Prevalence and causes of visual impairment in The Barbados Eye Study

OBJECTIVE

To determine the prevalence and causes of low vision and blindness in a predominantly black population.

DESIGN

Population-based prevalence study of a simple random sample of Barbados-born citizens aged 40 to 84 years.

PARTICIPANTS

Four thousand seven hundred nine persons (84% participation).

METHODS

The standardized protocol included best-corrected visual acuity (with a Ferris-Bailey chart), automated perimetry, lens gradings (LOCS II), and an interview. Participants with visual acuity of worse than 20/30, other positive findings, and a 10% sample also had an ophthalmologic examination that evaluated the cause and extent of vision loss (resulting from that cause), if any.

MAIN OUTCOME MEASURES

Low vision and blindness were defined as visual acuity in the better eye between 6/18 and 6/120 and visual acuity worse than 6/120, respectively (World Health Organization [WHO] criteria).

RESULTS

Of the 4631 participants with complete examinations, 4314 (93%) reported their race as black, 184 (4%) reported their race as mixed (black and white), and 133 (3%) reported their race as white or other. Low vision was found in 5.9% of the black, 2.7% of the mixed, and 3.0% of white or other participants. Bilateral blindness was similar for black and mixed race participants (1.7% and 1.6%, respectively) and was not found in whites. Among black and mixed participants, the prevalence of low vision increased with age (from 0.3% at 40-49 years to 26.8% at 80 years or older). The prevalence of blindness was higher (P < 0.001) for men than women at each age group (0.5% versus 0.3% at ages 40-49 and 10.9% versus 7.3% at 80 years or more). Sixty percent of blindness was due to open-angle glaucoma and age-related cataract, each accounting for more than one fourth of cases. Other major causes were optic atrophy or neuropathy and macular and other retinal diseases. Few cases of blindness were due to diabetic retinopathy (1.4%), and none were due to age-related macular degeneration.

CONCLUSIONS

Using the WHO criteria, prevalence of visual impairment was high in this African-origin population, particularly at older ages. Most blindness was due to open-angle glaucoma and cataract, with open-angle glaucoma causing a higher proportion of blindness than previously reported. The increased prevalence of blindness in men may be due to the increased male prevalence of glaucoma in this population and warrants further investigation. Results underline the need for blindness prevention programs, with emphasis on effective treatment of age-related cataract and enhancing strategies for early detection and treatment of open-angle glaucoma.

Incidence of open-angle glaucoma: the Barbados Eye Studies. The Barbados Eye Studies Group

OBJECTIVE

To measure the 4-year risk of open-angle glaucoma (OAG) in a black population.

DESIGN

Population-based cohort study with 4 years of follow-up.

SETTING

Simple random sample of residents of Barbados, West Indies, aged 40 years or older.

PARTICIPANTS

A total of 3427 members of the cohort (85% of those eligible).

MAIN OUTCOME MEASURE

Development of glaucoma visual field defects and optic disc damage, confirmed by automated perimetry, independent fundus photographic gradings, and standardized ophthalmologic examinations.

RESULTS

The 4-year risk of OAG in black participants was 2.2% (95% confidence interval, 1.7%-2.8%), based on 67 newly developed cases of OAG. Incidence rates increased from 1.2% at ages 40 to 49 years to 4.2% at ages of 70 years or more, tending to be higher in men than women (2.7% vs 1.9%). About half of the incident cases were undiagnosed previously, and the rest were receiving OAG treatment. Of the 67 new cases of OAG, 32 had intraocular pressure of 21 mm Hg or less at baseline (1.2% incidence) and 35 had higher pressures (9% incidence). Risk was highest among persons classified as having suspect OAG at baseline (26.1%), followed by those with ocular hypertension (4.9%) and lowest in the remaining population (0.8%).

CONCLUSIONS

This longitudinal study provides new information on OAG risk, as well as the first incidence measurement in a black population. Although intraocular pressure increased risk, about half of the new cases had baseline pressures of 21 mm Hg or less. Results substantiate the high OAG risk in the population of African origin, especially in older adults; the relative role of intraocular pressure; and the considerable underdetection of new disease after 4 years of follow-up.

Intractable nausea attributable to isolated deficiency of adrenocorticotropic hormone: prompt resolution after administration of glucocorticoid

OBJECTIVE

To highlight the vague symptoms of isolated adrenocorticotropic hormone (ACTH) deficiency and suggest helpful diagnostic tests and appropriate management.

METHODS

We present a detailed case report, including clinical and laboratory findings, and discuss the diagnostic approach to this rare disorder of isolated ACTH deficiency.

RESULTS

A 74-year-old woman had persistent severe nausea and other vague symptoms. Elaborate testing during a period of several weeks failed to determine the cause. Ultimately, isolated ACTH deficiency was diagnosed after documentation of subnormal random serum cortisol and ACTH levels as well as urinary free cortisol concentrations. Moreover, the nausea and other symptoms abated after administration of glucocorticoid. The patient was then maintained on orally administered dexamethasone, 0.5 mg twice daily, for 4 to 6 weeks, at which time the diagnosis was confirmed by a subnormal cortisol response on cosyntropin stimulation testing and an unmeasurable ACTH level after overnight oral administration of metyrapone. Although the cause of this patient's isolated ACTH deficiency remained undetermined, it was thought to be autoimmune in nature because of the presence of Graves' disease.

CONCLUSION

This report emphasizes the need for recognition of symptoms, appropriate testing to confirm the diagnosis, and prompt treatment with glucocorticoids in patients with isolated ACTH deficiency.

Incidence and progression of lens opacities in the Barbados Eye Studies

OBJECTIVE

To provide 4-year cumulative incidence and progression rates of age-related lens opacities in a population > or =40 years of age, which is mainly of African origin.

DESIGN

Cohort study that reexamined surviving members of the population-based Barbados Eye Study 4 years after baseline.

PARTICIPANTS

Three thousand four hundred twenty-seven members of the Barbados Eye Study cohort (85% of those eligible).

MAIN OUTCOME MEASURES

The Lens Opacities Classification System II (LOCS II) was used at the slit lamp. Cumulative incidence was defined as the development of any nuclear, cortical or posterior subcapsular (PSC) opacities (LOCS II scores > or =2) among persons without that opacity type at baseline. Cumulative progression was defined by at least two-step increases in scores among persons with preexisting lens opacities.

RESULTS

The incidence of cortical opacities was about five times greater in black than white participants (age-gender adjusted relative risk = 4.7; 95% confidence interval: 1.9-11.4). In the black population, the 4-year incidence rates were 22.2% (20.4%-24.0%) for any cortical, 9.2% (8.2%-10.4%) for any nuclear, and 3.3% (2.7%-4.0%) for any PSC opacities; rates increased greatly with age. Four-year progression rates were 12.5% for cortical, 3.6% for nuclear, and 23.0% for PSC opacities, without consistent pattern by age. Women had a greater risk of cortical and nuclear opacities (P<0.05) than men and greater progression of nuclear opacities. The presence of PSC opacities at baseline seemed to at least double the incidence and progression rates of other opacities. In persons initially opacity free, single cortical opacities were the predominant type to develop at followup. Visual acuity loss frequently accompanied incident opacities.

CONCLUSIONS

This longitudinal study provides new population-based data on the natural history of lens opacities. Incidence and progression of opacities, especially of cortical opacities, were high. After 4 years of followup, 1 in 4 to 5 participants developed cortical opacities, 1 in 11 developed nuclear opacities, and 1 in 30 developed PSC opacities. The information obtained attests to the public health impact of age-related cataract, as well as its extent, in this and similar black populations.

Diabetic retinopathy in a black population: the Barbados Eye Study

OBJECTIVE

The distribution of diabetic retinopathy in black populations is largely unknown. The authors present retinopathy data from the predominately black participants of the Barbados Eye Study (BES).

DESIGN AND PARTICIPANTS

Prevalence study of 4631 participants based on a random sample of the Barbados population 40 to 84 years of age (84% participation).

MAIN OUTCOME MEASURES

Diabetes was defined as self-reported history of physician-diagnosed diabetes or glycosylated hemoglobin greater than 10% (>2 standard deviations above the population mean of persons without a diabetes history). Retinopathy was assessed by independent gradings of 30 degrees color stereo fundus photographs of the disc and macula.

RESULTS

Diabetes was present in 19.4% of black (n = 4314), 15.2% of mixed (black and white; n = 184), and 7.5% of white/other (n = 133) self-reported racial groups. In the black/mixed population, regardless of diabetes status, the prevalence of retinopathy was 5.9%. In the 636 black and mixed participants with diabetes, the prevalence of retinopathy was 28.5%: 19.8% had minimum changes, 7.7% had moderate changes, and 0.9% had severe retinopathy. Clinically significant macular edema (CSME) was found in 8.6% of those with diabetes.

CONCLUSIONS

In the population of African origin, approximately 1 in 17 persons had retinopathy. Among those with diabetes, 28.5% had retinopathy and 8.6% had CSME. These results highlight the clinical and public health relevance of diabetic retinopathy in the black population.

Diabetes, hypertension, and central obesity as cataract risk factors in a black population. The Barbados Eye Study

OBJECTIVE

The increased cataract prevalence of black populations, especially of cortical cataract, remains unexplained. The authors evaluate the relationships of diabetes, hypertension, and obesity patterns to lens opacities, by age, among 4314 black participants in the Barbados Eye Study.

DESIGN AND PARTICIPANTS

Prevalence study of a random sample of the Barbados population, ages 40 to 84 years (84% participation).

MAIN OUTCOME MEASURES

Associations with age-related lens changes (grade > or = 2 in the Lens Opacities Classification System II at the slit lamp) were evaluated in logistic regression analyses by age (persons < 60 years and > or = 60 years). Results are presented as odds ratios (OR) with 95% confidence intervals.

RESULTS

Of the 1800 participants with lens changes, most had cortical opacities. Diabetes history (18% prevalence) was related to all lens changes, especially at younger ages (age < 60 years: OR = 2.23 [1.63, 3.04]; age > or = 60 years: OR = 1.63 [1.22, 2.17]). Diabetes also increased the risk of cortical opacities (age < 60 years: OR = 2.30 [1.63, 3.24]; age > or = 60 years: OR = 1.42 [1.03, 1.96]); additional risk factors were high diastolic blood pressure (age < 60 years: OR = 1.49 [1.00, 2.23]) and higher waist/hip ratio (all ages: OR = 1.36 [1.00, 1.84]). Diabetes was also related to posterior subcapsular opacities. Glycated hemoglobin levels were positively associated with cortical and posterior subcapsular opacities. Overall, 14% of the prevalence of lens changes could be attributed to diabetes.

CONCLUSIONS

The high prevalence of cortical opacities was related to diabetes, hypertension, and abdominal obesity, which also are common in this and other black populations. Interventions to modify these risk factors, especially in populations in which they are highly prevalent, may have implications to control visual loss from cataract, which is the first cause of blindness worldwide.

Lens opacities, demographic factors and nutritional supplements in the Barbados Eye Study

BACKGROUND

This study evaluated the association of age-related lens opacities with the use of nutritional supplements and demographic factors among 4314 black participants (> or = 40 years) in the population-based Barbados Eye Study.

METHODS

Lenses were classified at the slit lamp by the Lens Opacities Classification System II (LOCS II); a score > or = 2 was used to define the presence of gradable lens opacities, by type. Lens changes also included prior cataract surgery or cataract too advanced to grade. Associations with risk factors were evaluated by logistic regression analyses.

RESULTS

The study identified 1800 individuals with lens changes in at least one eye; 229 had nuclear opacities only; 851 had cortical opacities only. Older age and indicators of lower socioeconomic status (low education and/or non-professional occupation), were positively associated with both nuclear (odds ratio [OR] = 1.90) and cortical (OR = 1.47) opacities. Women had an increased risk of cortical opacities (OR = 1.41). Regular users of nutritional supplements were less likely to have lens changes (OR = 0.78) and, specifically, cortical opacities (OR = 0.77). The association with nutritional supplements was present in those < 70 years, but not at older ages.

CONCLUSIONS

The study supports the association of lower socioeconomic status with lens changes, including nuclear and cortical lens opacities. The findings also suggest that regular users of nutritional supplements have a one-fourth lower risk of lens changes and particularly, of cortical opacities; a result seen at ages under 70 years. The associations with potentially modifiable factors indicate the need for further evaluations, given the high prevalence of lens opacities.

Distribution of intraocular pressure. The Barbados Eye Study

OBJECTIVE

To provide data on the distribution of intraocular pressure (IOP) in a predominantly black population, which has a high prevalence of open-angle glaucoma.

DESIGN

Population-based prevalence study.

SETTING AND PARTICIPANTS

Participants (N = 4601) (age range, 40-84 years) who had undergone applanation tonometry measurements in the Barbados Eye Study. Self-reported race was 93% black, 4% mixed (black and white), and 3% white or other.

DATA COLLECTION

A standardized protocol included applanation tonometry and other ocular measurements, fundus photography, demographic data, and an interview.

MAIN OUTCOME MEASURES

The average of 3 IOP measurements at the Barbados Eye Study visit was used to compare IOP by self-reported race. Descriptive data on IOP by age, sex, glaucoma status, and cup-disc ratio were examined in the black population.

RESULTS

The IOP was highest in the population of African origin. The mean (+/-SD) IOP values for black, mixed, and white participants were 18.7 +/- 5.2, 18.2 +/- 3.8, and 16.5 +/- 3.0 mm Hg, respectively. An IOP greater than 21 mm Hg was present in 18.4%, 13.6%, and 4.6% of the black, mixed, and white participants, respectively. In analyses that were adjusted for age, sex, and glaucoma status, such values were 5 times as likely in black than white participants and 3.5 times as likely in mixed race participants (P < .01). Among the black participants, the mean IOP increased approximately 1 mm Hg for every increase in 10 years of age. After excluding persons with any type of glaucoma, suspected glaucoma, or a history of glaucoma treatment, women had significantly (P < .01) higher IOP values; however, no significant IOP trends by sex were evident in the group with glaucoma. The IOP was also positively associated (P < .05) with vertical cup-disc ratios. After 2 visits, the IOP remained 21 mm Hg or less in 21% of the persons with glaucoma vs 64% of those without glaucoma.

CONCLUSIONS

In the black participants, the IOP was higher than in the white participants. The IOP was also associated with age and cup-disc ratios. The results showed that open-angle glaucoma and a high IOP alone have a different distribution by sex; although open-angle glaucoma was more frequent in men, ocular hypertension was more frequent in women. These data have implications for the detection and causation of open-angle glaucoma in this high-risk population.

Prevalence of lens opacities in the Barbados Eye Study

OBJECTIVE

To present population-based data on type and extent of age-related lens opacities in the predominantly black population of the Barbados Eye Study.

DESIGN

Prevalence study.

SETTING AND PARTICIPANTS

The Barbados Eye Study included 4709 participants (84% of those eligible), who were identified from a random sample of Barbadian-born citizens aged 40 to 84 years.

DATA COLLECTION

Lens gradings at the slit lamp, obtained with the use of the Lens Opacities Classification System II.

MAIN OUTCOME MEASURE

Prevalence of posterior subcapsular, nuclear, and cortical opacities (defined as a grade > or = 2 in either eye), as well as prevalence of any lens changes (including history of previous cataract surgery and/or cataract too advanced to grade).

RESULTS

Overall, 41% of the Barbados Eye Study population had any lens changes, including 3% with aphakia or an intraocular lens. Among the population of African descent, cortical opacities (34%) were most prevalent, followed by nuclear (19%) and posterior subcapsular (4%) opacities. Prevalence of all opacity types increased with age (P < .001). Cortical and nuclear opacities were more frequent in women than men. When prevalence of a single kind of opacity was considered, 21% of participants had cortical only, 6% had nuclear only, and 0.4% had posterior subcapsular only; 13% had mixed opacities. Visual acuity loss to worse than 20/40 in the more affected eye was present in 48%, 26%, and 18% of nuclear only, posterior subcapsular only, and cortical only types, respectively, and in 53% of mixed opacities.

CONCLUSIONS

The Barbados Eye Study provides the first prevalence data on different types of lens opacities in a large, predominantly black population. Whereas nuclear opacities are most common in white populations, cortical opacities were the most frequent type in the Barbados Eye Study, a finding of possible etiologic relevance. Other results highlight a higher frequency of opacities in women than men and a high prevalence of visual acuity loss in affected eyes.

Risk factors for open-angle glaucoma. The Barbados Eye Study

OBJECTIVE

To evaluate risk factors for open-angle glaucoma among black participants in the Barbados Eye Study.

DESIGN

Population-based study of demographic, medical, ocular, familial, and other factors possibly related to open-angle glaucoma.

SETTING AND PARTICIPANTS

The Barbados Eye Study included 4709 Barbados residents identified by a simple random sample of Barbadian-born citizens, 40 to 84 years of age; participation was 84%. This report is based on the 4314 black participants examined at the study site; 302 (7%) met the Barbados Eye Study criteria for open-angle glaucoma.

DATA COLLECTION

A standardized protocol included applanation tonometry, Humphrey perimetry, fundus photography, blood pressure, anthropometry, and an interview. An ophthalmologic examination was performed for participants who met specific criteria.

MAIN OUTCOME MEASURES

Open-angle glaucoma was defined by the presence of both characteristic visual field defects and optic disc damage. Association of open-angle glaucoma with specific factors was evaluated in logistic regression analyses.

RESULTS

Age, male gender, high intraocular pressure, and family history of open-angle glaucoma were major risk factors; the latter association was stronger in men than women. Lean body mass and cataract history were the only other factors related to open-angle glaucoma. Although hypertension and diabetes were common in Barbados Eye Study participants, they were unrelated to the prevalence of open-angle glaucoma. However, associations were found with low diastolic blood pressure-intraocular pressure differences and low systolic and diastolic blood pressure/intraocular pressure ratios.

CONCLUSIONS

In the Barbados Eye Study black population, persons most likely to have open-angle glaucoma were older men and had a family history of open-angle glaucoma, high intraocular pressure, lean body mass, and cataract history. These results suggest the importance of possible genetic or familial factors in open-angle glaucoma. The role of vascular risk factors is consistent with our finding of low blood pressure to intraocular pressure relationships, but the results could be explained by the high intraocular pressure in open-angle glaucoma.

Features of age-related macular degeneration in a black population. The Barbados Eye Study Group

OBJECTIVE

To report on the frequency of features of age-related macular degeneration in a black population based on fundus photograph gradings.

DESIGN

Population-based study.

SETTING

Barbados, West Indies.

STUDY POPULATION

Residents of Barbados, selected by a random sample of Barbados-born citizens, aged 40 to 84 years.

MAIN OUTCOME MEASURE

Gradings from 30 degrees stereoscopic macular photographs.

RESULTS

Black participants (n = 3444) completed examinations at the study site and had gradable macular photographs in both eyes. Drusen larger than 63 microns occurred with comparable frequency in men and women. The frequency of small drusen decreased with age, while medium and large drusen were more common in older participants. Frequencies of all age-related macular degeneration-related characteristics were similar for men and women except for small drusen, which occurred more commonly in women. Confluent drusen and pigment atrophy also increased significantly with age. Exudative features occurred in 0.5% of the participants.

CONCLUSIONS

This study provides population-based data on the frequency of features of age-related macular degeneration based on photographic gradings of a black population. Features of early age-related macular degeneration were common, but appeared at a lower frequency than has been reported for white populations. Exudative disease was infrequent, occurring in about one of 200 participants.

The Barbados Eye Study. Prevalence of open angle glaucoma

OBJECTIVE

To describe the design of the Barbados Eye Study and report on the prevalence of open angle glaucoma (OAG) in a predominantly black study population.

DESIGN

Population-based prevalence study.

SETTING AND PARTICIPANTS

Residents of Barbados, West Indies, identified from a simple random sample of Barbadian-born citizens 40 through 84 years old.

DATA COLLECTION

Participants had a comprehensive study visit that included automated perimetry, applanation tonometry, and fundus photography; persons with specific examination findings, as well as a 10% sample of participants, were referred for an ophthalmologic examination and additional tests.

OUTCOME

A diagnosis of OAG required both visual field and optic disc criteria for glaucoma damage after excluding other causes.

RESULTS

The 4709 participants (83.5% of those eligible) had demographic characteristics that were similar to the census population. Of the 4631 participants who were tested at the study site, 95% completed Humphrey automated perimetry and 97% had photographic or clinical disc gradings; 93% of those referred completed the ophthalmologic examination. In this adult population, the prevalence of OAG by self-reported race was 7.0% (302/4314) in black, 3.3% (6/184) in mixed-race, and 0.8% (1/133) in white or other participants. In black and mixed-race participants, the prevalence reached 12% at age 60 years and older and was higher in men (8.3%) than in women (5.7%), with an age-adjusted male-female ratio of 1.4. In addition, over 3% of the participants were classified as having suspect OAG.

CONCLUSIONS

To our knowledge, the Barbados Eye Study is the largest glaucoma study ever conducted in a black population and identified more people with OAG than did any previous population study. The prevalence of OAG was high, especially at older ages and in men. Among participants 50 years old or older, one in 11 had OAG, and prevalence increased to one in six at age 70 years or older. The results highlight the public health importance of OAG in the Afro-Caribbean region and have implications for other populations.

Comparison of diabetic retinopathy detection by clinical examinations and photograph gradings. Barbados (West Indies) Eye Study Group

OBJECTIVE

To compare the use of clinical examination and fundus photograph gradings in detecting diabetic retinopathy in a population that includes persons with and without diabetes.

DESIGN

Population-based epidemiologic study.

SETTING

Sir Winston Scott Polyclinic, Bridgetown, Barbados, West Indies.

PARTICIPANTS

Subset of a random sample of the country's population aged 40 to 86 years.

RESULTS

Among 1168 black persons with fundus photograph evaluations, ophthalmologic examinations, diabetes history, and glycated hemoglobin data, 21% reported a history of diabetes; 9.5% had definite diabetes (glycated hemoglobin > 11.5%); and 13.3% had a diabetes history and glycated hemoglobin value less than or equal to 11.5%. The frequency of diabetic retinopathy in this group was 7.7% (90/1168) by clinical examination, 8.7% (102/1168) by photograph gradings, and 6.7% (78/1168) by both methods.

CONCLUSIONS

These results suggest that in certain populations that include diabetics and nondiabetics, a clinical examination by an ophthalmologist will detect most cases of diabetic retinopathy identified by disc and macula photographs read by skilled graders. However, it will lead to an underestimate of prevalence. Staff availability and cost, issues not examined in this study, should determine which approach is selected.

A pilot project of glaucoma in Barbados

The prevalence of open-angle glaucoma is believed to be very high among West Indian blacks. To begin investigating the prevalence and risk factors for glaucoma and other eye diseases in Barbados, WI, a pilot study was conducted. The pilot project identified a stratified, random national sample of 300 persons over 35 years of age who were invited to participate in an ophthalmic examination and an interview. Of those contacted 89% were eligible and 95% of these agreed to participate. The overall glaucoma prevalence in the participants was 6%; it was 13% among black and mixed persons over 54 years. Age related cataract, hypertension, and diabetes were frequent findings. Although the sample size of the pilot project is small, the results suggest a high prevalence of glaucoma in Barbados, a finding that merits further study.

Design of a pilot study of glaucoma in Barbados

In Barbados, West Indies, open-angle glaucoma is a major cause of blindness, presenting early and with advanced visual loss. This report describes the design of a pilot project that evaluated the feasibility of an epidemiologic study to measure glaucoma prevalence and ascertain risk factors in this population. A major goal of the pilot project was to test the proposed sampling and recruitment methods for the larger study. The pilot project identified a random national sample of 300 persons ≥ 35 years, 100 from each of three geographic strata, who were invited to participate in a comprehensive interview and ophthalmologic examination. Because the pilot study was still ongoing at the time of this report, data are available only on the first 172 persons in the sample; 88 percent of those contacted were eligible for the study and 97 percent agreed to participate without any differential participation by geographic area. Preliminary data on the first 170 persons examined show that 20 to 25 percent of participants had best corrected visual acuity of 20/40 or worse; about 10 percent had intraocular pressure >21 mmHg; over 20 percent had cup-disc ratios of ≥0.5; and ten persons had open-angle glaucoma.

Eye health

The status of eye care in the Caribbean is discussed. Methods of primary eye care providers at all levels from primary to tertiary in the region are presented against a background of the major causes of blindness, cataract, glaucoma, and diabetic retinopathy. Epidemiological surveys examining prevalence, risk factors, and intervention programs are being undertaken.

Nutritional status in alcoholics with and without liver disease

Nutritional status, dietary calories, dietary protein, quantity of ethanol (ET), and severity of liver disease were tested in 62 alcoholics with liver disease (ALC LD). Twenty alcoholics without liver disease (ALC) and 20 abstinents (ABS) were also examined. Despite adequate protein intake ALC LD and ALC had significantly lower body weights, triceps skinfolds, and arm muscle circumferences than ABS. Poorer nutritional status in abusers is probably related to toxic effect of ET. ALC LD compared with ALC had no difference in ET (2.05 +/- 0.15 and 1.80 +/- 0.22 g/kg/day, respectively), in weight, triceps skinfold and the arm muscle circumference. ALC LD consumed fewer dietary calories, less protein (covering more of total calories with ET) and had a lower serum albumin. Decreased serum albumin in ALC LD was related to liver disease rather than to malnutrition: it inversely correlated with bilirubin but not with dietary protein. In ALC LD there was no correlation between ET, calories, or protein in the diet and severity of liver disease. The concept that ALC Ld is related to ET dose and/or malnutrition thus could not be confirmed. Other predisposing factors may be instrumental in the pathogenesis of ALC LD.

Clinical Experiences in 14C-tripalmitin breath test for fat malabsorption

The 14C-tripalmitin breath test has been used routinely in our institution for the diagnosis of fat malabsorption as well as for the differential diagnosis of malabsorption due to pancreatic insufficiency. The test was performed in 124 patients over a period of about three years. The sensitivity and specificity of the test for fat malabsorption were better than 85.7 and 87.0%, respectively, with the efficiency better than 86.4%. When used in conjunction with Viokase administration, the test is useful as a means of separating pancreatic malabsorption patients from patients with other forms of malabsorption.

The effects of dietary fiber on gastrointestinal motor function

For normal individuals and probably for persons with diverticular disease, dietary fiber affects stool bulk and decreases transit time. The unproven rationale for the use of fiber in irritable colon and diverticular disease assumes that these diseases are the result of increased intraluminal pressure caused by excessive segmentation over a period of years. In short-term experiments, certain fibrous materials do decrease intraluminal pressures, usually in response to a stimulus such as food but sometimes under resting conditions as well. It seems likely that the physical and probably chemical characteristics of fiber influence the motor responses of the alimentary tract. Anecdotal testimonials to the merits of fiber abound, but firm evidence that even wheat bran, the most commonly studied fiber, is effective is difficult to obtain. Controlled clinical trials have been attempted and to date have given conflicting results. Careful studies using a number of well-defined fibrous materials are urgently required to determine the physiological mechanisms of action of different fibers on gastrointestinal motor activity.

Wheat bran as an etiologic factor in certain diseases. Some second thoughts

The author questions "the bran hypothesis" that a deficiency of natural fiber--wheat bran in particular--is responsible for a number of prevalent diseases in Western societies, namely diverticular disease, cancer of the colon, gallstones, and myocardial disease. In re-examining the hypothesis, he cites reports which fail to support the theory. For instance, the incidence of diverticular disease in women has increased since 1925, yet there is no evidence that their diets have changed or are different from those of men. Also, it is a mistake to equate wheat bran with fiber in general, and it cannot be shown that dietary fiber in general has declined. In addition, clinical studies have failed to show beneficial results in treating diverticular disease and irritable colon by adding bran to the diet. Similar problems arise in testing the hypothesis that natural fiber can prevent cancer of the colon and lower serum cholesterol and triglycerides. Recent interest in dietary fiber is welcome, for it has been grossly neglected, but much research is still needed to place it in proper perspective.

"Nonalcoholic" chronic hepatitis in the alcoholic

Ten alcoholic patients with biopsy proved chronic active or chronic persistent hepatitis were observed. In each patient, the responsible etiological agent appeared to be ethanol. Laboratory abnormalities could be distinguished statistically from those in a group of 121 patients with alcoholic hepatitis by their higher SGPT (262 +/- 139 versus 62 +/- 7 U per ml, P is less than 0.01), lower ratio of SGOT:SGPT (1.96 +/- 0.34 versus 4.71 +/- 0.40, P is less than 0.01), and lower white blood cell count 5,833 +/- 763 versus 10,370 +/- 742, P is less than 0.01). However, the overlap between the groups was sufficiently large that without histological confirmation the correct diagnosis was in doubt for any given patient.

Natural fiber and bowel dysfunction

This paper reviews the current status of knowledge with relation to the effects of natural fiber on intestinal physiology. The one clear feature that emerges from literature is that most types of natural fiber increase the bulk of the stool. It is probable also that transit time is affected. Transit time appears to be decreased in persons with initially a slow time when they use certain forms of natural fiber and it may be that persons with rapid transit have a decrease in the rate of passage as fiber is added to the diet. Data on colonic intraluminal pressures are scanty, but those that exist seem to indicate that the addition of bran to the diet results in a decrease in overall colonic pressures. Much has been written and speculated about the role of natural fiber in the prevention or therapy of irritable colon and diverticular disease. Clinical studies, while enthusiastic, are preliminary and there are no hard data to indicate that the use of these materials are, in fact, helpful. Such clinical trials that have been published are, in general, small, poorly controlled and overall equivocal in their conclusions. A great deal of further work requires to be done to justify the claims that have been made on the role of fiber in altering normal or abnormal bowel habit.

Dietary fiber and diverticular disease

Can the regular consumption of bran and other fibrous foods help in preventing diseases of the colon? Indirect evidence supports the idea, although much remains to be learned. It seems probable that bulkier feces could increase the diameter of the colon and prevent sudden sharp rises in pressure that are believed to be responsible for the formation of diverticula. For most people, fiber is probably harmless and it may do some good.

Emotion-related gastritis

The relationship of emotional stress to abnormalities of the gastric mucosa was considered in a review of 788 consecutive upper gastrointestinal endoscopies. Fifty-three precent of patients with gastritis not related to any generally accepted predisposing or precipitating cause had significant emotional problems documented on their clinical records, while only 10% of the comparable group of duodenal ulcer patients and 25% of a similar group of medical in-patients had significant emotional problems documented. Since this difference was statistically significant (P less than 0.01 and P less than 0.05, respectively), the data suggest that emotional stress may play a contributing role in the production of gastric mucosal abnormaltieis.

Absence of effect of bran on blood-lipids

Healthy medical students were divided into two groups. One group was given double the normal fibre intake of their diet as a high-fibre-containing breakfast cereal; the other group (control) was given a breakfast cereal containing negligible amounts of dietary fibre. Otherwise the nutrient intake of the two groups was maintained constant. No differences in the serum-cholesterol, serum-triglyceride, serum-calcium levels were found between the two groups during or at the end of the study. The addition of a tolerable amount of dietary fibre to the diet does not affect serum-lipids.

Control factors in the release of gastrin by direct electrical stimulation of the vagus

The release of gastrin by direct electrical stimulation of the vagus was studied together with the relative effects on the response of antral and duodenal acidification. As expected, gastrin levels increased to three times the normal simulated response following antral neutralization. In contrast, duodenal acidification failed to influence the vagal release of gastrin when the antrum was neutralized although it had a minor effect when the antrum was acidified. Thus the antral pH dominates over duodenal pH as a factor in controlling gastrin release. Surprisingly, atropine in doses which blocked acid release and produced marked cardiac effects failed to inhibit the release of gastrin from the antrum on vagal stimulation. This suggests that, using this model, vagal release of gastrin, if cholinergic, is highly resistant to atropine.

Selective or truncal vagotomy? Five-year results of a double-blind, randomized, controlled trial

The 5-year results of a double-blind, randomized, controlled trial of selective versus truncal vagotomy, each with pyloroplasty, are reported. of 100 patients entering the trial, 95 are available for study. There were 4 suspected or proven recurrent ulcers in the truncal group and 1 suspected but no proven recurrence in the selective group. The incidence of episodic diarrhoea was significantly less in the selective group; 4 mild and no severe cases compared with 11 mild and 2 severe cases among the truncal vagotomies. There was no severe dumping; mild symptoms were more common in the selective group but not significantly so. Miscellaneous dyspeptic symptoms were a little more common in the truncal group. Taking all these symptoms into consideration, the Visick clinical status of the selective group was superior. Weight changes, haemoglobin levels, and calcium levels were similar and satisfactory in each group. Selective vagotomy is superior to truncal vagotomy when each is combined with pyloroplasty.

Pyloroplasty versus gastrojejunostomy. Results of a double-blind, randomized, controlled trial

A double-blind, randomized, controlled trial of Finney pyloroplasty and gastrojejunostomy, each with selective vagotomy, is reported. There were no operative deaths but 5 patients have subsequently died or have been lost to follow-up, leaving 94 patients, with a mean follow-up time of 3 1/2 years. There has been 1 proven recurrence after gastrojejunostomy and 2 after pyloroplasty, with 1 further suspected recurrence in each group. The clinical grading marginally favoured gastrojejunostomy. There was no significant difference in the incidence of bilious vomiting, dumping, diarrhoea, or other disturbances, but there was a significantly greater increase in bowel frequency after pyloroplasty. Weight changes were similar, and there was no gross anaemia or calcium deficiency in either group. Gastrojejunostomy is reversible and pyloroplasty is not, and therefore we recommend gastrojejunostomy as the drainage procedure of choice when drainage is necessary after vagotomy.

Coeliac and hepatic nerve function following selective vagotomy

In the intact patient insulin hypoglycaemia increases the output of amylase and bile-acids despite the exclusion of acid from the duodenum. This effect is abolished by truncal vagotomy. After selective vagotomy a partial response from the pancreas occurs consistent with preservation of a direct route in the coeliac nerve and the loss of vagally released pancreatic secretagogues. A similar effect in the biliary system could not be demonstrated.