Sphygmomanometers in use in general practice: an overlooked aspect of quality in patient care

OBJECTIVES

To assess the condition, accuracy and safety of mercury and anaeroid sphygmomanometers in use in general practice and to pilot a scheme for sphygmomanometer maintenance within the district.

DESIGN

Instruments were checked on site according to set protocols which related to established guidelines and standards and data were entered into a specially designed database. Mercury sphygmomanometers were removed to the laboratory for servicing. Practices received written feedback on the condition of each instrument checked, repairs undertaken and advice, where necessary, for further work required. Participant views on the scheme were sought.

MATERIALS AND METHODS

A total of 472 instruments (75.4% mercury) located in 86 general practices (87.8% of practices participated) in a health district in the West Midlands. Instruments were checked against 28 (mercury) and 25 (anaeroid) quality standards and (for mercury instruments) against British Hypertension Society guidelines.

RESULTS

69.1% of mercury and 95.7% of anaeroid instruments checked, had no service records. Of the remainder, only 29 mercury (8.1%) and one anaeroid (0.9%) had a record of a check or service within the previous 12 months. None of the instruments met all of the relevant quality standards and 14 (3.9%) mercury and seven (6.1%) anaeroid instruments met less than half. A large proportion of mercury sphygmomanometers tested had defects likely to affect recommended measurement technique. Only two-thirds were accurate at all pressure levels tested. Only 38.8% of anaeroid instruments were accurate at all test pressure levels.

CONCLUSIONS

The level of defects noted could have an impact on diagnosis and monitoring of hypertension.

Patient education and emergency room visits

Patients visit emergency rooms for urgent and non-urgent care. Because emergency room visits are more costly than visits to primary care clinics and are less likely to involve preventive care, third party payers and institutions have always tried to shift patients away from the emergency room and towards primary care clinics where appropriate. Hypothesizes that an intervention based in an adult primary care clinic might enable this, especially if it involved patients who used both the clinic and the emergency room. Surveys patients to determine why they used the emergency room and to identify barriers to using the primary care clinic instead. Based on the survey results, an intervention was developed to facilitate use of the primary care clinic. Discusses the methodology used in the survey and analyses results. Concludes that it is difficult to change patient behaviour to fit the demands of the health care system. Possibly, it would be better to change the system to fit the behaviour patterns of the patients.

Observed changes in the lipid profile and calculated coronary risk in patients given dietary advice in primary care

BACKGROUND

Dietary advice is usually the first-line treatment for increased blood cholesterol in primary care with a reduction in levels as the expected response. In practice, the diet adopted by the patient may lead to changes in blood lipids characterised by a greater decrease in high-density lipoprotein (HDL) than total cholesterol. The ratio of total cholesterol to HDL cholesterol is an important factor in calculated coronary risk using the Framingham model, from which most risk tables currently in use have been derived. This suggests that either coronary risk may increase after dietary advice or that risk should always be assessed on measurements made before any intervention has taken place.

AIM

To report observed changes in blood lipids and calculated coronary risk following dietary advice in primary care.

METHOD

Subjects with at least one coronary risk factor and baseline cholesterol above 5.2 mmol/l from an inner-city general practice had cardiovascular risk factors, including fasting lipids, recorded before receiving dietary advice. At follow-up several months later, risk factor measurements were repeated. Ten-year coronary risk was calculated using the Framingham model. Lipid levels and coronary risk at baseline and follow-up were compared.

RESULTS

There was a significant decrease in both total cholesterol and HDL cholesterol in both sexes. However, in 56% of subjects, HDL decreased by a greater proportion than the total cholesterol. These subjects showed a highly significant increase in the total cholesterol/HDL cholesterol ratio (median = 0.8 [semi-interquartile range = 1.5], P < 0.001, which was correlated with a change in triglycerides (rs = 0.309, P < 0.001). In those who had an increase in the total cholesterol/HDL cholesterol ratio, calculated coronary risk increased from 5.45% (13.2) at baseline to 7.25% (15.5) (P < 0.001). In all subjects, the change in calculated coronary risk associated with dietary advice ranged from -15% to 15%.

CONCLUSIONS

Low fat dietary advice in this primary care setting was frequently associated with undesirable changes in the lipid profile. The majority of subjects showed an increase in the total cholesterol/HDL cholesterol ratio, owing primarily to a decrease in HDL. Consequently, calculated coronary risk increased in over one-half of the subjects. Owing to our incomplete understanding of HDL metabolism, it is unclear whether the fall in HDL is actually detrimental; however, it seems prudent to give dietary advice to patients to avoid excess simple carbohydrate as a fat substitute. This helps avoid a rise in triglycerides, which appears to be associated with an increase in the ratio. These results confirm that coronary risk should always be calculated using measurements made before intervention.

Rethinking public health: new training for new times

The new public health agenda will require major changes in the way health authorities, local authorities, Trusts and Primary Care Groups organise and manage their activities. The requirement is for inter-agency co-ordination and inter-professional and inter-sectoral working to a shared agenda, yet the human and resources development planning to achieve these goals has not been done. This paper summarises the key training issues and argues for a collaborative, decentralised and quality assured approach to multidisciplinary public health management education and training. Only with such a joined up human resources plan can Our Healthier Nation succeed where The Health of the Nation signally failed.

Tuberculosis in Far North Queensland, Australia

SETTING

Regional thoracic clinic in tropical Australia.

OBJECTIVE

To document recent experience with tuberculosis in Far North Queensland, Australia, with particular reference to tuberculosis in indigenous people.

METHODS

Retrospective survey of all cases of tuberculosis in Far North Queensland between January 1993 and December 1997.

RESULTS

There were 87 cases of tuberculosis; 54 were pulmonary, of which 67% were sputum smear-positive. Crude annual incidence of tuberculosis in indigenous people was 35.9/100,000 population compared to 2.32/ 100,000 in non indigenous people. There were 15 deaths, seven of which were felt to be avoidable. Nine of 11 relapses of previously treated disease occurred in Aboriginals. There were six cases of initial drug resistance, of which four were imported from overseas. Contact tracing identified four active cases of tuberculosis and 102 recently infected contacts. Preventive treatment in infected contacts was completed in only 41%, largely because of poor compliance related to alcohol consumption.

CONCLUSION

Tuberculosis remains common in Far North Queensland, with excess cases observed mainly in the indigenous population. Aboriginals are at high risk of both death from and relapse of tuberculosis. Tuberculosis control in indigenous people scattered over such a vast area remains challenging, and the results at present are sub-optimal.

Treatment of malnutrition with 1.1% amino acid peritoneal dialysis solution: results of a multicenter outpatient study

A peritoneal dialysis (PD) solution containing 1.1% amino acids as the osmotic agent was evaluated in a 3-month randomized, prospective, open-label study in malnourished PD patients. Patients in the treatment group (DAA) received one or two exchanges daily with the amino acid solution, depending on tolerance, in place of glucose solutions. Controls (DD) received their usual therapy with glucose dialysate. Fifty-four DAA and 51 DD patients completed the study. In DAA, but not in DD patients, there was a significant increase at month 3 in serum insulin-like growth factor-1 (IGF-1) levels and significant decreases in serum potassium (all 3 months) and inorganic phosphorus levels (months 1 and 3), indicating a general anabolic response. Prealbumin and transferrin levels were significantly increased in DAA but not in DD patients at month 1, but the groups did not differ at months 2 and 3. In patients with baseline albumin levels less than 3.5 g/dL (bromcresol green [BCG] method), DAA patients showed increases in albumin, transferrin (months 1 and 2), and prealbumin levels (all 3 months) relative to baseline values, whereas these serum protein levels were unchanged in DD patients, although the changes from baseline did not differ between groups. In this subgroup, midarm muscle circumference (MAMC) did not change in DD or DAA patients. In patients with baseline albumin levels of 3.5 g/dL or greater, DD patients had decreases in albumin and total protein levels at all 3 months and in prealbumin levels at months 1 and 2, relative to baseline. In DAA patients, there were fewer changes in serum proteins. MAMC increased significantly from baseline in DAA but not in DD patients, although changes from baseline did not differ between DAA and DD groups. DAA patients showed no changes in peritoneal membrane transport characteristics. The results indicate that treatment with one or two exchanges daily of this amino acid-based PD solution is safe and provides nutritional benefit for malnourished PD patients.

Enteral glutamine supplementation for very low birth weight infants decreases morbidity

Glutamine, described as a "conditionally essential" amino acid for critically ill patients, has not been routinely added to parenteral amino acid formulations for critically ill neonates and is provided in only small quantities by the enteral route when enteral intake is low. We conducted a blinded, randomized study of enteral glutamine supplementation in 68 very low birth weight neonates randomly assigned to receive glutamine-supplemented premature formula versus premature formula alone between days 3 and 30 of life. Primary end points consisted of hospital-acquired sepsis, tolerance to subsequent enteral feedings (days with no oral intake), and duration of hospital stay. Hospital acquired sepsis was 30% (control group) and 11% (glutamine group). Logistic regression with birth weight as a covariate showed that: (1) feeding group was significant (p = 0.048) in determining the probability of developing proven sepsis over the course of hospitalization and (2) the estimated odds of developing sepsis were 3.8 times higher for infants in the control group than for those treated with glutamine. Glutamine-supplemented infants had better tolerance to enteral feedings as measured by percent of days on which feedings needed to be withheld (mean percentage of 8.8 vs 23.8, p = 0.007). Analysis of T cells demonstrated a blunting of the rise in HLA-DR+ and CD16 subsets in glutamine-supplemented infants. There were no differences in growth; in serum ammonia, urea, liver transaminase, or prealbumin concentrations; or in mean hospital stay. This study provides evidence for decreased morbidity in very-low-birth-weight neonates who receive enteral glutamine supplementation.

Morphometric evaluation of lower cervical pedicle and its projection

STUDY DESIGN

This study evaluated the lower cervical pedicle from C3 to C6 to provide information for accurate transpedicular screw fixation in this region.

OBJECTIVES

To measure the dimensions of the lower cervical pedicle and to determine the correct location of the pedicle axis on the posterior aspect of the lateral mass.

SUMMARY OF BACKGROUND DATA

Several anatomic studies and clinical applications of transpedicular screw fixation in the cervical spine have been documented, but little quantitative data concerning the lower cervical pedicle and its projection are available.

METHODS

Forty dry cervical specimens from C3 to C6 (160 cervical vertebrae) were used for this study. Anatomic evaluation included pedicle height, width, effective length, and anguli. The distances from the projection point of the pedicle axis to reference lines related to the lateral edge of the lateral mass (vertical) and the inferior edge of the superior facet (horizontal) also were measured. The means, ranges, and standard deviations were calculated for all of the specimens and separately for male and female spines.

RESULTS

Statistically significant differences in dimensions of males and females were found in one linear and one angular measurement, which included the pedicle height of C6 and the pedicle sagittal angle of C4. The greatest variation for males and females was found in the pedicle sagittal angle, with a range of 4.3-9.8 degrees. The distances from the projection point to the horizontal line did not show any real pattern of change from C3 to C6, whereas the distances from the projection point to the vertical line consistently increased from cephalad to caudad.

CONCLUSIONS

Taking into consideration some variations between individuals, this information, combined with evaluation of results of preoperative axial computed tomography and conventional radiography, may enhance the safety of transpedicular screw fixation in the lower cervical spine.

Is Helicobacter pylori transmitted from cats to humans?

BACKGROUND

Subsequent to the isolation of Helicobacter pylori from domestic cats, it has been suggested that the organism might be transmitted from cats to humans. This hypothesis has already gained considerable media attention.

MATERIALS AND METHODS

In a previous study of risk factors for H. pylori infection, 447 factory workers from Stoke on Trent in the UK had provided blood samples for H. pylori serological workup. They had also completed a detailed questionnaire concerning their living conditions, including the possession of any household pets, in childhood. Logistic regression was used to assess the association between cat ownership in childhood and H. pylori seropositivity.

RESULTS

After adjustment for potential confounders, it was found that subjects who had owned a pet as a child were slightly more likely to be H. pylori seropositive than subjects who had not. There was, however, no difference between subjects who had owned a cat and those with other pets.

CONCLUSIONS

These data do not support the hypothesis that H. pylori infection might be transmitted from cats to humans.

Helicobacter pylori transmission: evidence from a comparison with hepatitis A virus

OBJECTIVE

To assess the possibility that faecal-oral contact might play a role in the transmission of Helicobacter pylori.

DESIGN

A cross-sectional comparison of the patterns of hepatitis A and H. pylori seropositivity.

METHODS

At interview, blood samples and questionnaire data were collected from a group of 467 male volunteers, aged 18-65, from Stoke-on-Trent, UK. Serum samples from each subject were then analysed for anti-H. pylori and anti-hepatitis A antibodies.

RESULTS

Overall, 100 of 175 H. pylori seropositive subjects (57.1%) and 113 of 292 H. pylori seronegative subjects (38.7%) were hepatitis A seropositive (chi 2 = 15.0, P < 0.001). This difference was not statistically significant after adjustment for age group and father's occupation, as a surrogate for socioeconomic status in childhood (P = 0.15). The seroprevalence of hepatitis A increased with age at a rate of 2.3% per year, compared to only 1.0% per year for H. pylori (P = 0.015).

CONCLUSION

These data suggest that the case for faecal-oral transmission of H. pylori, in a manner similar to the spread of hepatitis A, is not proven and that other modes of transmission, for instance through oral-oral contact, should also be considered.

Helicobacter pylori gastritis and serum pepsinogen levels in a healthy population: development of a biomarker strategy for gastric atrophy in high risk groups

This study aimed to estimate the prevalence and type of chronic gastritis in an asymptomatic working population and to determine whether a combination of serum pepsinogen levels and Helicobacter pylori serology could be used to identify a subgroup with atrophic gastritis at elevated risk of gastric carcinoma. A 10% subsample of 544 male volunteer factory workers aged 18-63 years and participating in a larger study underwent endoscopy and biopsy. Of these men, 29 were seropositive for Helicobacter pylori; all but three (89.7%) had chronic gastritis. Serum pepsinogen A levels increased with progression from a corpus predominant pattern of gastritis through pangastritis to an antral predominant pattern. Nine subjects had corpus atrophy, which was in most cases accompanied by fasting hypochlorhydria and hypergastrinaemia. A combination of pepsinogen A below 80 ng ml-1 and Helicobaceter pylori seropositivity detected corpus atrophy with sensitivity 88.9% and specificity 92.3%. A second screening stage, using a pepsinogen A/C ratio of below 2.5 as a cut-off, resulted in a reduction in numbers requiring further investigation but with some loss of sensitivity (77.8%). Application of this two-stage screening programme to the original sample of 544 workers would have resulted in 11 (2.2%) men being selected for follow-up, excluding 25 (5.1%) false negatives. Our results suggest that a combination of serum pepsinogen levels and Helicobacter pylori serology could be useful as a biomarker strategy for detection of individuals at increased risk of gastric carcinoma and for non-invasive investigation of the natural history of Helicobacter pylori gastritis.

Variability in serum pepsinogen levels in an asymptomatic population

OBJECTIVE

To investigate the variability in serum pepsinogen levels in an asymptomatic population.

DESIGN

Cross-sectional survey of 420 men aged 18-63 years, without symptoms or a history of gastric disease, recruited from four factories in Stoke-on-Trent.

METHODS

During an interview, data on history of gastric health, 'lifestyle' and occupation were collected, blood samples were taken for measurement of serum pepsinogen and anti-Helicobacter pylori antibody levels and height and weight were measured.

RESULTS

Extreme (low/high) levels of pepsinogens A and C, indicative of chronic gastritis, were found in 24 (5.7%) and 61 (14.5%) of the participants, respectively. Low A-C ratios, indicative of moderate or severe gastric atrophy, were found in 13 (3.1%) participants. Of the variables examined, Helicobacter pylori serology had the strongest influence on serum pepsinogen levels. Serum pepsinogen A and C levels were significantly higher in the 33.6% of participants who were seropositive. The effect was more marked for pepsinogen C; thus, A-C ratios were lower in seropositive individuals. In seronegative participants, both pepsinogen A and pepsinogen C levels increased with increasing age; pepsinogen A levels increased with increasing height and were higher in smokers, but decreased with increasing weight. The effect of smoking on pepsinogen A levels was also detectable in seropositive individuals, but was considerably less marked. Among seronegative participants, those employed on the 'shop-floor' in manual jobs had higher serum pepsinogen C levels and lower A-C ratios than office-based workers.

CONCLUSION

H. pylori serology was a major source of variation in serum pepsinogen levels, but causes of gastritis other than H. pylori were indicated. Independent of these effects, serum pepsinogen levels may also vary with age, height and weight. Screening of serum pepsinogen levels in the general population may identify 5-15% who require further investigation. Other 'filters' may be required in conjunction with serum pepsinogen levels to identify those needing investigation for significant gastric pathology.

Relation between infection with Helicobacter pylori and living conditions in childhood: evidence for person to person transmission in early life

OBJECTIVES

To relate the prevalence of infection with Helicobacter pylori in adults to their living conditions in childhood to identify risk factors for infection.

DESIGN

Prevalence study of IgG antibodies to H pylori (> 10 micrograms IgG/ml, determined by enzyme linked immunosorbent assay (ELISA)) and reported living conditions and other socioeconomic factors in childhood.

SETTING

Three factories in Stoke on Trent.

SUBJECTS

471 male volunteers aged 18 to 65 years.

MAIN OUTCOME MEASURES

Seroprevalence and variables in childhood.

RESULTS

Seroprevalence of H pylori increased with age (22/74 (29.7%) at < 30 years v 29/46 (63%) at 55-65 years; P < 0.001 for trend) and was related to manual occupation (14/65 (21.5%) for non-manual v 162/406 (39.9%) for manual; P = 0.003). After data were adjusted for age and occupation subjects from large families, whose childhood homes were crowded or who regularly shared a bed in childhood, were significantly more likely to be seropositive (adjusted odds ratio (95% confidence interval) 2.15 (1.41 to 3.30) for crowding and 2.13 (1.38 to 3.30) for sharing a bed), but there was no relation with possession of a bathroom, inside toilet, refrigerator, or household pets in childhood.

CONCLUSIONS

Close person to person contact in childhood is an important determinant of seroprevalence of H pylori in adulthood, suggesting that the infection is transmitted directly from one person to another and may be commonly acquired in early life.

Ethnic differences in risk markers for heart disease in Bradford and implications for preventive strategies

OBJECTIVES

To assess and compare the prevalence of established risk markers for ischaemic heart disease in a sample of Asian and non-Asian men and to relate these observations to preventive strategies.

SETTING

Two factories in the textile industry in Bradford, West Yorkshire, UK. Subjects--288 male manual workers aged 20 to 65 years.

DESIGN

Cross sectional study within one occupational/social class stratum.

MEASUREMENTS AND MAIN RESULTS

Age, body mass index, plasma lipids, fibrinogen and serum insulin values, blood pressure, smoking habits, alcohol consumption, and exercise routines were recorded. Plasma total cholesterol concentrations were significantly lower in Asian than non-Asian men (5.3 mmol/l v 5.8 mmol/l respectively, p < 0.0001), as were low density lipoprotein cholesterol concentrations (3.4 mmol/l v 3.7 mmol/l, p = 0.0150), and high density lipoprotein (HDL) cholesterol (1.1 mmol/l v 1.3 mmol/l, p < 0.0001). Hypercholesterolaemia (concentration > 6.5mM) was present in nearly one quarter of non-Asians but less than one eighth of Asian men. Triglyceride values were not significantly higher in Asians. Smoking rates were high in non-Asians (43.8%) and only slightly lower in Asians (39.1%). Asian smokers smoked fewer cigarettes per day on average (9.3 v 16.1, p = 0.0001). Almost a quarter of non-Asian men (23.1%) and 26.6% of Asian men had raised blood pressure. Systolic pressures were higher in non-Asian men (138.3 mmHg v 133.0 mmHg, p = 0.0070), but diastolic pressures showed no ethnic differences. Diabetes was more prevalent in Asian men (10.9% v 4.4% p < 0.05), who also showed higher serum insulin concentrations after glucose loading (22.3 mU/l v 10.2 mU/l, p < 0.0001). Plasma fibrinogen values were higher in non-Asian men (2.9 g/l v 2.6 g/l, p < 0.0001) and these were associated with smoking. Nearly all non-Asians (92.5%) consumed alcohol at some time whereas 62.5% of Asians habitually abstained from alcohol consumption. Among the drinkers, non-Asian men consumed on average, 23.9 units per week and Asian men 18.4 units per week (p = 0.083). The mean body mass index for Asian men was 24.5 kg/m2 which was not significantly different to the mean in non-Asian men (25.2 kg/m2). The frequency of exercise in leisure time was low in both groups with 44.4% of non-Asian and 21.1% of Asian men taking moderate exercise weekly, and even fewer, regular strenuous exercise (16.3% and 8.6% respectively).

CONCLUSIONS

The plasma cholesterol and fibrinogen concentrations, prevalence of hypertension, smoking habits, alcohol intakes, and infrequency of exercise in leisure time in these non-Asian men in Bradford were consistent with an increased risk of heart disease. The pattern of risk markers was clearly different in Asian men. Only their lower HDL cholesterol concentrations, marginally higher triglyceride values, higher prevalence of diabetes, and very low frequency of exercise in leisure time would be consistent with a higher risk of heart disease compared with non-Asians. The implications of these observations for heart disease preventive strategies are discussed.

Periodic posture stimulation of the baroreceptors and the local vasomotor reflexes

In a supine subject, lowering of the foot from heart level to 50 cm below is known to stimulate the local reflex response and the baroreceptor outflow. We lowered and raised the leg of a supine subject periodically, with the leg stationary between movements (square wave). The Traube-Hering-Mayer wave (THM congruent to 0.1 Hz) was captured by or locked on to the leg movement over a certain frequency range, this is usually called the entrainment range. Square wave periodic leg movement in this manner on 10 male subjects, mean age 22 years, demonstrated that the THM frequency can be entrained. The lower limit of the entrainment bandwidth is 0.0841 (SD 0.0030) Hz and the upper limit is 0.1176 (SD 0.0013) Hz. Further examination showed that this phenomenon is independent of the breathing input. Comparison with the Traube-Hering-Mayer entrainment techniques of breathing and periodic neck suction using the Eckberg collar which stimulates the baroreceptors showed similar results. This work supports the hypothesis that the local reflex response and the baroreceptor outflow entrain the THM frequency.

Nitrate and N-nitrosoproline excretion in two Italian regions with contrasting rates of gastric cancer: the role of nitrate and other factors in endogenous nitrosation

Exposure to nitrate and propensity for endogenous nitrosation were examined in 80 healthy males, aged 25-40 years, residing in areas of Italy with long-standing high (Florence) and low (Cagliari) rates of gastric cancer. Nitrate exposure was assessed by measurement of urinary nitrate excretion over 12 hr, and endogenous nitrosation was assessed using the N-nitrosoproline test (NPRO-test). Our hypothesis was whether the geographic variation in cancer rate correlated with nitrate exposure or nitrosating ability. Exposure to background sources of NPRO was significantly higher in the high-risk subjects (phi = 0.04) whereas no differences were found in exposure to nitrate or in urinary NPRO levels after L-proline loading (test NPRO levels). The regional difference in test NPRO was almost completely accounted for by background NPRO exposure. Examination of individual rather than grouped data revealed that exposure to nitrate was a major factor in NPRO formation. No other factors studied (age, dietary-questionnaire-assessed intake of anti-oxidant vitamins) had a significant effect. Geographical variation in gastric cancer risk did not, therefore, correlate with either nitrate exposure or propensity for endogenous nitrosation of L-proline.

Auditory deficits and motor dysfunction following iminodipropionitrile administration in the rat

The behavioral effects of 3,3'-iminodipropionitrile (IDPN) were studied using reflex modification of the acoustic startle response and figure-eight maze activity. A number of experiments were conducted with separate groups of adult male Long-Evans hooded rats exposed to saline or 50-500 mg/kg IDPN for 3 consecutive days. Auditory thresholds (reflex modification), motor activity, and grip strength were measured 1 day, and 1, 3, and 9 weeks postdosing. Reflex inhibition was monitored daily, prior to, during, and for 7 days following exposure. Auditory thresholds for 5- and 40-kHz tones were elevated approximately 25 dB and 50 dB, respectively. The onset of this auditory dysfunction in the 200-mg/kg/day group, as demonstrated by a loss of reflex inhibition, was 2 days for the 40-kHz tone and 4 days for the 5-kHz tone. Motor activity was increased up to 400% in the 200-mg/kg group, whereas there was no alteration in hindlimb grip strength. These data demonstrate dosage- and time-dependent alterations in auditory and motor function following IDPN exposure.

Impact of a natural disaster on a psychiatric inpatient population: clinical observations

Natural disasters do not always lead to post-traumatic stress disorders (PTSD) for their victims, although stress-related symptoms are commonly reported as results of such disasters. The impact of a natural disaster on the treatment of a hospitalized psychiatric population has never been systematically evaluated. In the fall of 1986, severe river flooding caused evacuation of a 160-bed psychiatric facility. One hundred and twenty-one hospitalized patients were taken to nearby hospital facilities, and many were separated from their primary therapists, fellow patients or both. A mail survey two months post-evacuation assessed stress-related symptoms, the patients' opinions of the impact of the flood on their treatment and functioning, and the patients' views of the evacuation procedures. Patients also responded to questions about their cognitive and affective reactions during each phase of the disaster. Clear evidence of PTSD was not found with this population; however, the findings underscore the importance of keeping patients with familiar staff and peers when possible. Differences between this study and previous disaster studies are noted, and suggestions for coping with natural disasters in inpatient or residential psychiatric facilities are offered.

Surgical suppression of gastric acid secretion. Lessons from long-term follow-up studies

This paper reviews data from case controls studies, cohort studies, and long-term follow-up papers of over 30,000 patients following surgical reduction of gastric acid secretion 20-40 years postoperatively. There is an increase in gastric cancer which becomes highly significant 20 years after Billroth II resection and rises thereafter, many studies showing a three- or four-fold increase compared with a non-operative control or contrast population. There is little doubt that surgical depression of gastric acid secretion is associated with the development of carcinoma of the stomach. The mechanisms by which this development may occur are discussed.