Monitoring the standards of care in the hospital setting

The way in which doctors practise medically undoubtedly has effects on the ways in which other staff, the nurse, occupational therapist, physiotherapist etc. are able to practise, just as their style affects the doctor. But all share the common aim of providing the best possible care for their patients. Changing service provisions have affected mental handicap services more than most. It is crucial at a time of great change within health service systems that good medical practices evolved over many years experience are not lost or neglected by changing philosophies or care models. Medical aspects of care of the mentally handicapped person which evolved in hospitals should be flexible enough to be used in the settings used by any district. Medical standards of care must be maintained and improved despite changes to the service.

fMRI neurofeedback of higher visual areas and perceptual biases

The self-regulation of brain activation via neurofeedback training offers a method to study the relationship between brain areas and perception in a more direct manner than the conventional mapping of brain responses to different types of stimuli. The current proof-of-concept study aimed to demonstrate that healthy volunteers can self-regulate activity in the parahippocampal place area (PPA) over the fusiform face area (FFA). Both areas are involved in higher order visual processing and are activated during the imagery of scenes and faces respectively. Participants (N=9) were required to upregulate PPA relative to FFA activity, and all succeeded at the task, with imagery of scenes being the most commonly reported mental strategy. A control group (N=8) underwent the same imagery and testing procedure, albeit without neurofeedback, in a mock MR scanner to account for any non-specific training effects. The upregulation of PPA activity occurred concurrently with activation of prefrontal and parietal areas, which have been associated with ideation and mental image generation. We tested whether successful upregulation of the PPA relative to FFA had consequences on perception by assessing bistable perception of faces and houses in a binocular rivalry task (before and after the scanning sessions) and categorisation of faces and scenes presented in transparent composite images (during scanning, interleaved with the self-regulation blocks). Contrary to our expectations, upregulation of the PPA did not alter the duration of face or house perception in the rivalry task and response speed and accuracy in the categorisation task. This conclusion was supported by the results of another control experiment (N=10 healthy participants) that involved intensive exposure to category-specific stimuli and did not show any behavioural or perceptual changes. We conclude that differential self-regulation of higher visual areas can be achieved, but that perceptual biases under conditions of stimulus rivalry are relatively robust against such internal modulation of localised brain activity. This study sets the basis for future investigations of perceptual and behavioural consequences of localised self-regulation of neural activity.

•

Healthy participants trained differential self-regulation of higher visual areas.

•

They were instructed to up-regulate the PPA whilst keeping FFA activity down.

•

Up-regulation of the PPA was accompanied by frontal and parietal activation.

•

No shift in perceptual biases in scene/face perceptual rivalry tasks was observed.

Pattern classification of valence in depression

Neuroimaging biomarkers of depression have potential to aid diagnosis, identify individuals at risk and predict treatment response or course of illness. Nevertheless none have been identified so far, potentially because no single brain parameter captures the complexity of the pathophysiology of depression. Multi-voxel pattern analysis (MVPA) may overcome this issue as it can identify patterns of voxels that are spatially distributed across the brain. Here we present the results of an MVPA to investigate the neuronal patterns underlying passive viewing of positive, negative and neutral pictures in depressed patients. A linear support vector machine (SVM) was trained to discriminate different valence conditions based on the functional magnetic resonance imaging (fMRI) data of nine unipolar depressed patients. A similar dataset obtained in nine healthy individuals was included to conduct a group classification analysis via linear discriminant analysis (LDA). Accuracy scores of 86% or higher were obtained for each valence contrast via patterns that included limbic areas such as the amygdala and frontal areas such as the ventrolateral prefrontal cortex. The LDA identified two areas (the dorsomedial prefrontal cortex and caudate nucleus) that allowed group classification with 72.2% accuracy. Our preliminary findings suggest that MVPA can identify stable valence patterns, with more sensitivity than univariate analysis, in depressed participants and that it may be possible to discriminate between healthy and depressed individuals based on differences in the brain's response to emotional cues.

A randomised trial of primary tamoxifen versus mastectomy plus adjuvant tamoxifen in fit elderly women with invasive breast carcinoma of high oestrogen receptor content: long-term results at 20 years of follow-up

BACKGROUND

Long-term analysis of a randomised trial in Nottingham comparing tamoxifen versus surgery as initial treatment demonstrated that in oestrogen receptor (ER)-unselected cases, surgery achieved better local control, with no difference in overall survival. It was suggested that for patients with ER-rich tumours, local control and survival may be comparable. We now present long-term follow-up of a randomised trial designed to address this clinical scenario.

PATIENTS AND METHODS

One hundred and fifty three fit elderly (≥70 years) women with clinically node-negative primary invasive breast carcinoma <5 cm of high ER content [histochemical (H) score ≥100] were randomised 2:1 to primary tamoxifen (Tam) (N = 100) or mastectomy with adjuvant tamoxifen (Mx + Tam) (N = 53).

RESULTS

With median follow-up of 78 months, there was no statistically significant difference in 10-year rates of regional recurrence (9.0% versus 7.5%), metastasis (8.0% versus 13.2%), breast cancer-specific survival (89.0% versus 86.8%) or overall survival (64.0% versus 66.0%) between Tam and Mx + Tam; however, local control was inferior with Tam (local failure rates 43.0% versus 1.9%; P < 0.001).

CONCLUSION

Irrespective of the degree of ER positivity, surgery achieved better local control. However, there was excellent and similar survival in both groups. Tam could be considered in those who are 'frail', refuse or prefer not to initially undergo surgery.

Long-term clinical outcome of oestrogen receptor-positive operable primary breast cancer in older women: a large series from a single centre

INTRODUCTION

A Cochrane review of seven randomised trials (N=1571) comparing surgery and primary endocrine therapy (PET) (oestrogen receptor (ER) unselected) shows no difference in overall survival (OS). We report outcome of a large series with ER-positive (ER+) early invasive primary breast cancer.

METHODS

Between 1973 and 2009, 1065 older (≥ 70 years) women (median age 78 years (70-99)) had either surgery (N=449) or PET (N=616) as initial treatment.

RESULTS

At 49-month median follow-up (longest 230 months), the 5-year breast cancer-specific survival (BCSS) and OS were 90 and 62%, respectively. Majority (74.2%) died from causes other than breast cancer. The rates (per annum) of local/regional recurrence (<1%) (following surgery), contralateral tumour (<1%) and metastases (<3%) were low. For patients on PET, 97.9% achieved clinical benefit (CB) at 6 months, with median time to progression of 49 months (longest 132 months) and significantly longer BCSS when compared with those who progressed (P<0.001). All patients with strongly ER+ (H-score >250) tumours achieved CB and had better BCSS (P<0.01). Patients with tumours having an H-score >250 were found to have equivalent BCSS regardless of treatment (surgery or PET; P=0.175), whereas for those with H-score ≤ 250, surgery produced better outcome (P<0.001).

CONCLUSION

Older women with ER+ breast cancer appear to have excellent long-term outcome regardless of initial treatment. Majority also die from non-breast cancer causes. Although surgery remains the treatment of choice, patients with ER-rich (H-score >250) tumours tend to do equally well when treated by PET. This should be taken into account when therapies are considered.

Neurofeedback: A promising tool for the self-regulation of emotion networks

Real-time functional magnetic resonance imaging (fMRI) affords the opportunity to explore the feasibility of self-regulation of functional brain networks through neurofeedback. We localised emotion networks individually in thirteen participants using fMRI and trained them to upregulate target areas, including the insula and amygdala. Participants achieved a high degree of control of these networks after a brief training period. We observed activation increases during periods of upregulation of emotion networks in the precuneus and medial prefrontal cortex and, with increasing training success, in the ventral striatum. These findings demonstrate the feasibility of fMRI-based neurofeedback of emotion networks and suggest a possible development into a therapeutic tool.

Surgery versus primary endocrine therapy for elderly women with estrogen receptor-positive early operable primary breast cancer: Survival analysis and correlation with oestrogen receptor positivity

612

Background: A recent Cochrane review of seven randomised trials involving 1,446 elderly women (unselected for oestrogen receptor (ER) status) has shown no significant difference in overall survival between surgery (with or without adjuvant tamoxifen) and primary endocrine therapy using tamoxifen. We now report results of a large series from a single centre with a dedicated elderly breast cancer service, with long term follow-up. Methods: During a period of > 20 years, 1,031 elderly (> 70 years) women with ER positive (H-score >50) early operable primary breast cancer received either surgery (with or without adjuvant endocrine therapy) (N = 436) or primary endocrine therapy (N = 595) (>80% using tamoxifen) as initial treatment, with complete follow-up information till deaths. The initial treatment was decided based on fitness for surgery and patient choice. Analysis was carried out on breast cancer specific survival and degree of ER positivity. Results: After a median follow up of 49 months (range 0 - 261 months), patients between 70 - 80 years, treated by surgery, had better 5-year breast cancer specific survival compared to their counterparts treated by primary endocrine therapy (95% versus 85%; p < 0.001). For patients > 80 years, there was however no statistical difference between the two groups (90% versus 90%; p = 0.813). The median survival has not reached yet in all groups. Patients in the latter group (> 80 years) were found to have a higher chance of having strongly ER positive tumours (57% versus 50% in patients between 70 - 80 years with H-score >200; p- < 0.02). Conclusions: In a selected group of elderly women (> 80 years) who tend to have strongly ER positive tumours, surgery and primary endocrine therapy did not appear to produce any difference in breast cancer specific survival. This subject is currently being investigated in a national randomised trial in the UK.

No significant financial relationships to disclose.

Risk assessment in offenders with intellectual disability: the evidence base

A review of the current literature on risk assessment and management in offenders with intellectual disability (ID) revealed little direct evidence for the specific population. Theoretical models and non-ID populations have been abstracted and adapted, but not validated, for those with ID. The varying conceptual frameworks of risk, and its assessment and management, must be considered in context. Difficulties remain with the consideration of offences versus offence-like behaviour, offender versus those with similar needs, and indeed, what is regarded as 'intellectual disability'. Mainstream forensic assessment has moved towards a more dynamic appreciation of risk and risk management, as opposed to risk elimination. This development is more in line with the normalization principles of 'risk-taking' in ID. Consideration is given to future research and development priorities.

Thymidine phosphorylase and dihydropyrimidine dehydrogenase protein expression in colorectal cancer

It is essential for actively proliferating cells to increase their rate of DNA synthesis to progress through the cell cycle. This is reflected in the increased uracil usage that is a common feature in solid tumours. Thymidine phosphorylase (TP) anabolises formation of pyrimidine nucleosides available for DNA synthesis, whereas dihydropyrimidine dehydrogenase (DPD) catabolises the degradation of pyrimidine bases, thereby reducing levels of uracil and thymine available for DNA synthesis. In addition, tissue levels of TP or DPD have been associated with the clinical efficacy of pyrimidine anti-metabolites commonly used in the treatment of colorectal cancer. There is little information, however, on the relative expression or degree of co-ordinated regulation of either protein in primary or metastatic colorectal cancer. DPD and TP protein levels were measured in 15 primary colorectal carcinomas, 10 colorectal liver metastases and 25 adjacent uninvolved tissues. DPD was reduced in 67% (10/15) of colorectal tumours (mean tumour/normal = 0.52) and in all liver metastases (mean tumour/normal = 0.41) compared with the corresponding normal tissue. In contrast, TP was increased in 80% (12/15) of colorectal tumours (mean tumour/normal = 18.91) and in all metastases (mean tumour/normal = 3.70). TP and DPD protein expression were highly variable in uninvolved and tumour tissues. The ratio of TP:DPD was higher in 87% of colorectal tumours and in all liver metastases compared with the adjacent uninvolved tissues. This suggests the presence of co-ordinated regulation of these pyrimidine metabolic enzymes and offers a strategy for optimising the use of pyrimidine-based chemotherapy.

Life-threatening status asthmaticus treated with inhaled nitric oxide

Inhaled nitric oxide (NO) was administered to 5 consecutive children with life-threatening status asthmaticus who required mechanical ventilation and did not respond to maximal medical management. Four showed a >20% decrease in baseline PaCO(2) (median PaCO(2) = 154 mm Hg, range = 95 to 229 mm Hg) occurring rapidly after the administration of inhaled NO. Three children, in addition to the index case, received continuous inhaled NO therapy, ranging from 5.5 to 21.5 hours. Systemic hypotension was not observed, and the maximum methemoglobin level was 1.9%. Four children survived to hospital discharge. Although the precise mechanism of action is not known, it appears that inhaled NO merits further study and may represent a life-saving therapy in this select patient population.

Cloning and initial characterization of the human DPYD gene promoter

Dihydropyrimidine dehydrogenase (DPD) is the rate-limiting enzyme in the degradation of pyrimidine bases and pyrimidine-based antimetabolites. Reduced DPD activity is associated with toxicity to 5-fluorouracil (5FU) therapy in cancer patients and with neurological abnormalities in paediatric patients. Although variant DPYD alleles have been identified in DPD-deficient patients, they do not adequately explain polymorphic DPD activity or associated clinical phenotypes in vivo. DPD may be transcriptionally regulated as mRNA levels correlate with activity and are differentially regulated in human tissues. A 1.85 kb 5' flanking region of the human DPYD gene was cloned and has transcriptional activity in cultured cells. Analysis of this 5' flanking region in rhesus and cynomolgus monkeys demonstrated conservation (>96%) between humans and primates. Putative binding sites for ubiquitous and cell-specific factors were identified. A polymorphism that disrupts a putative gamma-interferon response element was identified in a cancer patient with reduced DPD activity and severe 5FU toxicity. Further insight into regulation of DPD expression may identify new avenues for the treatment of clinical problems associated with DPD deficiency.

Regulation of dihydropyrimidine dehydrogenase in colorectal cancer

Dihydropyrimidine dehydrogenase (DPD) is responsible for degradation of the pyrimidines uracil and thymine and the inactivation of the chemotherapeutic agent 5-fluorouracil. DPD activity is highly variable in cancer populations, and this variation may influence the antitumor efficacy of 5-fluorouracil. However, little is known about the regulation of DPD mRNA expression in any tissues. Using a reverse transcription competitive PCR assay, we quantified DPD mRNA levels in 10 matched colorectal tumors and adjacent normal mucosae and 7 colorectal liver metastases and adjacent normal livers. Lower levels of DPD mRNA expression were observed in colorectal tumor compared with adjacent normal colon mucosa (median, 0.01 versus 0.37 amole/microg total RNA, P = 0.02). DPD mRNA expression was also lower in metastases than adjacent normal liver tissue (median, 0.11 versus 1.17 amole/microg total RNA, P = 0.001). DPD mRNA expression was higher in normal liver than normal colonic mucosa (median, 1.17 versus 0.37 amole/microg total RNA, P = 0.02). A significant relationship was observed between DPD mRNA and catalytic activity (r(s) = 0.66, P<0.001). The tumor:normal ratio for DPD mRNA, protein, and activity was relatively stable in liver (0.25, 0.55, and 0.51, respectively) but varied considerably in colon (0.085, 0.9, and 1.25, respectively), consistent with enhanced translation of DPD transcript in primary colorectal tumor. This suggests that DPD can be regulated at the levels of both transcription and translation.

Eniluracil treatment completely inactivates dihydropyrimidine dehydrogenase in colorectal tumors

PURPOSE

To determine the effect of eniluracil on colorectal tumor dihydropyrimidine dehydrogenase (DPD) activity.

PATIENTS AND METHODS

Patients who were to undergo primary colorectal tumor resection received oral eniluracil 10 mg/m(2) twice daily for 3 days before surgery. Mononuclear cells were obtained before the start of eniluracil and on the morning of surgery, to measure DPD activity, protein, and mRNA. Plasma uracil was also measured at these two time points to assess the effect of eniluracil on pyrimidine accumulation. DPD activity, protein, and mRNA were also assessed in colorectal tumors and adjacent normal mucosa of patients who received eniluracil and untreated control patients.

RESULTS

DPD activity in tumors from 10 untreated patients ranged from 30 to 92 pmol/min/mg of protein. In contrast, there was no detectable tumor DPD activity in 10 patients who received eniluracil. A similar pattern was observed in mononuclear cells, where median pretherapy activity was 366.5 pmol/min/mg of protein (range, 265 to 494 pmol/min/mg of protein) and was undetectable immediately before surgery. Plasma uracil changed from a median less than 0.2 micromol/L before therapy to 27.76 micromol/L before surgery. No difference in DPD protein or mRNA was observed between pretherapy and presurgery mononuclear cell samples or between treated and untreated tumor samples.

CONCLUSION

This study provides definitive evidence that eniluracil completely inactivates DPD activity in human solid tumors. The increased plasma uracil and decreased DPD activity are consistent with systemic inactivation of the enzyme. The mechanism of inactivation is at the catalytic level, because no changes in DPD protein or mRNA were observed. Treatment with eniluracil will eliminate DPD activity as a source of pharmacokinetic fluorouracil variability or resistance in human colorectal cancer.

Dose response to inhaled nitric oxide in pediatric patients with pulmonary hypertension and acute respiratory distress syndrome

OBJECTIVE

To determine the pulmonary vascular functional dose response to inhaled nitric oxide (NO) for infants and children with acute respiratory distress syndrome and pulmonary artery hypertension.

DESIGN

Prospective, clinical observational study.

SETTING

Thirteen-bed pediatric intensive care unit at a 168-bed children's hospital.

PATIENTS

Infants and children requiring mechanical ventilation with an oxygenation index greater than 10.

METHODS

Children with severe acute respiratory distress syndrome received inhalation therapy with NO after conventional mechanical ventilation failed to result in improvement. Inhaled NO was sequentially titrated from 10 parts per million to 20, 40, 60, and 80 ppm at 10-minute intervals. A reduction of at least 30% in the pulmonary vascular resistance index (PVRI), or a reduction in mean pulmonary artery pressure of at least 10%, or an increase in the hypoxemia score of at least 20%, or a decrease in the oxygenation index of at least 20% from pretreatment values was considered a therapeutic response. After sequential titration, children who responded received continuous inhaled NO at the lowest dose associated with a therapeutic response.

RESULTS

Fourteen children received 15 trials with inhaled NO (median age, 63.4 months; range, 0.4 to 201 months). One patient's condition deteriorated during the titration phase, unrelated to NO treatment, and the patient was withdrawn from the study protocol. The mean (+/- SD) pretreatment oxygenation index was 35 +/- 15, which decreased to 32 +/- 20 at 80 ppm of inhaled NO (p = 0.01). Ten children had pulmonary artery catheter measurements. The PVRI decreased by 30% or greater in seven children (70%). One child had a minimal decrease in PVRI during the titration phase but demonstrated an increase of more than 30% after NO therapy was discontinued. Mean pretreatment PVRI (270 +/- 106) decreased to 207 +/- 92 dynes/sec per cubic centimeter per square meter at 80 ppm of inhaled NO (p = 0.06). Pretreatment mean pulmonary artery pressure (31 +/- 7) decreased to 28 +/- 5 mm Hg at 80 ppm of inhaled NO (p = 0.04). Six trials (43%) showed an increase of 20% or greater in their hypoxemia score. Maximum improvement in the hypoxemia score and reduction in OI, PVRI, and mean pulmonary artery pressure occurred at 20 to 40 ppm of NO. Ten trials led to continuous inhaled NO therapy ranging from 7 to 661.5 hours, with a median of 47 hours. Systemic hypotension was not observed in any patient, and the maximum methemoglobin level was 5%.

CONCLUSION

Inhaled NO appears to be a safe, although variably effective, therapy for the treatment of infants and children with acute respiratory distress syndrome. The maximum dose response occurs between 20 and 40 ppm of inhaled NO. Systemic side effects did not occur in any child who received NO therapy.

Involvement of CD4+ cells in lymphocytic choriomeningitis virus-induced autoimmune anaemia and hypergammaglobulinaemia

Development of pathology varies widely between different strains of mice after intracerebral inoculation with the so-called 'docile' isolate of Lymphocytic Choriomeningitis (LCM) virus. The C3HeB/FeJ and B10. Br/SgSnJ mouse strains have been of special interest because they display autoimmune haemolytic anaemia with varying degrees of apparent immunological involvement. In this report, we examined the role of CD4+ T helper cells in this autoimmune response by treating mice with the CD4-specific GK1.5 monoclonal antibody. We also determined if polyclonal activation of B lymphocytes, induced either by LCM virus or by lactate dehydrogenase-elevating virus, another well known B cell activator, correlated with the development of anaemia in these mice. Our results strengthened the central role of the immune system in the anaemia in C3H mice by showing that depletion of CD4+ cells largely, if not completely, abrogated this anti-erythrocyte autoimmune reaction. As reported by others, we found that the anaemia was more mild in B10.BR mice than in C3H mice. However, we could not confirm the difference in the degree of B lymphocyte polyclonal activation between these mice. Furthermore, lactate dehydrogenase-elevating virus had no apparent effect on erythrocytes, even though this virus also induced a sharp increase in plasma IgG levels.

Lung volume changes during relatively fluent speech in stutterers

We investigated breathing patterns in stutterers during relatively fluent speech and compared these with normal subjects for similar speech tasks. Rib cage and abdominal displacements and esophageal, gastric, and transdiaphragmatic pressures provided indexes of diaphragmatic, rib cage, and abdominal muscle contraction. We found that stutterers spoke either at substantially higher or lower lung volumes than normal subjects, confining their speech to the inspiratory capacity or expiratory reserve volume. During spontaneous speech, stutterers did not cross functional residual capacity (FRC) for most breaths. In addition, stutterers used several different motion pathways from breath to breath. At high lung volumes stutterers used the diaphragm to provide inspiratory braking. At lung volumes below FRC stutterers recruited their abdominals. This contrasted with normal subjects who spoke in the middle part of the vital capacity and who recruited inspiratory and expiratory rib cage muscles above and below FRC, respectively. Breath sizes were log-normally distributed in stutterers compared with a gaussian distribution in normal subjects (P < 0.001). During reading, stutterers tended to cross FRC (P < 0.01), used very similar initiation lung volumes from breath to breath (P < 0.001), and used similar motion pathways to achieve deflation. We conclude that stutterers sustain fluency by speaking at abnormally high or low lung volumes and that this may account for the different muscle patterns observed in stutterers compared with normal subjects.

Inflammatory pseudotumor of the retroperitoneum

A child presenting with the findings of inflammatory disease was found to have a pseudotumor of the retroperitoneum. Following surgical removal, all signs of the systemic inflammatory process resolved. These rare, benign tumors of unknown etiology must not only be differentiated from locally invasive malignant lesions, but may present with findings suggesting a chronic inflammatory disorder.

Further haemorrhage after admission to hospital for gastrointestinal haemorrhage

During 1967 and 1968 817 episodes of acute alimentary tract haemorrhage were treated in Aberdeen hospitals. In 229 cases further haemorrhage occurred in hospital, with a mortality of 28.8%; the mortality among patients who did not have this complication was 7.8%. This was true of any kind of further haemorrhage. As judged by transfusion requirements and mortality the severity of the further haemorrhage was unaffected by its occurrence as haematemesis and melaena or as melaena only or by whether it took place before or after 48 hours from the time of admission. The occurrence of further haemorrhage did not appear to be affected by the sex or blood group of patients, by aspirin ingestion, or by a history of a previous haemorrhage.The effects of the occurrence of further haemorrhage, of the age being over 60 years, or of coincidental disease being present were of descending importance in regard to mortality.Among 151 patients with peptic ulcer and further haemorrhage half required urgent surgery and 20% died. Further haemorrhage is a dangerous condition and its occurrence should immediately signal the need for vigilance and for urgent consultation between physician and surgeon. Any delay in treatment entails increased mortality.

Epidemiology and course of gastrointestinal haemorrhage in North-east Scotland

A prospective study was made of 817 consecutive episodes of major gastrointestinal haemorrhage in patients admitted to hospital during 1967-8 from the defined population of North-East Scotland. The yearly admission rate was 116 per 100,000 population. Comparison of the data for city and country residents showed no appreciable differences. In the duodenal ulcer group there was an undue incidence of bleeding among foremen and skilled workers and among those who were unmarried or widowed.Both the clinical history and the results of any previous barium meal examinations were unreliable guides to the source of the current haemorrhage. Prognosis was worse for patients who did not have a dyspeptic history and was better for those who had bled on a previous occasion. The simultaneous ingestion of alcohol and aspirin had an adverse effect on the occurrence of bleeding. Forty-seven per cent. of the patients had another major coincidental disease.Mortality was 13.7% in the whole series and 8.6% in those with peptic ulcer (duodenal ulcer 7.1%, gastric ulcer 16.9%). In 28% of the patients further haemorrhage occurred after admission to hospital and caused a 28.8% mortality. Seventy-four patients were already in hospital when they first bled and 44% of them died.

Aspirin and alcohol in gastrointestinal haemorrhage

The intake of aspirin, of alcohol, and of a combination of both, among 817 patients admitted for gastrointestinal haemorrhage is reported. The incidence of ingestion in six diagnostic groups is compared with that in two control groups. Analysis confirms that there is a markedly significant association between overt haemorrhage and the ingestion of aspirin, but this was not shown for alcohol taken alone: the combination of aspirin and alcohol showed a highly significant synergistic effect.