Elevation of tumor necrosis factor in head injury

Tumor necrosis factor (TNF) is a cytokine which mediates protein wasting in pathological states by promoting the catabolism of visceral tissues and skeletal muscle. The role that TNF plays in nitrogen wasting following head injury was studied by measuring TNF in the serum of 21 patients with severe head injury. Parallel measurements of TNF and urinary nitrogen excretion were performed on days 1, 3, and 5 after head injury. TNF values after head injury ranged from 65 pg/ml to 7500 pg/ml, with a mean of 1147 pg/ml, compared to control values of serum TNF of less than 38 pg/ml. The mean daily urinary nitrogen loss was 13 g/day with a range of 2.8 to 27.6 g/day, and the mean nitrogen balance was -5.8 g with a range of +4.6 to -19.1 g. While both serum TNF levels and nitrogen loss were increased after head injury, the elevation of TNF did not correlate strongly with nitrogen wasting.

General surgical injuries in survivors of the M1 Kegworth air crash. Nottingham, Leicester, Derby, Belfast Study Group

The general surgical consequences of the M1 Kegworth air crash are described. Considering the severe nature of the injuries sustained by the survivors, surprisingly few required general surgical intervention. Intra-abdominal injuries were rare despite the abdomen's apparent vulnerability to injury; only five laparotomies were performed. However, 30 (34%) of survivors demonstrated significant bruising from lap belts and 13 patients had haematuria. The majority of operations carried out were orthopaedic related.

What does radiotherapy add to survival over endoscopic intubation alone in inoperable squamous cell oesophageal cancer?

The place of radiotherapy in the management of squamous cell oesophageal cancer remains uncertain. Survival of oesophageal cancer patients from the Nottingham area in the years 1982-5 was reviewed. Surgical resection was attempted in 44 of 131 patients with squamous cell oesophageal cancer. Among the remainder 32 had endoscopic intubation alone, 27 had radical radiotherapy alone (six) or combined with endoscopic intubation (21), and 28 had other treatment combinations including surgical intubation and palliative radiotherapy. Patients treated by intubation alone had a mean age of 75 years. They were significantly older and metastases were more common (31%) in this group than in patients treated with radiotherapy (mean age 69 years), of whom 11% had metastases. Some 34% (11 of 32) of patients treated by intubation alone died within 30 days of diagnosis and were therefore not eligible for radiotherapy. Beyond 30 days, survival in the radiotherapy group (median survival 188 days; 95% confidence limits 133-253) was not significantly greater than that for the group treated by intubation alone (median survival 98 days (73-154)). The radiotherapy patients had a median hospital stay of 46 days compared with 23 days for the patients treated by intubation alone. In patients with squamous cell oesophageal cancer unsuitable for surgery, the survival advantage associated with radiotherapy and intubation is small and does not compensate for the extra morbidity and prolonged hospital stay. A controlled trial of radiotherapy in these patients is now needed.

Spinal cord ischemia-induced elevation of amino acids: extracellular measurement with microdialysis

Excitatory amino acids have been implicated in the production of calcium mediated neuronal death following central nervous system ischemia. We have used microdialysis to investigate changes in the extracellular concentrations of amino acids in the spinal cord after aortic occlusion in the rabbit. Glutamate, aspartate, glutamine, asparagine, glycine, taurine, valine, and leucine were measured in the microdialysis perfusate by high pressure liquid chromatography. The concentrations of glutamate, glycine, and taurine were significantly higher during ischemia and reperfusion than controls. Delayed elevations in the concentrations of asparagine and valine were also detected. The elevation of glutamate is consistent with the hypothesis that excitotoxins may mediate neuronal damage in the ischemic spinal cord. Increased extracellular concentrations of asparagine and valine may reflect preferential use of amino acids for energy metabolism under ischemic conditions. The significance of increased concentrations of inhibitory amino acid neurotransmitters is unclear.

Evaluation of a fiberoptic intracranial pressure monitor

The fiberoptic device is a relatively new type of intracranial pressure (ICP) monitor which appears to offer certain advantages over conventional monitoring systems, particularly its ability to measure brain parenchymal pressures. This study was undertaken to analyze the accuracy and drift characteristics of the fiberoptic device and to compare pressures in the subdural, intraparenchymal, and intraventricular compartments. The device was accurate to +/- 3 mm Hg over a 0- to 30-mm Hg range in vitro. The maximum daily drift was +/- 2.5 mm Hg, with an average daily drift of +/- 0.6 mm Hg and an average drift over a 5-day period of +/- 2.1 mm Hg. In vivo, the pressures and waveform characteristics obtained with the fiberoptic device and with a strain-gauge transducer connected to a ventriculostomy were very similar. Alterations in ICP were induced by various therapeutic and pathological manipulations, and the pressures in the three intracranial compartments were compared. Changes in ICP appeared to be reflected simultaneously and equally in all three compartments. Furthermore, changes in ICP secondary to a unilateral mass lesion were identical in both supratentorial parenchymal compartments when measured simultaneously. It is concluded that the fiberoptic device is an accurate and reliable system for ICP monitoring; the pressures recorded in the subdural, intraparenchymal, and intraventricular compartments paralleled each other in all of the physiological and pathological states tested. Although the drift associated with this device is less than that reported for previously available systems, its maximal cumulative drift over a 5-day period of +/- 6 mm Hg is significant. Since the fiberoptic device cannot be recalibrated in situ, it is suggested that the device be replaced if monitoring is to be continued for periods longer than 5 days.

Intravenous cocaine abuse and subarachnoid haemorrhage: effect on outcome

A retrospective study of subarachnoid hemorrhage associated with intravenous cocaine injection was undertaken in a large urban hospital. Patients who used intravenous cocaine had significantly poorer outcomes when compared with subarachnoid haemorrhage patients with no known exposure to the drug.

Reduction in spinal cord postischemic lactic acidosis and functional improvement with dichloroacetate

Pyruvate dehydrogenase complex (PDHC) is a major enzyme of glucose metabolism. Dichloroacetate (DCA) is a noncompetitive inhibitor of PDHC kinase, an enzyme that inactivates PDHC. We examined the effects of DCA on extracellular lactate and pyruvate concentration changes and spinal somatosensory evoked potentials (SSEP) in ischemic rabbit spinal cords. In the first group of 26 animals, the aorta was occluded until postsynaptic SSEP waves were completely suppressed for 10 min, a period of ischemia that causes neurologic deficits in 50% of untreated animals. DCA (25 mg/kg) was given to 13 of these animals before ischemia. In the second group of 24 animals, the aorta was occluded until the postsynaptic SSEP waves were absent for 20 min, a period of ischemia that produces paraplegia in 100% of untreated animals. DCA (25 mg/kg) was given to 16 of these animals just before the aortic occlusion was released. After occlusion, extracellular spinal lactate concentrations increased abruptly while pyruvate concentrations fell. Both lactate and pyruvate concentrations reached a plateau during the ischemic period but increased when the aortic balloon was deflated. DCA-treated animals had lower lactate and pyruvate peak concentrations during reperfusion, as well as more rapid and greater recovery of SSEP at 2 h after reperfusion. DCA did not alter spinal metabolism during the ischemia but appeared to produce a more rapid shift to glucose metabolism on reperfusion. Thus, DCA treatment resulted in better electrophysiological recovery after both moderate and severe ischemia, either by reducing lactic acidosis or by increasing the recovery rate of aerobic energy production.

Palliative therapy of malignant esophageal stricture with the bipolar tumor probe and prosthetic tube

Patients with malignant esophageal stricture and dysphagia were prospectively randomized to receive palliative therapy with the bipolar tumor probe (17) or prosthetic tube insertion (13). Both treatments gave good relief of dysphagia compared with pretreatment values on a dysphagia score, the results being statistically significant (p less than 0.005). However, there was no difference in the improvement achieved by one method compared with the other. The tumor probe was not difficult to use and complication rates were comparable. In the Atkinson tube group, two patients developed complications related to the position of the prosthesis and in three others food blocked the tube. Treatment with the tumor probe needed repeating at intervals (median, 28 days; range, 2 to 86 days) in all but four individuals to maintain palliation, with each patient needing a median of two treatments (range, 1 to 8). The probe may have advantages in very high esophageal lesions and may facilitate the treatment of tumor overgrowth or undergrowth of a tube. The prosthetic tube may give long-lasting relief of dysphagia and remains the treatment of choice for bronchopulmonary fistulas.

Clinical experience with a continuous monitor of intracranial compliance

Intracranial compliance, as estimated from a computerized frequency analysis of the intracranial pressure (ICP) waveform, was continuously monitored during the acute postinjury phase in 55 head-injured patients. In previous studies, the high-frequency centroid (HFC), which was defined as the power-weighted average frequency within the 4- to 15-Hz band of the ICP power density spectrum, was found to inversely correlate with the pressure-volume index (PVI). An HFC of 6.5 to 7.0 Hz was normal, while an increase in the HFC to 9.0 Hz coincided with a reduction in the PVI to 13 ml and indicated exhaustion of intracranial volume-buffering capacity. The mean HFC for individual patients in the present study ranged from 6.8 to 9.0 Hz, and the length of time that the HFC was greater than 9.0 Hz ranged from 0 to 104.8 hours. The mortality rate increased concomitantly with the mean HFC, from 7% when the mean HFC was less than 7.5 Hz to 46% when the mean HFC was 8.5 Hz or greater. The length of time that the HFC was 9.0 Hz or greater was also associated with an increased mortality rate, which ranged from 16% if the HFC was never above 9.0 Hz to 60% if the HFC was 9.0 Hz or greater for more than 12 hours. In 12 patients who developed uncontrollable intracranial hypertension or clinical signs of tentorial herniation during the monitoring period, 75% were observed to have had an increase in the HFC to 9.0 Hz or more 1 to 36 hours prior to the clinical decompensation. The more rapid the increase in the HFC, the more likely the deterioration was to be caused by an intracranial hematoma. Continuous monitoring of intracranial compliance by computerized analysis of the ICP waveform may provide an earlier warning of neurological decompensation than ICP per se and, unlike PVI, does not require volumetric manipulation of intracranial volume.

A double-blind dose ranging study of BRL 24924 and metoclopramide on lower oesophageal sphincter pressure in healthy volunteers

1. A double-blind placebo controlled dose ranging study of the effect of single oral doses of 1 and 2 mg BRL 24924 and 10 mg metoclopramide on lower oesophageal sphincter pressure has been performed in 20 healthy volunteers. 2. The 2 mg dose of BRL 24924 caused a statistically significant increase in mean lower oesophageal sphincter pressure (P less than 0.05) at 30-45 min post-dose (20.8 +/- 7.1 cm H2O BRL 24924; 16.4 +/- 5.7 cm H2O placebo). BRL 24924 1 mg and metoclopramide 10 mg failed to increase lower oesophageal sphincter pressure at any time. However, eight volunteers with a hypotensive resting lower oesophageal sphincter pressure (less than 15 cm H2O) showed a statistically significant rise in pressure at 120 min for both 1 mg, 2 mg (P less than 0.01; P less than 0.001) BRL 24924 and 10 mg metoclopramide (P less than 0.01). No other significant effect was detected on oesophageal manometry. 3. BRL 24924 (2 mg) has statistically significant effects on lower oesophageal sphincter pressure. However, further studies in patients with gastro-oesophageal reflux disease and oesophagitis are needed to evaluate its clinical efficacy, especially where a hypotensive lower oesophageal sphincter pressure predominates.

Alterations in the corticomotor evoked potential following spinal cord ischemia

A simple yet reliable model of spinal cord ischemia has been previously developed by inserting a Swan-Ganz catheter into the abdominal aorta of rabbits and inflating the balloon just inferior to the renal arteries. Recent investigations have shown that paraplegia is consistently reproduced if the balloon remains inflated for 20 min after loss of the N3 component of the somatosensory evoked potential. Because of its high reliability, this model has been frequently and successfully used to determine the efficacy of pharmacological agents thought to provide protection against spinal cord ischemia. Results from the present report demonstrate that a similar degree of reliability can be achieved in this model for testing motor activity. A simple method of evoking highly reproducible motor potentials, that can be percutaneously recorded from the spinal cord in response to cortical stimulation, was developed. Predictable and repeatable changes in the configuration of the corticomotor evoked potential were found during spinal cord ischemia and reperfusion. With this added dimension of functional assessment, future application of the current spinal cord ischemia model have been greatly expanded.

Quantitative assessment of the response to therapy in achalasia of the cardia

Radionuclide oesophageal transit studies and manometry have been carried out in 15 patients with achalasia of the cardia, before treatment, after a course of nifedipine and after pneumatic bag dilatation. Transit studies were also done in 10 patients after cardiomyotomy and in 10 normal subjects. Images were recorded with the subjects seated in front of a gamma camera while swallowing a 10 ml bolus of 99Tcm-tin colloid and then after a further drink of 50 ml water. There was marked retention of tracer in the oesophagus in patients with achalasia compared with rapid clearance in control subjects. Bag dilatation significantly reduced lower oesophageal sphincter pressure but there was no significant difference in the 50% clearance time or percentage dose retained at 100s before and after the treatments. Oesophageal clearance of tracer after the additional drink of water, was improved by bag dilatation. Oesophageal transit in the patients after cardiomyotomy was similar to that in patients who had undergone bag dilatation. There was considerable retention of the tracer in the oesophagus overnight, but this did not result in pulmonary aspiration. Radionuclide oesophageal transit studies provided a quantitative assessment of therapy in achalasia and the proportion of tracer retained after the additional drink proved to be a sensitive measure of response to treatment. Nifedipine proved ineffective as a treatment for achalasia. Bag dilatation and cardiomyotomy were of similar value.

Cardiovascular and metabolic responses to severe head injury

The cardiovascular and metabolic responses to severe head injury were studied in the acute phase after severe head injury with the object of determining if a common response was present and, if so, its significance in the management of the patients' intracranial and systemic physiological states. The cardiovascular response to head injury was studied by measurement of cardiac output, pulmonary capillary wedge pressure, arterial blood pressure, arterial and mixed venous blood gases and arterial and mixed venous epinephrine and norepinephrine serially in 15 patients during the first three days after injury. A hyperdynamic state was found characterized by increased cardiac output and cardiac work, moderate hypertension, tachycardia, decreased or normal systemic and pulmonary vascular resistance, increased pulmonary shunting and increased oxygen delivery and utilisation. Arterial E and NE levels correlated well with the cardiac output, cardiac work, blood pressure, heart rate, oxygen delivery, and oxygen utilization but not with vascular resistance or pulmonary shunt. The magnitude of the hyperdynamic state did not correlate with intracranial pressure, Glasgow Coma Score, or findings on CT scan. The metabolic response to head injury was studied by measurement of resting metabolic expenditure (RME) in 14 comatose head-injured patients in the first nine days after injury. During this period patients were fed with a continuous parenteral infusion of a formula containing 2 Kcal/cc and 10 mg nitrogen/liter. Indirect calorimetry was carried out for 102 patient-days. The mean resting metabolic expenditure (RME) for nonsedated, nonparalyzed patients was 138 +/- 37% of that expected for a non-injured resting person of equivalent age, sex, and body surface area. Nitrogen excretion was measured for 109 patient-days. The mean excretion was 20.2 +/- 6.4 mg/day. The mean protein caloric contribution was 23.9 +/- 6.7% and was greater than 25% for six patients, compared to normal values of 10-15%. Despite hyperalimentation, positive nitrogen balance for any 3-day period was achieved in only seven patients, and required replacement of 161% to 240% of RME with the parenterally administered formula. Head-injured patients had a metabolic response similar to that reported for patients with burns of 20-40% of the body surface.

Oesophageal transit of marshmallow after the Angelchik procedure

The oesophageal transit time of half a marshmallow was measured radiologically in 17 controls, 28 patients with gastro-oesophageal reflux pre-operatively, 36 patients soon after implantation of the Angelchik prosthesis (2-9 weeks) and in 23 patients later postoperatively (9-48 months). Sixteen postoperative patients also underwent oesophageal manometry. All control and pre-operative patients had a marshmallow transit time of less than 1 min; 67 per cent of the early postoperative patients had prolonged transit and 70 per cent of the late tests were similarly abnormal. Prolonged oesophageal transit as measured by marshmallow swallow correlated well with symptoms of solid food dysphagia. Most, but not all, patients with an abnormal marshmallow swallow had abnormal manometric findings. The oesophageal transit of solid food is significantly slowed after the Angelchik procedure and this is not a transient postoperative phenomenon.

Cerebral arteriovenous oxygen difference as an estimate of cerebral blood flow in comatose patients

The hypothesis that cerebral arteriovenous difference of oxygen content (AVDO2) can be used to predict cerebral blood flow (CBF) was tested in patients who were comatose due to head injury, subarachnoid hemorrhage, or cerebrovascular disease. In 51 patients CBF was measured daily for 3 to 5 days, and in 49 patients CBF was measured every 8 hours for 5 to 10 days after injury. In the latter group of patients, when a low CBF (less than or equal to 0.2 ml/gm/min) or an increased level of cerebral lactate production (CMRL) (less than or equal to -0.06 mumol/gm/min) was encountered, therapy was instituted to increase CBF, and measurements of CBF, AVDO2, and arteriovenous difference of lactate content (AVDL) were repeated. When data from all patients were analyzed, including those with cerebral ischemia and those without, AVDO2 had only a modest correlation with CBF (r = -0.24 in 578 measurements, p less than 0.01). When patients with ischemia, indicated by an increased CMRL, were excluded from the analysis, CBF and AVDO2 had a much improved correlation (r = -0.74 in 313 measurements, p less than 0.01). Most patients with a very low CBF would have been misclassified as having a normal or increased CBF based on the AVDO2 alone. However, when measurements of AVDO2 were supplemented with AVDL, four distinct CBF patterns could be distinguished. Patients with an ischemia/infarction pattern typically had a lactate-oxygen index (LOI = -AVDL/AVDO2) of 0.08 or greater and a variable AVDO2. The three nonischemic CBF patterns had an LOI of less than 0.08, and could be classified according to the AVDO2. Patients with a normal CBF (mean 0.42 +/- 0.12 ml/gm/min) had an AVDO2 between 1.3 and 3.0 mumol/ml. A CBF pattern of hyperemia (mean 0.53 +/- 0.18 ml/gm/min) was characterized by an AVDO2 of less than 1.3 mumol/ml. A compensated hypoperfusion CBF pattern (mean 0.23 +/- 0.07 ml/gm/min) was identified by an AVDO2 of more than 3.0 mumol/min. These studies suggest that reliable estimates of CBF may be made from AVDO2 and AVDL measurements, which can be easily obtained in the intensive care unit.

Palliation of malignant upper-third oesophageal stricture by bipolar diathermy probe

Bipolar thermocoagulation probes have been used to palliate dysphagia in six patients with an inoperable squamous cell carcinoma of the upper third of the oesophagus. Median dysphagia grade was improved following treatment, and the only serious complication was the development of a tracheo-oesophageal fistula in one patient. Bipolar thermocoagulation probes are an alternative treatment for malignant strictures of the upper third of the oesophagus, a group that may be difficult otherwise to palliate.

A study of the local toxicity of agents used for variceal injection sclerotherapy

Injection sclerotherapy is widely used in the treatment of oesophageal varices. However, few studies have compared the local toxicity of sclerosant agents which may be important if serious local complications are to be avoided. In this study the depth of injury caused by submucosal injection of increasing concentrations of sodium tetradecyl sulphate, polidocanol, 5% ethanolamine oleate and 5% varicosid in rabbits stomach, has been compared by histopathological examination. Macroscopic ulceration was seen in 14.6% of injection sites. Increasing concentrations of sodium tetradecyl sulphate and polidocanol produced increasingly extensive microscopic inflammation. Five percent varicosid caused more inflammation than 5% ethanolamine and only 3% polidocanol and 5% varicosid caused full thickness inflammation. Only 5% ethanolamine produced inflammation consistently confined to the mucosa and submucosa. On the basis of this study we feel that 5% ethanolamine is the most suitable agent for injection sclerotherapy.

Benign oesophageal stricture in Barrett's columnar epithelialised oesophagus and its responsiveness to conservative management

The response to treatment of peptic oesophageal stricture associated with columnar lined (Barretts) oesophagus (CLO) has been compared with that in peptic stricture without CLO. Benign oesophageal stricture was present in 23 (41%) of 56 patients consecutive with CLO. In 18 the stricture lay at the squamocolumnar mucosal junction and was associated with reflux oesophagitis, in five it was situated in the columnar lined segment and in four of these it was known to have been preceded by a chronic ulcer at the site of the stricture. Controls were an age and sex matched group of patients with benign stricture related to reflux oesophagitis unassociated with columnar epithelialisation. CLO associated strictures involving squamous mucosa were situated significantly (p less than 0.01) higher in the oesophagus than non-CLO strictures. The response to endoscopic dilatation and active medical treatment was significantly better, as judged by the need for subsequent dilatation (p less than 0.01) in the CLO than in the non-CLO group. It is concluded that associated columnar epithelialisation of the oesophagus is not in itself an indication for antireflux surgery in the management of benign stricture and these usually respond well to dilatation and medical treatment.

A double-blind placebo-controlled trial of BRL 24924 on lower oesophageal sphincter pressure and gastro-oesophageal reflux in healthy volunteers

BRL 24924 is a new gastrointestinal prokinetic agent with properties similar to metoclopramide but with increased potency and devoid of side-effects associated with blockade of dopamine receptors in the central nervous system. A double-blind placebo-controlled trial of the effect of a single oral dose of 2.2 mg BRL 24924 on lower oesophageal sphincter pressure and gastro-oesophageal reflux has been performed in 20 healthy volunteers. BRL 24924 significantly increased mean lower oesophageal sphincter pressure (21.9 cmH2O BRL; 15.9 cmH2O placebo: P less than 0.017) but failed to alter either the frequency or the duration of gastro-oesophageal reflux after provocation following a test meal. BRL 24924 has significant effects on lower oesophageal sphincter pressure but no effect on provoked post-prandial reflux in healthy volunteers. Further studies in patients with gastro-oesophageal reflux and oesophagitis are needed to evaluate the clinical efficacy of this compound.

Alterations in cerebral availability of metabolic substrates after severe head injury

Cerebral and systemic metabolism of oxygen, glucose, lactate, pyruvate, beta-hydroxybutyrate, acetoacetate, and amino acids were studied in 27 comatose patients during the first 7 days after a head injury. Systemic oxygen consumption was elevated initially and gradually returned toward normal over the week of study. In contrast, cerebral oxygen consumption was depressed and decreased further over the week of study. Cardiac output and cerebral blood flow were increased with respect to systemic and cerebral metabolic requirements, and remained elevated for the entire week of study. Systemic hyperglycemia and lactic acidosis were present. The injured brain often made a sizeable contribution to the lactic acidosis. The arterial concentrations of pyruvate, beta-hydroxybutyrate and acetoacetate were low. The early postinjury arterial amino acid profile was typically an increased level of alanine, taurine, glutamic acid, and a reduced concentration of valine, leucine, isoleucine, threonine, serine, ornithine, and arginine. At 3-4 days postinjury, as the early abnormalities were returning toward normal, glutamine, lysine, phenylalanine, tyrosine, and methionine became elevated. These late increases in amino acids occurred at the time of the peak in plasma catecholamine concentrations. The net cerebral flux of amino acids followed the same general pattern of evolution over time as did the arterial concentration of amino acids. On days when the availability of the individual amino acid was increased, the net cerebral flux tended to be positive; when the availability was decreased, the net cerebral flux was zero or there was a net efflux of the amino acid. There was a significant linear relationship between the arterial concentration and the net flux of 13 of the 17 amino acids studied. Unlike the fasting state in normal man, in which beta-hydroxybutyrate and acetoacetate are important metabolic substrates, cerebral metabolism after head injury is almost totally dependent upon the aerobic and anaerobic metabolism of glucose. This is at least in part due to injury-induced limitations in the variety of substrates that are available for the brain to extract.

Value of endoscopic surveillance in the detection of neoplastic change in Barrett's oesophagus

Fifty-six patients with Barrett's oesophagus diagnosed between 1977 and 1986 were prospectively studied by 6-monthly endoscopic surveillance and biopsy. During follow-up to-date, four patients have developed high-grade dysplasia and three have adenocarcinoma of the oesophagus. Two of the adenocarcinomas were preceded by progressively severe dysplastic changes but in the third no dysplasia had been previously detected. The incidence of adenocarcinoma was 1 per 56 patient-years of follow-up. Changes in symptomatology or gross endoscopic appearances were usually absent, even after adenocarcinoma had developed, indicating that biopsy is essential for early diagnosis. The high risk of malignant change makes endoscopic surveillance advisable in all patients with Barrett's oesophagus.

Oesophageal transit of small tablets

Oesophageal transit has been studied in six asymptomatic subjects aged 29-80 years. Using gamma scintigraphy, the transit of a liquid and five small tablets was monitored in each subject. All the subjects exhibited normal liquid swallowing, with 50% oesophageal clearance times of less than 5 s. In three subjects all the tablets passed through the oesophagus within 6 s, but transit was prolonged in 60% of the swallows in the other subjects. Tablet hold up occurred more frequently in the elderly. An additional drink of water cleared all lodged tablets into the stomach. To minimize possible mucosal irritation, the taking of even small tablets should be followed by an additional drink of water.

Lung vascular permeability in patients with acute pancreatitis

Acute pancreatitis may be complicated by acute lung injury associated with increased lung vascular permeability to plasma protein. The pulmonary accumulation of the plasma protein transferrin, radiolabelled in vivo with indium-113m, was monitored using a portable probe radiation detector in sixteen patients with acute pancreatitis. Plasma protein accumulation (PPA) indices were within normal limits (less than 0.5 X 10(-3)min-1) in all survivors (n = 10) and elevated in all but one of the non-survivors. All non-survivors had severe acute pancreatitis as judged by standard criteria. Thus increased lung vascular permeability was not a constant feature of uncomplicated acute pancreatitis and was only observed in patients with multisystem failure accompanied by clinically evident acute lung injury.

Choice of therapy for achalasia in relation to age

Over an 11-year period 132 patients with achalasia underwent a total of 253 pneumatic bag dilatations of the cardia as the initial treatment. Adequate symptomatic relief was obtained in the majority, but 16 needed cardiomyotomy after pneumatic dilatation had failed to give lasting symptomatic relief. Older patients, aged 60 years or more, showed longer-lasting improvement with pneumatic dilatation than did younger ones and only 1 patient over 50 required cardiomyotomy. Benefit from pneumatic dilatation showed a closer relationship to age than to oesophageal diameter. Of 50 patients followed for more than 5 years, 48% required no further treatment, 40% needed at least one further dilatation to achieve symptomatic relief and 12% came to cardiomyotomy. This study suggests that pneumatic dilatation is safe, effective and particularly useful in the management of the elderly achalasic patient.