosis associated with onset of acute laminitis in ponies

The hypothesis that equine laminitis is caused by thrombosis of vessels in the laminar corium (dermis) was investigated. Hemostatic alterations were evaluated by determining platelet count, platelet survival, platelet adhesiveness to vascular subendothelium, activated clotting time, and whole blood recalcification time. Thrombosis of vessels in the hoof wall was evaluated by scintigraphic studies of the hoof wall after administration of indium-111 (111In)-labeled platelets, contrast arteriography, and histologic examination. Platelet count remained constant before and at the onset of lameness; however, survival of 111In-labeled platelets was shortened. Scintigraphy of affected feet revealed accumulation of 111In-labeled platelets distal to the coronary band. Arteriography of disarticulated saline-perfused feet revealed marked reduction in blood supply to affected hooves. Histologic examination of the laminar dermis disclosed variable numbers of microthrombi in dermal veins of affected feet from 3 of 4 ponies with laminitis. Whole blood recalcification time was shortened at 8 hours after administration of carbohydrate and was prolonged at the onset of laminitis. Activated clotting time was prolonged at 32 hours after carbohydrate administration and at the onset of lameness. Plasma endotoxin-like activity was detected in 1 of 4 affected ponies. These data confirm that microvascular thrombosis existed at the onset of lameness in ponies with carbohydrate-induced laminitis and indicate that systemic coagulopathy may have preceded development of thrombosis.

Influence of cigarette smoking on the outcome of coronary care unit admissions with chest pain

We studied the effect of current smoking habits in the period immediately before admission to hospital in 90 consecutive patients presenting with chest pain, 50 of whom were shown to have myocardial infarction. Urine cotinine/creatinine (cot/creat) ratio measured within 4 hours of admission was used as an objective marker of cigarette smoking in the preceding 18 hours. Fifty-seven patients had urine cot/creat ratios suggesting recent smoking, although four of these denied smoking. Patients with myocardial infarction had higher median cot/creat ratios (3.31 micrograms/mg, range 0-17.8) compared with patients with non-infarct chest pain (0.5 microgram/mg, range 0-37.2). Sixteen patients with cardiac rhythm disturbances following infarction had significantly higher cot/creat ratios than the 34 infarct patients without this complication (median and range 8.34 micrograms/mg; 0-17.8 V. 1.87 micrograms/mg; 0-16.4, P < 0.01). Tobacco use in the 24 hours before myocardial infarction may predispose to cardiac rhythm disturbance, irrespective of infarct size.

The minimum effective dose of lignocaine to prevent injection pain due to propofol in children

In a single-blind study of 100 children aged 1 to 10 years, the minimum effective dose of lignocaine required to prevent injection pain due to propofol was 0.2 mg.kg-1 when veins on the dorsum of the hand were used. This is more than twice the adult value. We concluded that injection pain should not limit the use of propofol in children if an adequate amount of lignocaine is mixed immediately prior to injection.

Changing perspective on gastrointestinal complications in patients undergoing cardiac surgery

There has been a documented shift towards increasing age and severity of illness in the patient population undergoing cardiac surgery. To determine if there was a coincident change in frequency, gastrointestinal (GI) complications were prospectively recorded in a consecutive series of 5,438 patients undergoing cardiac surgery from 1983 to 1991. There were 73 complications in 69 patients (incidence = 1.4%) defined as any GI condition that required transfer to an acute care unit, surgical intervention, blood transfusion, or treatment that prolonged the hospital course. Fourteen patients died, a mortality rate of 20% for patients with GI complications (p less than 0.001 versus patients without GI complications). The most frequent complications were those of gastric ulceration despite routine use of H2-receptor blocking agents. Thirty-six patients had upper GI (UGI) bleeding from gastric ulceration with 4 patients requiring operative intervention to control hemorrhage and 6 fatalities in patients with UGI bleeding. Two additional patients died of septic complications following gastroduodenal perforation or penetration. Six patients experienced bowel obstruction or prolonged bowel dysfunction (three Ogilvie's syndrome) with two requiring laparotomy. There were four cases of cholecystitis, two cases of pancreatitis, and the remaining cases were equally divided among common septic complications (diverticulitis and ischemic injury among others). Three patients with massive intestinal infarction died. GI complications were significantly associated with older patients (p less than 0.01) and valve surgery (p = 0.002) but were not more common in women. When considered as a separate group, patients with acid-peptic complications had longer perfusion times, increased use of vasopressors, and more frequent utilization of the intra-aortic balloon pump. In contrast to prior studies, this investigation indicates that GI complications associated with acid-peptic erosion of the UGI tract tend to occur in a different patient group than those with other GI complications. Older patients and/or those with a prior history of peptic ulcer symptoms, as well as those who experience prolonged perfusion times, low cardiac output, or prolonged ventilatory support, should be under rigorous gastric pH surveillance and receive aggressive prophylactic treatment with high-dose H2 antagonists, antacids, and/or sucralfate.