28 Can Comprehensive Geriatric Assessment be Achieved in the Emergency Department?

Background

Our National Health Service is facing unprecedented challenges to accommodate our frailer healthcare users. The gold standard tool for the identification and management of frailty is the Comprehensive Geriatric Assessment (CGA) and has been shown to lead to better outcomes in terms of morbidity and mortality.

Introduction

With a largely elderly demographic profile in the East of England, the Norfolk and Norwich University Hospital opened the first Older People’s Emergency Department (OPED) in the UK in 2017. This work reviews the effectiveness of a geriatrician-led CGA in a dedicated OPED, which operates during daylight hours, compared to usual care in Accident & Emergency (A&E).

Methods

99 patients assessed in OPED and 99 patients assessed overnight in A&E during February 2019 were included in this retrospective study. Electronic case notes for each patient were reviewed by the authors and results were expressed as percentages.

Results

OPED outperformed A&E in all components of the CGA; strongest areas included assessing for pain, falls risk and activities of daily living. Both departments performed well in reviewing medications and assessing for safeguarding concerns. Areas for improvement include assessing for mood disorders, sensory impairment, discussing Do Not Attempt Cardiopulmonary Resuscitation status, and end of life care plans. The average length of stay of OPED patients was only 7.3 days compared to 8.7 days in A&E, and 89% of OPED patients were discharged back to their usual residences compared to 87% in A&E.

Conclusions

The improved CGA process in OPED has led to better outcomes, notably through a reduction in the average length of inpatient stay. Nevertheless, certain components of the CGA still require improvement. Further examination is needed to assess long-term mortality to support the use of CGA in the emergency setting.

Examination of the Interproximal Wear Mechanism: Facet Morphology and Surface Texture Analysis

Dentition is considered a dynamic system with forces that directly affect dental treatment stability and success. Understanding the biomechanical forces that influence tooth alignment is essential for both planning and performing dental treatments, as well as for anthropological and evolutionary studies. While there is currently an abundance of research on the mechanics of dental wear at the occlusal surface, the mechanics of interproximal dental wear is largely unexplored. The fretting mechanism, a wear process resulting from small-amplitude cyclic motion of 2 solid contacting surfaces, was refuted as a possible mechanism for occlusal wear but has never been considered for interproximal wear. Therefore, the aim of the current study was to reveal the biomechanical process of the interproximal wear and to explore whether the fretting mechanism could be associated with this process. Premolar teeth with interproximal wear facets were examined by 3-dimensional surface texture analysis using a high-resolution confocal disc-scanning measuring system. The unique texture topography of 3 areas in the proximal surface of each tooth was analyzed by applying 3D dental surface texture analysis. Each area showed unique texture characteristics, presenting statistically significant differences between the inner area of the facet and its margins or the surface outside the facets borders. Based on these results, we concluded that fretting is a key mechanism involved in interproximal wear.

Outbreaks of influenza: a virus in vaccinated elderly residents

Annual influenza immunisation is the recommended practice for people such as the elderly, for whom influenza poses a substantial risk of serious illness and death. Influenza vaccines are effective in preventing, or ameliorating influenza, reducing complications and mortality (Department of Health, 2001, 2002). In long-stay residential accommodation, influenza immunisation should prevent rapid spread of infection causing outbreaks (Communicable Disease Centre, 2003).

This paper reports on two outbreaks of influenza that occurred in vaccinated elderly in residential institutions. In both outbreaks the isolated virus strain was included in the composition of the influenza vaccine for that winter season. Suboptimal protection against influenza may be provided in the vaccinated elderly, due to declining competency of the ageing immune system. Furthermore, the occurrence in the late winter of these outbreaks may demonstrate waning immunity following immunisation early in the season.

Morphologic features and development of granulomatous vasculitis in feline infectious peritonitis

Feline infectious peritonitis (FIP) is a fatal, coronavirus (CoV)-induced systemic disease in cats, characterized by granulomas in organs and granulomatous vasculitis. This study describes the morphologic features of granulomatous vasculitis in FIP as well as its development in the course of monocyte-associated feline CoV (FCoV) viremia in five naturally infected Domestic Shorthair cats with FIP. Monocyte-associated FCoV viremia was demonstrated by immunohistology, RNA in situ hybridization, and electron micropscopy. Granulomatous phlebitis at different stages of development was observed. Vasculitic processes ranged from attachment and emigration of FCoV-infected monocytes to vascular/perivascular granulomatous infiltrates with destruction of the vascular basal lamina. Monocytes as well as perivascular macrophages were activated because they were strongly positive for CD18 and expressed cytokines (tumor necrosis factor-alpha and interleukin-1beta) and matrix metalloproteinase-9. In addition, general activation of endothelial cells, represented by major histocompatibility complex II upregulation, was observed in all cases. These results confirm FIP as a monocyte-triggered systemic disease and demonstrate the central role of activated monocytes in FIP vasculitis.

PCR and the notification of meningococcal disease

The polymerase chain reaction (PCR) can be used to investigate suspected meningococcal infection, with rapid results. We became aware that Birmingham Health Authority was not being informed about certain patients on whom meningococcal PCR had been performed. To establish whether notification was overlooked in some patients with suspected meningococcal disease, or whether PCR was performed on patients in whom it was thought meningococcal disease was unlikely, we compared numbers of patients notified to us over six months who had PCR with numbers of patients not notified who had PCR. Between 1st August 1999 and 31st January 2000, 54 PCR requests were made on seventy-seven notified patients; 51 PCR requests were made on non-notified patients and none were positive. Median age and length of stay were shorter in the non-notified patients. We conclude: (i) PCR may be being used inappropriately on younger patients who have shorter admissions and are unlikely to have meningococcal disease; (ii) in a number of patients initially admitted and notified with meningococcal disease the diagnosis is subsequently reconsidered. A 'denotification' procedure for such patients could make information on meningococcal disease more reliable.

Sharing knowledge with nursing home staff: an objective investigation

Nursing home staff are at the forefront of coping with swallowing and communication disorders. Our study, which is ongoing, collates information on the existing knowledge of such staff and demonstrates how their understanding can be increased by speech and language therapists' input. Twenty nursing homes agreed to participate in training (91% uptake). To date 16 nursing homes (113 staff) have completed training in swallowing and eight nursing homes (47 staff) in communication problems. Questionnaires were completed before and after training. There was a highly significant improvement after training.

Lactic acidosis associated with stavudine administration: a report of five cases

Type "B" lactic acidosis has been described in patients receiving the nucleoside analogs zidovudine, didanosine, and fialuridine. Lactic acidosis has also been described in 4 patients receiving combination therapy with stavudine and lamivudine. We describe the development of chronic type "B" lactic acidosis in 3 patients receiving stavudine as a single agent and in 2 patients receiving combination therapy with stavudine and either lamivudine or delavirdine, a nonnucleoside analog. All patients presented with abdominal pain, vomiting, and hepatic steatosis. Other signs of mitochondrial toxicity included pancreatitis and myopathy (2 cases). The mean duration of stavudine therapy was 9.4 months, and the mean observed peak lactate level+/-SD was 10.3+/-5 mmol/L. After discontinuation of stavudine treatment, lactic acidosis improved in 4 patients after 4-60 weeks, and 1 patient died. Evaluations for other causes of lactic acidosis, including hypoxemia, malignancy, sepsis, and cardiogenic shock, were negative.

Who killed whom?: victimization and culpability in the social construction of murder

Based on in-depth interviews with relatives of people convicted of murder, this article examines the ways in which everyday understandings of 'murder' are socially constructed, as revealed by the narratives of murderers' relatives. To this end, interviewees' explanations of the killings are analysed and a distinction is drawn between interviewees who understood the killings committed by their relatives as manslaughter and those who accepted the murder verdict. In defining the offences in this way, interviewee s identified the significance of victimization and culpability to understandings of interpersonal violence. Through the analysis of interview data, it is possible to examine the ways in which 'murder' is seen to have occurred only when particular criteria of victimization and culpability are met.

A comparison of three methods of analgesia in children having day case circumcision

Sixty-one children were randomized to receive one of three methods of analgesia for day case circumcision. Group 1 received a penile block, group 2 received a penile block plus diclofenac suppository and group 3 received a diclofenac suppository alone. CHEOPS pain scoring was performed in the recovery area, one h after awakening and two h after awakening. There was no difference between the groups except in the recovery area when group 3 cried more and had a higher pain score than group 2. Parental follow-up questionnaires for the subsequent two days showed no difference in measured parameters between the groups.

Apathetic thyrotoxicosis

A previously fit 37-year-old woman was admitted with acute left ventricular failure, atrial fibrillation and a left-sided thromboembolic stroke. Her ventricular rate progressively increased despite full digitalisation. She had a cardiac arrest and was successfully resuscitated. Investigations revealed evidence of hyperthyroidism and she was treated for thyrotoxic crisis. She has made a complete recovery from the hemiparesis and is now in sinus rhythm. She denied any symptoms of hyperthyroidism. This patient had apathetic thyroid crisis, which is exceedingly rare in the young.

Rates of bone loss in peri- and postmenopausal women: a 4 year, prospective, population-based study

1. Age-related bone loss is well established but reported rates of bone loss in the spine and femur vary widely. The aim of the present study was to investigate changes in bone mineral density in the lumbar spine and proximal femur in healthy postmenopausal women. 2. One hundred and thirty-eight population-based women, aged 45-65 years, recruited from general practice registers in 1990, were assessed at baseline; 108 returned for repeat assessment 4 years later, of whom 31 had taken hormone replacement therapy for 12 months or more of the 4-year study period. Bone densitometry of the lumbar spine and proximal femur was performed by dual-energy X-ray absorptiometry. Serum 25-hydroxyvitamin D and oestradiol were measured by RIA and serum intact parathyroid hormone by radio-immunometric assay. 3. The mean age at follow-up was 62 years (mean of 13.6 years after menopause). Lumbar spine bone mineral density was significantly higher in women who had received hormone replacement therapy for more than 12 months during the study period than in those who had not (P < 0.01). There was no difference between these two groups in the femoral neck or trochanteric bone mineral density. In the lumbar spine, the annual change in bone mass in untreated women was -0.39% (95% confidence intervals -0.60 to -0.09; P < 0.02) whereas there was a small gain in women receiving hormone replacement therapy [+0.36% (-0.12 to 0.84; P not significant)]. The annual change in bone mass in the femoral neck and trochanter was -0.51 and -0.45 respectively in untreated women (P < 0.01 and P < 0.02), and -0.16 and -0.15 in those receiving hormone replacement therapy (P not significant). 4. Our results demonstrate relatively low rates of bone loss in the spine and proximal femur in these healthy, population-based peri- and postmenopausal women. Hormone replacement therapy appeared to be associated with a significant protective effect on spinal, but not femoral, bone mineral density.

Fishing in a polluted estuary: fishing behavior, fish consumption, and potential risk

People make subjective judgments about hazards relying on what they know and feel. These risk perceptions may be based on accurate or inaccurate information and are often optimistically biased. The existence of uncertainties in the evaluation of many environmental hazards effects how risks are perceived. This paper examines fish consumption and risk perception of urban fishermen in the New York/New Jersey estuary, in areas where there were consumption advisories. We interviewed 318 fishermen and crabbers in the Arthur Kill, Raritan Bay, and New Jersey shore. Fish were eaten an average of at least four times per month in all regions, but fishermen in the Arthur Kill fished most frequently, averaging over eight times per month. Although 60% of fishermen and crabbers in the Arthur Kill reported hearing warnings about consuming fish caught in these waters, 70% of fishermen and 76% of crabbers said they are their catch. Significantly fewer fishermen in the Bay and Shore regions had heard warnings (28% and 30%, respectively), and more reported consuming their catch (88% and 82%, respectively). In all regions, most people thought that the fish were safe to eat, many believing they were "fresher" than store bought fish. Thus, most people ignored the consumption advisories in effect for these waters. Some of these people are consuming high quantities of fish and crabs, and thus are exposed to potentially deleterious levels of contaminants. In general, people failed to consider the possibility of chronic effects and did not perceive that this enjoyable, familiar pastime could be hazardous. Further, fishermen generally had great confidence in their own knowledge, which proved to be inaccurate in many cases, and often expressed distrust in the information source (government). Clearly, simply issuing consumption advisories is insufficient to promote risk-reducing behavior.

Prevention of lower limb pain in soldiers using shock-absorbing orthotic inserts

The utility of shock-absorbing boot and sneaker inserts for reducing the occurrence of lower limb pain among male US Army basic trainees was evaluated. Every other training unit was given inserts. The inserts were issued prior to the start of training when combat boots and sneakers were fitted. According to post-training questionnaires and the participants' medical records, the inserts did not have any preventive effect on occurrence of lower limb problems during training. Five hundred seventeen trainees were issued inserts, 397 were followed but not issued inserts, and 218 were not issued but purchased them on their own. Thirty-eight percent of those issued inserts had lower limb pain problems compared with 29% of those not issued inserts and 38% of those who bought their own. There was no statistical difference between these rates of occurrence. Prior to training, there were minor differences between the groups' scores on physical fitness test scores and run times. These differences disappeared during training so that there were no differences among the groups on either training or clinical variables during or after basic training.

Prediction and portrayal of repetitive stress-induced lower limb pain disorders among soldiers in basic training using videothermography

OBJECTIVE

Thermography has been widely espoused for both detecting and portraying pain problems. Development of repetitive stress-induced lower limb pain during army basic training is a relatively common occurrence. This study was designed to assess the usefulness of thermography for differentiating soldiers who developed lower limb pain during training from those who did not. This information was intended to be used to determine the usefulness of pretraining thermograms taken just as people came into the army in predicting which trainees would develop these conditions during training.

DESIGN

Videothermographic pictures were taken of the lower limbs of 639 newly enlisted soldiers who had just arrived at a large U.S. Army base but had not yet begun basic training. The amount of symmetry was correlated with the development of lower limb pain. Each soldier reporting lower limb pain and "controls" with nonpain problems (usually minor colds) received a thermographic evaluation identical to the original evaluation when they came for their medical examination.

RESULTS

Among prebasic trainees, 37% showed 1.0 degrees C of asymmetry somewhere in their lower limbs, 14% were asymmetrical by between 1.1 degrees and 2.0 degrees C, 5% by 3.0 degrees C and 4% by 4.0 degrees C or more. Thus, only 40% of the prebasic trainees were within accepted "normal" limits before participating in training. Thirty-nine percent of those with asymmetrical thermograms developed lower limb pain compared with 28% of those with symmetrical thermograms (significant at p < 0.05). It was impossible to predict from any thermographic measurement on the lower limbs which soldiers were most likely to develop lower limb pain. This held true even for those pretrainees with the greatest asymmetries. Eighty-four percent of trainees reporting lower limb pain produced abnormal thermograms regardless of whether or not they produced abnormal thermograms prior to training.

CONCLUSION

Thermograms were of little value for either predicting or portraying repetitive stress-induced lower limb pain in this population.

Self-reported tooth loss and bone mineral density in older men and women

It has been reported that postmenopausal women with osteoporosis have a higher than expected number of dentures and fewer teeth than women without osteoporosis. The relationship between self-reported tooth loss and bone mineral density (BMD) at the hip and spine in 608 men and 874 women, aged 65-76 years, was examined in a cross-sectional study. BMD was measured using dual X-ray absorptiometry. Twenty-four per cent of men and 27% of women had no natural teeth. There was a consistent decrease in BMD with increasing numbers of teeth lost in men. This relationship was independent of age, body mass index and smoking habit (trochanter r = -0.14, p < 0.0005; Ward's triangle r = -0.1, p < 0.005; and lumbar spine r = -0.07, p < 0.05) with between 5% and 9% difference in mean BMD at various sites between men who had all their teeth and men who had no teeth. There was no significant association between self-reported tooth loss and BMD in women. Tooth loss is associated with lower BMD in men; this relationship is less consistent in women.

Bone mineral density and its relationship to skin colour in Caucasian females

Low bone mineral density (BMD) is associated with a high risk of osteoporosis and fracture. While women with darker skin, such as women of American African origin, are reputed to have lower risk osteoporosis and fractures compared with women with fair skin such as Caucasian women, with Oriental women having intermediate levels of risk, the reasons for these differences are not clear. We examined the relationship between BMD and skin colour in a population based study of 2005 Caucasian women with a mean age of 58.1 years, resident in Cambridge and categorized into fair, medium and dark complexions by self-report. There was no difference between the three categories of skin colour with regard to body size or life-style characteristics. Women with self-reported fair skin had lowest BMD values, women with self-reported dark skin had highest BMD values, and women with self-reported medium skin colour had intermediate values at all sites. These differences were significant at the trochanter and Ward's triangle of the hip (P values of 0.01 and 0.03, respectively). These associations were independent of age and weight. The associations remained after stratifying for smoking habit and years since menopause. In a cohort of Caucasian women resident at latitude 52 degrees North, fair-skinned women have lower BMD values than darker-skinned women. This association between skin colour and BMD may reflect sunlight exposure times and underlying vitamin D status.

Alcohol consumption and bone mineral density in older men

It is well documented that alcohol abuse is associated with an increased risk of fracture in men, but the relationship of moderate alcohol intake to bone mineral density (BMD) is not as clear. We examined the relationship between self-reported alcohol intake and BMD measured at the hip and spine using dual X-ray absorptiometry in a population-based cohort of men. The men were categorized as (1) non-drinkers and drinkers and (2) as having no, low, medium, and high alcohol intake (units/week). 458 men aged 69.1 +/- (SD) 2.8 (range 64-76) years were studied. Drinkers were significantly younger (p = 0.01), had lower recorded caffeine intake (p = 0.02), and had fewer pack years of smoking (p = 0.04) than non-drinkers. The mean BMD at the hip was significantly higher in drinkers as compared with non-drinkers (p = 0.02) before and after adjusting for age and weight. However, after further adjusting for pack years of smoking, caffeine intake, and physical activity, the difference remained significant at the trochanter only. Men categorized in the highest tertiles of alcohol intake (> 11 units/week) were younger (p = 0.3), had lower caffeine intake (p = 0.008), and had significantly higher gamma-glutamyltransferase levels (p = 0.002) than the other categories. The crude mean BMD at femoral neck, trochanter, and Ward's triangle was significantly higher in men who drank 1-4 units of alcohol per week. However, most of this association disappeared when BMD was adjusted for age and weight except at the trochanter.(ABSTRACT TRUNCATED AT 250 WORDS)

Cigarette smoking and bone mineral density in older men

Cigarette smoking is cited as having a detrimental effect on bone mineral density (BMD), with associated increased fracture risk. Most of the data are from studies of women, with few studies of men. We examined the relationship between BMD and cigarette-smoking habit in a population-based study of men who were categorized by self-report as 'never smokers', 'current smokers' and 'ex-smokers'. BMD was measured using dual X-ray absorptiometry (DXA). We examined 453 men aged 65-76 years (mean 69.1). Non-smokers ('never' and 'ex' smokers) were heavier than current smokers (p = 0.05). There was no significant relationship between BMD and smoking habit at any site except the trochanter, where current smokers had significantly lower BMD than did non-smokers. However, after adjusting for age and weight there was no longer a significant relationship. BMD did not relate to pack-years of cigarette smoking. Current smokers consumed significantly more alcohol than non-smokers (p = 0.031), but adjusting for alcohol intake did not alter the BMD-smoking relationship. Cigarette smoking appears not to affect BMD in this group of older men.

Predictive testing for Huntington disease: social characteristics and knowledge of applicants, attitudes to the test procedure and decisions made after testing

An investigation has been made of the social characteristics and knowledge and experience of Huntington disease (HD) for the first 80 individuals considering presymptomatic testing (applicants) at the medical genetics centres in Edinburgh and Glasgow and of attitudes to the test procedure and decisions made after testing for those who received a result. Sixty-one percent of applicants were female and 31% were over 40 years old. Almost all had a symptomatic parent but 38% did not know HD was in their family until they were over 25 years old and 48% had never received genetic counselling. Thirty-eight percent of applicants first heard of the test at the genetic clinic, 20% from a relative and 20% from the media, but none had received information from their GP. Thirty-one applicants did not have the test because they voluntarily withdrew (17 individuals), their family structure was unsuitable or no informative result was possible (11 individuals), or they were diagnosed clinically as being affected (3 individuals). Those who voluntarily withdrew did not differ significantly from the 49 who received a result in social characteristics or knowledge and experience of HD. Twenty-two individuals were found to be at increased risk (IR) (> 50% of becoming affected) and 27 to be at decreased risk (DR) (< 50% of becoming affected). There was a median period of 9 months between entering the test procedure and receiving a result and the main criticism of the procedure was that it took too long to complete and several individuals experienced considerable anxiety while awaiting their result.(ABSTRACT TRUNCATED AT 250 WORDS)

Age-associated bone loss in men and women and its relationship to weight

The relationship of bone mineral density (BMD) to age and weight was investigated in a cross-sectional study of 942 community-dwelling men and women aged 65-74 years. BMD continues to decline after the age of 65 at a similar rate in men and women. BMD was positively associated with weight in both men and women with similar regression slopes; approximately one third of the decline in BMD with age could be explained by the associated age-related decline in weight. Maintaining weight in later life may prevent some of the age-related loss of bone. Whatever factors are responsible for the age-related decline in bone mass apply similarly in men and women at these older ages: there is no evidence for accelerated decline in women in this age group.

Parity and bone mineral density in middle-aged women

A retrospective study was carried out to determine the relationship between parity and bone mineral density (BMD) in middle-aged women. Eight hundred and twenty-five woman aged 41-76 years were recruited from four general practice registers in Cambridge. Subjects were unselected as to their health status. Each subject completed a detailed health questionnaire. Participation rate was 50%. The main outcome measure was BMD measured at the spine (L2-4, n = 825) and hip (neck, intertrochanter and Ward's triangle; n = 817) by dual-energy X-ray absorptiometry (DXA) using the Hologic QDR-1000 densitometer. It was found that the unadjusted mean BMD was significantly higher at all sites among the parous women (p = 0.031 to < 0.00001), and remained significantly higher at the femoral neck (p = 0.025), intertrochanter (p = 0.001) and Ward's triangle (p = 0.045) after adjusting for age and body mass index (BMI). Similar findings were seen after stratifying for potential confounding variables. There was a consistent upward trend of BMD with increasing parity at all sites. Parity remained a significant independent predictor of BMD at all sites after controlling for age, BMI, menopausal status, oral contraceptive and hormone replacement therapy use, smoking status and breast-feeding status in multiple linear regression analyses. There was, on average, a 1.0% increase in BMD per live birth. Our findings therefore suggest a positive relationship between parity and bone mass.

Milk consumption and bone mineral density in middle aged and elderly women

OBJECTIVES

To study the effects of historical milk consumption on current bone mineral density at the hip and spine.

DESIGN

Cross sectional study.

SUBJECTS

284 community based women aged 44-74 years recruited from four general practice age-sex registers in Cambridge. Subjects categorised their average milk consumption up to age 25, from age 25-44, and from age 44 to the present time as > or = 1 glass/day, < 1 glass/day but > 1 glass/week, or < 1 glass/week.

MAIN OUTCOME MEASURES

Bone mineral density at the hip and spine measured by dual energy x ray absorptiometry.

RESULTS

Data on milk consumption up to age 25 years were available for 252 women. There was a consistent upward trend in bone mineral density at all sites with increasing historical milk consumption (total hip, femoral neck, trochanter, intertrochanter, P < 0.05; Ward's triangle, P = 0.005). Adjustment for age and body size did not alter these trends. Milk consumption up to age 25 was a significant independent predictor of bone mineral density at all sites in multiple linear regression analyses controlling for age, body mass index, menopausal status, smoking, ever use of hormone replacement therapy or oral contraceptives, physical activity, and alcohol intake. The effects of milk consumption from age 25-44 and from age 44 to the present were similar in direction though not statistically significant.

CONCLUSION

Frequent milk consumption before age 25 favourably influences hip bone mass in middle aged and older women.

Linkage disequilibrium and recombination make a telomeric site for the Huntington's disease gene unlikely

In a Scottish family in which Huntington's disease (HD) was segregating, recombination was observed between the D4S115/S111 and D4S43/S95 loci, with the HD gene associated with the more proximal D4S43/S95 locus. Analysis of linkage disequilibrium in Scottish families showed significant non-random association between the HD gene and alleles at the D4S95 and D4S98 loci. This adds to previous evidence that the HD locus is not sited at the telomere of chromosome 4.

[Psychotropic effects of captopril? Effect of a short-term treatment on reaction and concentration capabilities and space perception ability]

In a randomized, placebo-controlled double-blind trial 22 healthy normotensive young men (mean age 25 +/- 1.7 years) were given a single oral dose of 50 mg captopril or a placebo (11 subjects each). To test their concentration and proficiency, as well as spatial perception and reaction capacity four tests were administered: attention, concentration, hose-pattern perception and "Bonn Determination Device". Captopril had no negative effects on any test performances either one or five hours after its administration, or after a single daily dose for seven days. There was only a small, statistically not significant, difference in the effect on blood pressure between captopril and the placebo.

[Tryptic enzymes in the differential diagnosis of inflammatory diseases of the colon (author's transl)]

Inflammatory diseases of the colon can be differentiated by means of their chymotrypsin A excretion in the stool. In proctosigmoiditis and a group of comparable gastroenterological cases, the mean excretion level is between 170 and 200 mug per gram of stool. The chymotrypsin A level in proctocolitis, on the other hand, is significantly higher in all stages and increases with increasing activity of the disease. This brings a further diagnostic criterion to the clinical and endoscopic differences between proctosigmoiditis and proctocolitis (colitis ulcerosa). The fundamentally different behavior in the excretion of chymotrypsin A in the stool supports the hypothesis of two diseases differing from each other.