Development of a postal health status questionnaire to identify people with dyspepsia in the general population

OBJECTIVE

To develop and validate a postal health status questionnaire which will identify people with dyspepsia in the general population.

DESIGN

Validation against telephone interview and post re-post determination of reliability.

SETTING

A general practice population in the north of England.

SUBJECTS

A random sample of adults aged 20-69 years inclusive chosen from the general population.

MAIN OUTCOME MEASURES

Validity has been checked against telephone interview. A kappa statistic has been calculated for each question and clinical category.

RESULTS

Compared with interview the questionnaire is a valid, comprehensive and easily understood record of symptomatology. The kappa statistics (mean value 0.92) indicate a very reliable questionnaire.

CONCLUSION

The questionnaire accurately and reliably identifies people with dyspeptic symptoms.

Path.Finder: an interactive clinical information system. The day-to-day management of patients requires unified information sources

Presents Path.Finder, a locally managed health care information system built in response to the need for better communication of current research evidence and clinical practice guidelines. Concludes that this system will improve patient care by providing up-to-date, clinically useful information which is relevant locally. The technology and the information management system have been developed in parallel.

Silica induced suppression of the production of third and fifth components of the complement system by human lung cells in vitro

Although investigations to date have demonstrated the ability of the monocyte/macrophage to synthesize complement components, only a limited number of studies on complement synthesis by nonhepatic tissue cells have been reported. To begin to fill this gap in our knowledge we have recently evaluated the ability of lung tissue cells to synthesize and secrete various complement components in vitro. Using 35S-methionine incorporation and immunoprecipitation techniques we have previously demonstrated the ability human lung type II pneumocytes (A549) and human lung fibroblasts (WI-38), to synthesize and secrete a variety of both early and terminal complement components, as well as several regulatory proteins including Clr, Cls, C4, C3, C5, C6, C7, C8, C9, Factor B, Factor H, Factor I and Cls inactivator. Our present studies demonstrate the capability of silica to regulate complement component production by A549 cells, but not complement component production by WI-38 cells. Specifically, using sensitive ELISAs we demonstrated that a non-toxic dose of silica had the capability to suppress the production of both C3 and C5 by A549 pneumocytes by 40-50 percent, but had no effect on C3 or C5 synthesis by WI-38 fibroblasts. Additionally, using 35S-methionine incorporation and TCA precipitation techniques, we demonstrated that suppression of C3 and C5 production by silica treated A549 pneumocytes was not a result of suppression of total protein synthesis. These studies demonstrate that silica, which has been implicated in pulmonary diseases, has the capability to regulate local complement production by lung tissue cells in vitro. In vivo, this suppression of complement production by the type II pneumocytes could alter the local tissue reservoir of complement components during infection and pulmonary injury, thus resulting in depressed pulmonary host defense.

Implementing right-to-know legislation for health care workers in Manitoba: a bipartite sectoral train-the-trainer approach

In October 1988, right-to-know legislation was introduced in Canada. This presented a technical and administrative challenge to the health care sector. With over 170 health care facilities in Manitoba to be brought into compliance, some large, some small, some rural, some urban, a cooperative approach was needed. A labor-management steering committee with representatives from a cross-section of facilities as well as the various health care unions was formed to design and implement a train-the-trainer program. A small-group, highly participatory modular program was developed with input from all parties, and delivered across the province by trainers selected jointly by labor and management. The program achieved its goal of assisting member facilities to implement the legislation. Follow-up surveys and discussions with health care workers showed improved understanding of labelling requirements, material safety data sheet interpretation, and requirements for hazard control. This first bipartite program empowered the health care workforce to use its newly acquired right-to-know, and has provided the incentive to implement other cooperative safety and health programs.

Medical rehabilitation for the indigent in Louisiana: a primer for physicians

The impact of a stroke, head injury, spinal cord injury, or other disabling condition can be especially devastating for individuals without health insurance. Fortunately, a comprehensive system has evolved to address the needs of the indigent for medical rehabilitation services in Louisiana. The purpose of this paper is to familiarize readers with this complex system, and thereby to assist practicing physicians and other health care providers in better serving this large and medically needy population. First, state and federal medical assistance programs which cover rehabilitation services are reviewed; next, services available through Louisiana Rehabilitation Services are discussed; and finally, services available through the Handicapped Children's Services Program and various voluntary organizations are described.

Human immunodeficiency virus antibodies in sera of Australian blood donors: 1985-1990

OBJECTIVE

To describe the results of human immunodeficiency virus type 1 (HIV-1) antibody testing of blood donations in Australia.

DESIGN

Blood transfusion services tabulated the number of HIV-1 antibody tests carried out on blood donations and the number of donations found to be positive, from 1985 to 1990.

SETTING

All blood transfusion services in Australia.

PARTICIPANTS

All donors of blood in Australia from 1 May 1985 to 31 December 1990.

OUTCOME MEASURES

The proportion of blood donations found to have HIV-1 antibody, according to State or Territory, year of donation and, when available, age, sex and donation status (repeat or first-time) of the donor.

RESULTS

To the end of December 1990, 5,367,970 donations had been tested for HIV-1 antibody, and 46 were found to have the antibody, giving an overall prevalence rate of 0.86 per 100,000 donations. The highest rate was recorded in New South Wales, followed by Western Australia, and four of eight Australian States and Territories reported no donors with HIV-1 antibody. There has been no clear trend with time, but the rate is about 20% higher for 1989-1990 than for 1985-1986. Of donors found to have HIV-1 antibody, 67% were male and 33% female, and 41% reported no known or potential exposure to HIV-1 other than heterosexual contact. Among blood donors in two major Australian cities, the overall prevalence of HIV antibody was higher in those who were male, younger, and first-time donors. There has been a recent increase in the number of blood donors with HIV-1 antibody who were women reporting heterosexual contact as their only potential exposure.

CONCLUSION

The rate of HIV-1 antibody in Australian blood donations remains very low and shows no clear temporal trend, but specific donor characteristics define higher rates of antibody prevalence.

Effect of lipopolysaccharide on C3 and C5 production by human lung cells

Although studies to date have demonstrated the ability of the monocyte/macrophage to produce C components in vitro, very few studies on C production by nonhepatic tissue cells have been reported. Recently, using 35S-methionine incorporation and immunoprecipitation techniques our laboratory has demonstrated the ability of tissue cells, i.e., the human lung type II pneumocyte (A549) and human lung fibroblast (WI-38), to synthesize and secrete a variety of early and terminal complement components, as well as several regulatory proteins in vitro, i.e., C1r, C1s, C4, C3, C5, C6, C7, C8, C9, factor B, factor H, factor I, and C1s inactivator. In our studies, we extended these observations by demonstrating the capability of LPS to modulate C3 production by A549 pneumocytes. Specifically, using a sensitive ELISA we demonstrated that A549 pneumocytes exposed to LPS induced an 80 to 180% increase in C3 levels when compared to untreated A549 cells. Interestingly, LPS had no effect on C5 production or total protein synthesis by A549 pneumocytes. In the case of the WI-38 fibroblast, LPS had no effect on 1) C3 production, 2) C5 production, or 3) total protein synthesis in vitro. These studies demonstrate that agents such as LPS have the potential to selectively regulate C production (i.e., C3) in individual lung cells in vitro, and suggests that in vivo LPS may alter the local tissue reservoir of C components during infection and lung injury, thus impacting on pulmonary inflammation and host defense.

Effect of lipopolysaccharide on C3 and C5 production by human lung cells

Although studies to date have demonstrated the ability of the monocyte/macrophage to produce C components in vitro, very few studies on C production by nonhepatic tissue cells have been reported. Recently, using 35S-methionine incorporation and immunoprecipitation techniques our laboratory has demonstrated the ability of tissue cells, i.e., the human lung type II pneumocyte (A549) and human lung fibroblast (WI-38), to synthesize and secrete a variety of early and terminal complement components, as well as several regulatory proteins in vitro, i.e., C1r, C1s, C4, C3, C5, C6, C7, C8, C9, factor B, factor H, factor I, and C1s inactivator. In our studies, we extended these observations by demonstrating the capability of LPS to modulate C3 production by A549 pneumocytes. Specifically, using a sensitive ELISA we demonstrated that A549 pneumocytes exposed to LPS induced an 80 to 180% increase in C3 levels when compared to untreated A549 cells. Interestingly, LPS had no effect on C5 production or total protein synthesis by A549 pneumocytes. In the case of the WI-38 fibroblast, LPS had no effect on 1) C3 production, 2) C5 production, or 3) total protein synthesis in vitro. These studies demonstrate that agents such as LPS have the potential to selectively regulate C production (i.e., C3) in individual lung cells in vitro, and suggests that in vivo LPS may alter the local tissue reservoir of C components during infection and lung injury, thus impacting on pulmonary inflammation and host defense.

Biosynthesis of the third and fifth complement components by isolated human lung cells

Increasing research efforts have been directed at determining the contribution of locally synthesized (cell-derived) complement in host defense and inflammation. In the studies presented here, we determined the ability of a continuous cell line of type II pneumocytes (A549) and a cell line of human lung fibroblasts (WI-38) to produce complement components in vitro. Complement biosynthesis by A549 pneumocytes and WI-38 fibroblasts was demonstrated by incorporation of [35S]methionine into immunoprecipitable complement proteins. Using this technique, A549 pneumocytes were demonstrated to synthesize Clr, Cls, C4, C3, C5, C6, C7, C8, C9, Factor B, Factor H, Factor I, and C1s inactivator. In comparison, WI-38 fibroblasts were shown to synthesize Cls, C4, C3, C5, C6, C8, and C9. Because previous work has demonstrated the central role of C3, C5, and their activation products in regulating lung inflammation and tissue injury, we further investigated the production of C3 and C5 by both lung pneumocytes and fibroblasts using enzyme-linked immunospecific assays. A549 cells cultured in the presence of 15% fetal bovine serum (FBS) produced antigenic C3 (135 ng C3/ml/24 h) at a greater rate than did identical cells maintained in serum-free culture conditions (70 ng C3/ml/24 h). Similarly, antigenic C5 production by A549 pneumocytes was greatest in the presence of FBS when compared with cells maintained in serum-free culture conditions (245 ng C5/ml/24 h versus 155 ng C5/ml/24 h).(ABSTRACT TRUNCATED AT 250 WORDS)

Germin. Molecular cloning of cDNA that selects germin mRNA from bulk wheat mRNA

(1) Bulk mRNA from germinated wheat embryos was denatured with methylmercury and subjected to electrophoresis in agarose gel to obtain a fraction of mRNA that was modestly enriched with respect to its complement of translatable germin mRNA. This fraction of mRNA was used as a source of primary templates for preparing a cDNA library. (2) Escherichia coli JM101 was transfected with recombinant pUC8 plasmids containing cDNA inserts. Colonies of transformed bacteria (ca. 4 x 10(3)) were differentially screened by hybridizing them with cDNA probes that were prepared from RNA populations containing different proportions of translatable germin mRNA. (3) A 160 base pair (bp) cDNA, which hybridized more strongly to the probe made from the RNA population containing the greater proportion of translatable germin mRNA in colony hybridizations, also hybridized more strongly to the RNA population containing the greater proportion of translatable germin mRNA when it was used as a probe for Northern analysis. (4) As judged by peptide mapping of a protein made by cell-free translation, the 160-bp cDNA selected virtually pure germin mRNA from the bulk mRNA of germinated wheat embryos when it was used in "hybrid release" experiments. The same 160-bp cDNA was used to select a "full length" germin cDNA from a library prepared by the Gubler-Hoffman method.

Obstructive sleep apnea syndrome: preoperative radiologic evaluation

The purpose of this study was to determine whether lateral radiographs of the pharynx and fluoroscopy of the lateral pharynx in the sleeping patient could be used as predictors of surgical success in patients undergoing soft-palate surgery for obstructive sleep apnea. A total of 12 patients had surgery after radiologic evaluation. There were six surgical successes and six failures. No successes occurred in patients with a soft-palate length of less than 46 mm, nor were there any successes among patients whose initial point of obstruction on fluoroscopy was inferior to the level of the soft palate. There was one surgical failure among patients in whom fluoroscopy showed upper airway obstruction beginning at the level of the soft palate during sleep. Results suggest that a patient is most likely to benefit from soft-palate resection if the soft palate is long--we conservatively suggest greater than 40 mm--and if sleep fluoroscopy of the lateral pharynx shows airway obstruction beginning at the level of the soft palate.

Anticoccidial efficacy of halofuginone in turkeys reared to market weight

Floor-pen studies were conducted in three geographic locations to study the efficacy of halofuginone (3.0 ppm in feed) against important species of coccidia in turkeys. Severe coccidiosis exposure was obtained in studies in Georgia and Colorado and mild coccidiosis in Wisconsin. Coccidiosis caused by contamination of the feed with oocysts of Eimeria adenoeides, E. meleagrimitis, and E. gallopavonis was almost completely controlled by halofuginone at 3 ppm, even though intestinal lesion scores and weight loss were high in two studies. Halofuginone was also highly effective in preventing buildup of infection in pens contaminated by indirect means (movement by caretakers through the pens, etc.). Weight gains and feed conversion were best in poults receiving halofuginone, whether directly or indirectly exposed. There was no evidence that halofuginone caused any untoward reactions in the poults, even though the drug was fed until turkeys reached market weight.

Cystic fibrosis in adults: delayed diagnosis in three siblings

Cystic fibrosis (CF), which is transmitted as an autosomal recessive trait, is the most common lethal genetic disease in the United States. Median survival age for patients followed up at CF centers in the US is now 21 years. While the disease is diagnosed in most patients before the age of 5 years, in 10% of cases the diagnosis is not confirmed until after age 12. We report an unusual family in which the diagnosis of CF was first established in three siblings at the ages of 36, 40, and 44 years. We describe the clinical features of the patients, as well as issues relating to the diagnosis of CF in adults. This unusual pedigree supports the concept of genetic heterogeneity in CF.

A structurally novel stimulator of guanylate cyclase with long-lasting hypotensive activity in the dog

Studies were undertaken to characterize the activity of diphenyliodonium hexafluorophosphate (DIFP) as a structurally novel stimulator of soluble guanylate cyclase from rat lung and make comparisons to the activity of sodium nitroprusside (SNP). In addition, the effects of these two compounds on several cardiovascular parameters in anesthetized dogs were determined. DIFP stimulated guanylate cyclase activity within the same concentration range (10-300 microM) as SNP, causing a maximal 2-3-fold activation. The activities of both SNP and DIFP were dependent on the presence of dithiothreitol and inhibited by methylene blue. In anesthetized dogs, DIFP (i.v.) elicited a dose-related, long-lasting fall (greater than 3 h) in mean arterial pressure (MAP) which was accompanied by a reduction in total peripheral resistance and a transient rise in cardiac output. These effects on MAP were similar to those of SNP except they were of a much longer duration. In addition, both SNP and DIFP produced slight bradycardia and reduced negative dP/dt. These results suggest that DIFP and SNP, while structurally dissimilar, activate guanylate cyclase by a related mechanism which may be involved in vascular relaxation leading to reduced blood pressure.

Methodological considerations of epidemiological diagnoses in respiratory diseases

Since epidemiological research depends extensively on questionnaire responses, a comparison of such responses with a standardized medical evaluation was conducted. It was found that standardized questionnaires do well in comparison for certain kinds of information on chronic conditions. However, clinical evaluations will elicit more information, specifically of a milder nature. It was concluded that standardized epidemiological questionnaires are satisfactory for survey of chronic conditions.

Kaolin pneumoconiosis. Radiologic, pathologic, and mineralogic findings

Pulmonary tissue obtained at thoracotomy or autopsy from 5 kaolin workers with complicated pneumoconiosis was studied by optical light and scanning electron microscopy. Premortem or preoperative chest roentgenograms demonstrated small irregular shadows and large opacities typical of kaolin pneumoconiosis. On gross examination, there were firm, grey-brown nodules and masses in the parenchyma and in the hilar lymph nodes. Histologically, there was extensive pulmonary kaolinite deposition associated with formation of peribronchiolar macules and nodules. The latter were comprised of kaolinite aggregates traversed by bands of fibrous tissue rather than dense whorled collagen, as seen in silicosis. Crystallographic studies confirmed the presence of kaolinite in the lungs, but silica was not demonstrable by either analytical scanning electron microscopy or X-ray diffractometry. These findings illustrate the pathology of human kaolin pneumoconiosis, confirm the fibrogenic potential of kaolinite, and emphasize differences in pulmonary responses to kaolinite and to silica.

Long-term results of proximal gastric vagotomy

Proximal gastric vagotomy without drainage for duodenal ulcer was performed in 304 patients between 1969 and 1977. There was one operative death (0.3%) and two patients required secondary drainage (0.6%). Eleven patients died subsequently of unrelated causes. Follow-up 5 to 13 years after operation was conducted on 242 patients (80%). Of these, 141 were asymptomatic and 48 had only trivial symptoms, a success rate of 78%. Thirty-two patients had recurrent ulcer and 2 of them had Zollinger-Ellison syndrome. When these two were excluded, the recurrence rate was 12.4%. Two patients had duodenitis. Seven patients had unexplained pain and some of them may ultimately be shown to have recurrence. Appreciable esophageal reflux was seen in eight patients. Other symptoms, nearly all mild, were dumping in one, diarrhea in seven and bile reflux in six. Recurrent ulcer was treated by cimetidine initially in all 32 cases but ultimately by repeat vagotomy and antrectomy in 27, with no deaths and only one further recurrence (Zollinger-Ellison syndrome). After operative correction, the ultimate success rate (Visick grades I and II) was 90%.

The long-term results of proximal gastric vagotomy

Since 1969 we have performed proximal gastric vagotomy (PGV) in 514 patients. PGV without drainage was performed, before 1978, in 304 patients with one death (0.3%) and of these, 242 have been followed for from five to 13 years. Good clinical results were achieved in 78% but there were 32 recurrent ulcers. When two patients with Zollinger-Ellison Syndrome were excluded the late recurrence rate was 12.7%. There was no difference between the clinical results of men and women. When all the recurrent ulcers and two patients with gastric retention had been treated, mostly by operation, good results were recorded in 90% of our series. We conclude that PGV is the best operation at present available for uncomplicated duodenal ulcer.

Gastric ulceration after Nissen fundoplication

Thirteen patients developed gastric ulcers between 6 months and 8.5 years after Nissen fundoplication. Eight patients presented with epigastric pain alone, 3 with bleeding alone and 2 with both pain and bleeding. Nine ulcers (69 per cent) were high on the lesser curve, close to the fundoplication and 7 of these patients had recurrent hernias. Anatomical distortion produced by fundoplication is probably the most important aetiological factor, though gastric distention, bile reflux gastritis and ischaemia may be contributory.

Pneumoconiosis in Georgia kaolin workers

Middle Georgia kaolin workers (n = 459) were surveyed for the presence of pneumoconiosis by chest radiograph and for respiratory symptoms by questionnaire. Pulmonary function was measured in all workers by spirometry. The overall prevalence of pneumoconiosis in this population was 9.2%. Multivariate analysis demonstrated that the only significant correlates with the radiographic presence of pneumoconiosis were ages greater than 55 yr and greater than 15 yr work exposure in the job category associated with greatest dust exposure. There was no correlation between the radiographic presence of pneumoconiosis and respiratory symptoms, cigarette smoking, or history of tuberculosis. Except in cases of complicated pneumoconiosis (large opacities), spirograms of workers with radiographic evidence of pneumoconiosis were not significantly different from spirograms of workers with normal radiographs. Clinical impairment of pulmonary function does not occur except in advanced cases, and appears to be mild even in these.

Inhibition of hypoxic pulmonary vasoconstriction by nifedipine

Nifedipine is a potent slow channel calcium antagonist and systemic vasodilator recently reported to attenuate hypoxic pulmonary vasoconstriction in man. Other systemic vasodilators have also been shown to attenuate hypoxic pulmonary vasoconstriction, but their effects in some species may be mediated by reflex beta-adrenergic discharge. We evaluated the effect of nifedipine on the relation between pulmonary arterial pressure and blood flow during hyperoxia (inspired partial pressure of oxygen [PO2] 200 mm Hg) and hypoxia (inspired PO2 50 mm Hg) in denervated ventilated pig lungs perfused in situ with the animal's own blood. Ten lungs were ventilated with alternating 15 minute periods of hyperoxia and hypoxia. Hypoxia shifted the pulmonary artery pressure (x axis)-blood flow (y axis) relationship to the right and decreased its slope, indicating vasoconstriction. Nifedipine, given as a 0.1, 1, or 10 microgram/kg bolus into the pulmonary artery, caused a dose-dependent reduction of hypoxic pulmonary vasoconstriction. It is concluded that nifedipine is a potent pulmonary vasodilator acting locally within the lung and that it might be useful in the therapy of hypoxic pulmonary hypertension from chronic lung disease in man.

Entrapment neuropathy of the inferior branch of the suprascapular nerve by ganglia

In a 37-year-old man, bilateral infraspinatus muscle weakness was associated with compression of the suprascapular nerve. The compression occurred at the spinoscapular angle by bilateral development of ganglia. The lesion was confirmed by electromyography. Surgical approaches to the area are described along with a review of the literature on different diagnosis. Complete recovery of neurologic function was documented.

Airway response to sublingual nitroglycerin in acute asthma

To test the efficacy of sublingual nitroglycerin as a bronchodilator, we studied ten patients with acute asthma. After a baseline spirogram, each patient was given 1.2 mg of sublingual nitroglycerin, and subsequent spirograms were obtained a five-minute intervals for 15 minutes. Each patient was then given three subsequent doses of epinephrine (0.5 mg) subcutaneously at 15-minute intervals. Spirograms were obtained 15 minutes after each epinephrine dose. Forced expiratory volume at 1 s (FEV1) and forced vital capacity (FVC) did not change significantly following sublingual nitroglycerin, but both FEV1 and FVC improved significantly after epinephrine administration. Three patients experienced transient but severe hypotension after receiving sublingual nitroglycerin. The results suggest that sublingual nitroglycerin is not adequate initial therapy for asthmatic attacks and that the administration of sublingual nitroglycerin in acute asthma may be dangerous.

The management of pancreatic and pancreaticoduodenal injuries

From 1969 to 1979 39 injuries of the pancreas and duodenum were treated at the Royal Victoria Hospital, Belfast. The mortality was 31 per cent. Twenty-six injuries were due to stab, bomb or bullet. Two of the 17 with low velocity gunshot wounds died, whereas all 5 cases of high velocity missile injury died (P < 0·001). Ten of the 13 cases of blunt trauma were due to road traffic accidents. In 21 cases the body and tail of the gland were injured, and in 13 the head and neck. There were 5 isolated duodenal injuries and in 7 a combined pancreaticoduodenal injury. The mortality was directly related to the number of other organs damaged.

Three main methods of treatment were used—simple drainage, suture and drainage, and primary distal pancreatic resection. Serious complications, pancreatitis, fistula, secondary haemorrhage and sepsis were frequent after the first two methods but rare after distal resection.

Diagnosis was delayed in 4 cases of closed injury and 1 of these patients died. Pancreatic injury was missed 6 times at operation; in 4 cases retroperitoneal haematoma was not explored and 2 of these patients died.

Five of the 12 deaths were due to overwhelming bomb and bullet injury. In one case resuscitation was inadequate. The remaining 6 died of the complications of the original pancreatic injury, either because operation was delayed or because the injury was missed.

Our management was deficient in three areas: awareness of the need for laparotomy, recognition of the injury at operation and inadequate surgery. All open abdominal injuries must be explored; suspicion and careful assessment are essential in closed trauma. At operation the pancreas must be carefully examined; an upper retroperitoneal haematoma is an absolute indication for this. Simple drainage is only sufficient for trivial injury; for major injury of the body and tail we prefer distal resection. Roux loop drainage is suggested for injury to the head and neck, especially when associated with duodenal injury.

Running a weight control group: experiences of a psychologist and a general practitioner

A weight control group is described, led jointly by a general practitioner and a clinical psychologist. Approaches employed included dietary advice, behavioural advice, and group support. Of the original 16 members (including one group leader), seven dropped out at an early stage and the reasons for this are discussed. All members were re-weighed at intervals up to 18 months after the beginning of the six-month intensive period. They were also interviewed by a psychological research worker a year after the start of the group. The results suggest that a combined dietetic and psychological approach to weight control is of value.

Proximal gastric vagotomy, fundoplication, and lesser-curve necrosis

Out of 400 patients who underwent proximal gastric vagotomy (PGV), three developed lesser-curve necrosis (LCN) leading to perforation within the first seven days. In each case diagnosis was delayed but the patient survived after a second operation. In each an associated Nissen fundoplication had been carried out; we used the combined operation in only 33 patients. Delayed LCN occurred in a patient who had undergone splenectomy at the time of the PGV and in a fifth patient treated elsewhere who had also undergone fundoplication. These findings indicate that early postoperative gastric distension with gas, not readily voided after fundoplication, may aggravate local vascular factors and predispose to LCN. We suggest that PGV combined with fundoplication may be dangerous.

A computer program for testing average partial association in three-way contingency tables (PARCAT)

PARCAT is a computer program which implements alternative tests for average partial association in three-way contingency tables within the framework of the product multiple hypergeometric probability model. Primary attention is directed at the relationship between two of the variables, controlling for the effects of a covariable. This approach is essentially a multivariate extension of the Cochran/Mantel-Haenszel test to sets of (s x r) tables. A set of scores such as uniform, ridits, or probits can be assigned to categories which are ordinally scaled. In particular, if ridit scores with midranks assigned for ties are utilized, this procedure is equivalent to a partial Kruskal-Wallis test when one variable is ordinally scaled, and is equivalent to a partial Spearman rank correlation test when both variables are ordinally scaled.

Insulinoma (apud cell carcinoma) in a diabetic

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Management of recurrent peptic ulceration

A series of 117 consecutive patients having operations for recurrent peptic ulcer is reported. There were no initial deaths but 9 patients developed further recurrent ulcer and 2 of 8 who had a third operation died, giving an overall patient mortality of 1.7 per cent. A further 6 patients underwent a third operation to correct bile vomiting or dumping, with no deaths.

The mean time of onset of symptoms of recurrent ulcer was 1.9 years after proximal gastric vagotomy, 3.2 years after vagotomy and drainage, 3.3 years after gastrectomy and 12.6 years after gastrojejunostomy.

One hundred and four patients were followed for more than 1 year (mean 5.2 years) and the result was good in 77 per cent. After a third operation the proportion of good results was improved to 88 per cent.

Second recurrence occurred in 1 of 43 patients after revagotomy and gastrectomy, in 2 of 28 after resection alone and in 6 of 33 after vagotomy or revagotomy alone (P <0.05). When the patients whose primary operation included neither vagotomy nor gastric resection were excluded, there was a similar trend but the differences were not significant. It is suggested that gastric resection or re-resection should be combined with vagotomy or revagotomy whether the primary operation has been gastrectomy, vagotomy with or without drainage or gastrojejunostomy alone.

Cimetidine for recurrent ulcer after vagotomy or gastrectomy: a randomised controlled trial

In a randomised controlled trial cimetidine 1 g daily for six weeks was compared with placebo in the treatment of recurrent ulcers after gastrectomy or vagotomy for duodenal ulcer. Healing, assessed endoscopically, was seen in seven out of 12 patients given cimetidine and in five out of 12 controls. Four of the controls whose ulcers did not heal were subsequently treated with cimetidine, and in two the ulcers healed after six weeks. Pain recorded by the patient and consumption of alkalis were each slightly but not significantly less in the cimetidine-treated patients. When cimetidine is to be used for recurrent ulceration probably the dosage and duration of treatment should be increased.

Roux diversion for bile reflux following gastric surgery

Regurgitation of bile into the stomach after gastric surgery often causes severe and distressing symptoms, though the onset may be delayed for some years. We have used a Roux loop diversion as a secondary procedure for bile reflux in 36 patients, making the anastomosis from 18 to 40 cm below the stomach. There were no deaths and the clinical results were good in 20 of 27 patients followed up from 1 to 10 years. Vagotomy was omitted in 13 patients, 2 of whom subsequently developed jejunal ulceration. One patient developed an unexplained gastric ulcer and 2 operations failed because the loop was too short. The optimum length may well be 40 cm and vagotomy should be added in all cases. In 3 patients with associated dumping the upper 10 cm of the Roux loop was reversed.

Closure of gastrojejunostomy for the relief of post-vagotomy symptoms

When dumping, diarrhoea or bile vomiting follows vagotomy and gastrojejunostomy, simple closure of the stoma, without alternative drainage, has been performed in 19 patients. Thirteen patients, 5 with truncal, 7 with selective and 1 with proximal gastric vagotomy, have been followed up for 1-6 years. Five were completely relieved of symptoms, 7 improved and there was only 1 complete failure. Bile vomiting was more often relieved than dumping or diarrhoea. The procedure is safe and significant gastric retention does not occur provided that at least one year is allowed to elaspse after the primary operation.