Randomised study of the influence of non-steroidal anti-inflammatory drugs on the treatment of peptic ulcer in patients with rheumatic disease

Sixty-seven patients with rheumatic disease, treated with non-steroidal anti-inflammatory drugs (NSAIDs), entered a controlled trial with a diagnosis of duodenal (n = 51), gastric (n = 14), or gastric and duodenal (n = 2) ulcers. The main objectives of the study were a comparison of ranitidine and sucralfate in ulcer treatment, and to observe the influence of continued NSAID administration during peptic ulcer therapy. Ulcers healed within nine weeks in 52 patients. The mean healing time was similar in 27 patients given ranitidine 150 mg bd (4.9 weeks) and 25 patients given sucralfate 1 g qid (4.6 weeks). In patients with unhealed ulcers after nine weeks of treatment, healing was obtained in seven after further therapy for 3-9 weeks. Of the 30 patients who continued NSAIDs during treatment with either ranitidine or sucralfate, 23 ulcers healed (mean healing time: 5.0 weeks). Of 32 patients in whom NSAIDs were stopped, ulcer healing was documented in 29 (mean healing time: 4.6 weeks). The difference in healing rates was not statistically significant (p greater than 0.10). The outcome of ulcer treatment did not differ in patients with rheumatoid arthritis and patients suffering from osteoarthritis. During a 12 month follow up 14 symptomatic ulcer recurrences were recorded.

Severe acquired immunodeficiency in European homosexual men

Four previously healthy Danish homosexual men developed Kaposi's sarcoma or opportunistic infections with fever of unknown origin and lymphadenopathy. One patient died of a Pneumocystis carinii pneumonia. Three patients had defective cell-mediated immunity with absent leucocyte interferon production and decreased proliferative response to mitogens and antigens. T lymphocyte helper subsets and natural killer cell activity were reduced. Unstimulated mononuclear cells produced leucocyte migration inhibitor factor. Two patients were sexual partners and three had never been to the USA, where cases of severe acquired immunodeficiency have been reported. Thus, the syndrome must also be suspected in European homosexual men who present with fever of unknown origin, opportunistic infections, or Kaposi's sarcoma.

Natural history of global and critical brain ischaemia. Part I: EEG and neurological signs during the first year after cardiopulmonary resuscitation in patients subsequently regaining consciousness

Of 125 patients who had no detectable cortical activity (DCA) in the electroencephalograph (EEG) immediately upon resuscitation from circulatory arrest of primary cardiovascular aetiology, 37 subsequently regained consciousness; these patients had their EEG and neurological status serially investigated until they expired or had survived one year. The orderly cerebral recovery during postischaemic unconsciousness was characterized by a sequential appearance of EEG configurations and related neurological signs. The absence of DCA was at first accompanied by miosis and all the cranial nerve reflexes except the caloric vestibular reflex (phase of exclusive presence of cranial nerve reflexes) and then by motor responsiveness, predominantly decerebrate posturing (phase of cephalic reactivity). Electrocortical activity appeared thereafter first as a phase described as 'intermittent cortical activity' (ICA) accompanied by medium sized pupils, decorticate posturing and stereotypic reactivity and then as a phase described as 'continuous cortical activity' (CCA) associated with stereotypic reactivity. Consciousness returned 11-720 h later. The EEG and neurological recovery occurred independently after awakening; but elementary motor, sensory and mental faculties were regained in a characteristic sequence. Initially, the alert patient had a phase of 'severe disability' seen as communicating motor responses, eye-orientation and a bilateral Babinski response; in the subsequent phase of 'moderate disability' speech, auto-orientation, locomotor control, and a normal plantar response were then restored; finally in the phase of slight- or no disability allo-orientation, retention and recall reappeared. Thirteen patients made a complete recovery of all faculties 83--2150 h after cardiopulmonary resuscitation.

Over-estimation of glomerular filtration rate by single injection [51Cr]EDTA plasma clearance determination in patients with ascites

The total plasma (Clt) and the renal plasma (Clr) clearances of [51Cr]EDTA were determined simultaneously in nine patients with ascites due to liver cirrhosis. Clt (mean 78 ml/min, range 34-115 ml/min) was significantly higher than Clr (mean 52 ml/min, range 13-96 ml/min, P < 0.005). The ascitic fluid-plasma activity ratio of [51Cr]EDTA increased throughout the investigation period (5h). The results suggest that [51Cr]EDTA equilibrates slowly with the peritoneal space which indicates that Clt will over-estimate the glomerular filtration rate by approximately 20 ml/min in patients with ascites. To assess glomerular filtration rate in presence of ascites, the renal plasma clearance of [51Cr]EDTA should be used instead of the total plasma clearance.

Dynamics of albumin in plasma and ascitic fluid in patients with cirrhosis

BACKGROUND/AIMS

To determine dynamics of albumin in plasma and ascitic fluid of patients with cirrhosis.

METHODS

Forty-seven patients were classified in four groups: I--patients without fluid retention; II--patients with ascites not resistant to subsequent diuretic treatment; III--recompensated patients during diuretic treatment; and IV--patients with diuretic-resistant ascites. Transvascular and transperitoneal albumin transports were quantified by 131I-/125I-labelled human albumin.

RESULTS

TER(P) (i.e. the fraction of intravascular albumin (IVM) passing from plasma into the interstitial space per hour) was increased in all groups. In group IV patients the transport rate of albumin from plasma into the ascitic fluid (TER(PA)) was significantly higher than the transport rate from the ascitic fluid back into the plasma: TER(AP) (0.45 vs. 0.26% IVM/h, P < 0.002). In group II patients TER(PA) was similar to TER(AP) (0.27 vs. 0.25% IVM/h, ns). A direct correlation was found between TER(PA) and TER(AP) in both groups of patients (r = 0.78, P < 0.001).

CONCLUSION

In non-resistant ascites, there is a steady state between the transport of albumin into the peritoneal cavity and back into the plasma, but in resistant ascites the former transport is elevated. Thus, local factors may be important to treatment of ascites.

Predicting endoscopic diagnosis in the dyspeptic patient: the value of clinical judgement

OBJECTIVE

To compare the quality of chance-corrected clinical diagnosis in two groups of dyspeptic patients, using endoscopy as the diagnostic standard.

DESIGN

Structured interview before endoscopy and clinical predictions of endoscopic diagnosis as either malignancy, peptic ulcer, oesophagitis or non-ulcer dyspepsia. The quality of the predictions was corrected for chance using iota-correction. Patients gave a provisional prediction of their own endoscopic diagnosis.

SETTING

Two endoscopy units in Odense and Svendborg, Denmark.

PATIENTS

Two groups of dyspeptic outpatients: (1) 1026 patients referred for open-access endoscopy and (2) 207 empirically managed patients randomly assigned to prompt endoscopy as part of a clinical trial.

RESULTS

The overall diagnostic validity for all diagnoses was equal in the two groups of patients (57 and 59%) and was mainly accounted for by positive predictive values for non-ulcer dyspepsia of 75%. Elimination of random accuracy for non-ulcer dyspepsia showed a validity of only 23 and 21%. Patients with a major pathologic lesion (cancer, ulcer, complicated oesophagitis) were misclassified clinically as non-ulcer dyspepsia in 36 and 38% of cases. The sensitivity of a clinical prediction of ulcer was only 52 and 36%, despite positive predictive values of 34%, and most valid when corrected for chance in the group of patients referred for open-access endoscopy. The patients' provisional diagnoses had no predictive value.

CONCLUSION

Clinical diagnosis in dyspepsia was unreliable as it misclassified one-third of patients with a major pathological lesion. Fifty percent of patients with ulcer were misclassified and that clinical diagnosis could only be confirmed in one-third of the cases. The chance-corrected validity of non-ulcer dyspepsia was only slightly better than chance. There was no predictive value of the patients' predictions of their own diagnosis.

Differential diagnosis of jaundice: a pocket diagnostic chart

Based on extensive clinical and clinical chemical information (107 different items) from 1002 jaundiced patients, we developed a diagnostic algorithm which was evaluated on a test sample of another 110 jaundiced patients. A primary classification into categories of obstructive jaundice (probability of obstruction greater than or equal to 0.80), non-obstructive jaundice (probability of obstruction less than or equal to 0.20), and of doubtful causes of jaundice (probability of obstruction: 0.20-0.80) was attempted. Among 234 patients in the data base who were classified as obstructive, 220 (94%) proved to be so, as did 36 (97%) of 37 in the test sample. The corresponding figures for non-obstructive jaundice were 463 (96%) of 483 patients correctly classified in the data base and 47 (92%) of 51 patients in the test sample. Altogether 69% of the patients in the data base and 75% of those in the test sample were correctly classified, in 27% and 20% the cause of jaundice was doubtful, and only 4% and 5%, respectively, were misclassified. A slight majority of the patients in whom the algorithmic diagnoses were doubtful proved obstructive. A close correlation was found between the preliminary diagnoses made by the algorithm and by the clinicians. A secondary classification of the patients by the algorithm into benign versus malignant causes of obstructive jaundice performed equally well in the data base and the test sample.

Natural history of global and critical brain ischaemia. Part II: EEG and neurological signs in patients remaining unconscious after cardiopulmonary resuscitation

Of 125 patients who had no detectable cortical activity (DCA) on the electroencephalograph (EEG) immediately upon resuscitation from circulatory arrest of primary cardiovascular aetiology, 88 remained unconscious; these patients had their EEG and neurological status serially investigated until they died. Immediately upon re-establishment of circulation all cerebral functions could be absent; the brain death (irreversible loss of functions) was then signified by the appearance of poikilothermia, diabetes insipidus and reflex extension of the upper limb. Most often, some cranial nerve reflexes were present; the EEG configurations and related neurological signs then appeared in a sequence which resembled orderly postischaemic recovery: A phase without DCA was at first characterized by an exclusive presence of cranial nerve reflexes and then by the appearance of decerebrate posturing this phase was followed by another phase of intermittent cortical activity (ICA) with decorticate and stereotypic motor responses and a phase of continuous cortical activity (CCA) accompanied by stereotypic reactivity. These phases were most often incomplete due to failure of recovery of some cranial nerve reflexes or were abnormal due to the appearance of intermittent spikes and sharp waves. Progressive recovery could stagnate at any step and the cerebral functions be lost abruptly or gradually in reverse order of recovery. The decay was invariably due to cardiovascular or pulmonary complications. Brain autopsy revealed extensive neuronal loss and intravital autolytic changes in patients who had fulfilled clinical criteria of brain death for more than 72 h, but the histopathology showed no relationship to other clinical findings during the postischaemic course.

Predicting endoscopic diagnosis in the dyspeptic patient. The value of predictive score models

BACKGROUND

Score models to predict endoscopic diagnosis in dyspepsia may compensate for the unreliable clinical diagnosis. This study aimed to construct and test score models designed to predict diagnosis in dyspepstic patients managed in primary care.

METHODS

Three models to predict organic dyspepsia, major dyspepsia, or peptic ulcer were constructed by regression analysis of clinical data from 1026 consecutive dyspeptic patients referred for endoscopy. The models were tested in 207 patients in primary care, who were potential candidates for endoscopy. Validation experiments were analysed using receiver operating characteristic (ROC) curves.

RESULTS

Significant losses of predictive power were found for all models when applied to primary care patients, and no model could be used as a reliable decision support instrument in primary care.

CONCLUSIONS

Predictive score models developed in patients referred for endoscopy are not reliable when applied to patients in primary care who are potential candidates for endoscopy. Future models should be constructed and validated in unselected primary care populations.

Enzymatic determination of total 3 alpha-hydroxy bile acids in faeces. Validation in healthy subjects of a rapid method suitable for clinical routine purpose

A method for determining faecal bile acids, suitable for clinical purposes, is introduced. The analysis uses a 0.2-g stool specimen, a simple extraction procedure, and 3 alpha-steroid dehydrogenase determination. The method, which is rapid, has been validated by gas-liquid chromatography and by recovery of internal standards. Stool examination was done in 16 healthy volunteers on free diet and in 25 patients with non-gastrointestinal diseases who were on a fat- and fibre-fixed diet. No difference was found between the two groups, so the data were pooled, and the normal reference interval (mean +/- S.D.) for faecal bile acid output was calculated to be 0-975 mumol/24h.

Differential diagnosis of jaundice: applicability of the Copenhagen Pocket Chart proved in Stockholm patients

This paper shows that an algorithm for differential diagnosis of jaundice developed in Denmark has been successfully transferred for use in a Swedish hospital. The algorithm, which is based on data from nearly 1000 patients, utilises 21 items of information from the medical history, physical examination and blood chemistry. The algorithm recognises four diagnostic groups: benign obstructive jaundice, malignant obstructive jaundice, acute non-obstructive jaundice, and chronic non-obstructive jaundice. To each item of information, a score is attached reflecting its weight of evidence. Summing the scores for the symptoms and signs that are present leads to a probabilistic statement about the diagnosis. Because of missing data in the Swedish patient material, three of the items were excluded from the original algorithm. Corrections were made for differences in the distribution of diseases. In reclassification of 985 Danish patients the modified algorithm's "best bid", i.e. the diagnosis given the highest probability, was correct in 78% of cases. More important, 93% of the cases given a "confident" diagnosis (probability greater than 0.80) were correct. The corresponding figures when the algorithm was applied to Swedish patients were 76% and 93%, respectively. In both series the predicted probabilities were matched by a corresponding proportion of actual diagnostic hits. It is concluded that the algorithm leads to reliable estimates of diagnostic probabilities in jaundice and that the algorithm seems to work well in Sweden also.

Computer diagnosis in jaundice. Bayes' rule founded on 1002 consecutive cases

Extensive clinical and clinical chemical information was collected from 1002 consecutive jaundiced patients. Initial selection of variables based on Chi 2-tests or Mann-Whitney U-test allowed the removal of 64 of the 107 variables originally collected. A further selection of variables was carried out using a modified version of Bayes' rule thus reducing the number of variables from 43 to 22. Of the 982 patients with a final diagnosis 743 patients (76%) could be classified correctly into one of 13 diagnostic categories. The Bayes' rule was also applied to a test group of a further 110 jaundiced patients and found to perform equally well: of 108 patients with a final diagnosis 81 (75%) were correctly classified. A comparison between the clinician's diagnosis and the computer-aided diagnosis according to Bayes' rule demonstrated agreement with regard to one of the 13 diagnostic alternatives in 734 patients (75%), of whom 81 patients were wrongly diagnosed. In the test group agreement upon diagnosis was found in 80 patients (74%). By plausibly combining the computer-aided and the clinician's preliminary diagnoses, more correct classifications were obtained than with either method alone. Many diagnostic modalities such as ultrasound examination, CT-scan, and direct cholangiography are at hand today for the differential diagnosis of jaundice. Computer-aided diagnosis using Bayes' rule has proved a reliable tool for the clinician and can be used in the planning of a diagnostic strategy for the individual jaundiced patient.

Natural history of global and critical brain ischaemia. Part III: cerebral prognostic signs after cardiopulmonary resuscitation. Cerebral recovery course and rate during the first year after global and critical ischaemia monitored and predicted by EEG and neurological signs

The monitoring and predictive value of the electroencephalography (EEG) and neurological signs was evaluated in 125 patients who had sustained critical brain ischaemia during circulatory arrest of primary cardiovascular aetiology. Cranial nerve areflexia with mydriasis or extension of the upper limb in response to cutaneous stimulation reliably indicated brain death and appearance of the flexion reflex or of intermittent spikes and sharp waves in the EEG predicted an unfavourable outcome; but other EEG configurations and nuerological signs per se were inaccurate variables to assess the outcome. By contrast, the recovery course and rate were accurately assessed by the time for appearance of cerebral functions; the caloric vestibular reflex, decorticate posturing, stereotypic reactivity, intermittent and continuous electrocortical activity were regained within ultimate time limits of 900, 540, 455, 450, and 1020 min, respectively, corresponding to the longest delay compatible with recovery of function at all, and within critical time limits of 165, 180, 180, 200, and 630 min, respectively, corresponding to the longest delay compatible with recovery of consciousness. Moreover, intermittent electrocortical activity, consciousness, speech and ability to cope with personal necessities were regained within supercritical time limits of 3, 47, 156, and 336 h, respectively, corresponding to the longest delay compatible with complete restoration of post-awakening faculties within 1 year of resuscitation. Prognosis was currently ascertained during the period of unconsciousness as cephalic reactivities, and electrocortical activities were regained in an exponential relationship to time. Bradycardia or asystole prior to resuscitation and metabolic acidosis, hypotensive heart failure, recurrent circulatory arrest and pneumonia thereafter influenced the cerebral recovery adversely.

Effects of glucose, insulin and nicotinic acid on adipose tissue blood flow in rats

Adipose tissue blood flow (ATBF) was examined in rat parametrial fat by the 133-Xe elimination method. Intravenous infusion of glucose to fed rats resulting in blood glucose concentrations of 10-12 mmol X 1(-1) caused a significant reduction in ATBF (-37%). Similar infusions to 48 hour fasted rats had no consistant effect on ATBF. Glucose infusion caused a significant rise in plasma insulin concentrations in both fed and fasted animals, although the average concentration in fasted rats given glucose did not exceed the control value in fed animals. Insulin added to the glucose infusion caused a similar reduction in ATBF in fasted animals as that seen after glucose alone in fed animals (-38%). Guinea pig anti insulin serum administered intravenously to fed rats elicited an increase in blood glucose concentrations similar to that seen after glucose infusion, but was without effect on ATBF. These results suggest that the effect of glucose on ATBF is secondary to a release of insulin resulting in plasma levels above those found in fed control rats. Infusion of nicotinic acid also reduced ATBF without influencing blood glucose concentration and in spite of insulin concentrations lower than in fed control rats. Since both insulin and nicotinic acid inhibit the formation of c-AMP in adipocytes, it is hypothesized that both compounds decrease ATBF by decreasing the release of the vasodilator adenosine from the cells.

Validation of the PHEEM instrument in a Danish hospital setting

The Postgraduate Hospital Educational Environment Measure (PHEEM) has been translated into Danish and then validated with good internal consistency by 342 Danish junior and senior hospital doctors. Four of the 40 items are culturally dependent in the Danish hospital setting. Factor analysis demonstrated that seven items are interconnected. This information can be used to shorten the instrument by perhaps another three items.

Does sucralfate reduce acetylsalicylic-acid-induced gastric mucosal bleeding?

We studied the possible protection of sucralfate with regard to acetylsalicylic acid (ASA)-induced gastric mucosal bleeding as measured by a radiochromium assay of faecal blood loss in a double-blind crossover study involving 16 healthy male volunteers. Medication was given in two combinations during the 2nd and 5th week of the study: 1 g ASA and 1 g sucralfate four times daily, or 1 g ASA four times daily and placebo tablets. Mean faecal blood loss (+/- SEM) was 0.38 +/- 0.04 ml/day in the 1st week (no drugs administered), 7.17 +/- 1.60 ml/day during treatment with ASA + sucralfate, and 9.59 +/- 1.76 ml/day during treatment with ASA + placebo, the difference being not statistically significant. Individual bleeding values registered during sucralfate treatment correlated with those measured in the placebo period. However, three persons with pronounced bleeding after ASA + placebo had minimal bleeding after ASA + sucralfate. Sucralfate may have a protective potential by reducing ASA-induced gastric mucosal bleeding, but further studies are required to evaluate its protective mechanisms and to identify the groups of patients that could benefit from this.

Endoscopic retrograde cholangiopancreatography and transhepatic cholangiography in patients with suspected obstructive jaundice. A randomized study

To establish principles for choosing between endoscopic retrograde and percutaneous transhepatic cholangiography, we randomized 52 consecutive jaundiced patients with clinically suspected obstructive jaundice. The bile ducts were visualized in 85% by the endoscopic and in 84% by the transhepatic route. A conclusive diagnosis was reached in 89% and 68% of the patients, respectively, but the difference is not significant (0.10 less than P less than 0.20). If the planned type of cholangiography failed, the other method was tried. By comparing the total numbers of investigations, a conclusive diagnosis was achieved in 91% by endoscopic and 69% by transhepatic route, which is significantly different (P less than 0.05). We therefore prefer to do endoscopic cholangiography initially with transhepatic cholangiography as the complementary method.

Use of 360-degree assessment of residents in internal medicine in a Danish setting: a feasibility study

BACKGROUND

The aim of the study was to explore the feasibility of 360 degree assessment in early specialist training in a Danish setting. Present Danish postgraduate training requires assessment of specific learning objectives. Residency in Internal Medicine was chosen for the study. It has 65 learning objectives to be assessed. We considered 22 of these suitable for assessment by 360-degrees assessment.

METHODS

Medical departments of six hospitals contributed 42 interns to the study. Each resident was assessed by ten persons of whom one was a secretary, four were nurses and five senior doctors. The assessors spent 14.5 minutes (median) to fill in the forms.

RESULTS

Of the 22 chosen objectives, 15 could reliably be assessed by doctors, 7 by nurses and none by secretaries.

CONCLUSIONS

The method was practical in busy clinical departments and was well accepted by the assessors. Reliability of the method was acceptable. It discrimintated satisfactorily between the good and not so good performers.

A randomized trial of iohexol versus amidotrizoate in endoscopic retrograde pancreatography

To evaluate whether a low-osmolar contrast medium could decrease hyperamylasemia after endoscopic retrograde pancreatography, a prospective randomized double-blind trial of 54 consecutive patients with suspected pancreatic disease referred for endoscopic retrograde pancreatography was performed. The low-osmolar contrast medium iohexol and high-osmolar amidotrizoate were used. No statistically significant differences with regard to rise in pancreatic-type amylase, pain reaction, or diagnostic information were found. No case of acute pancreatitis was observed.

Precision requirements in a study of computer-aided diagnosis of jaundice (the COMIK study)

Some 700 icteric patients have now been investigated by the Copenhagen study group for computer-aided differential diagnosis of jaundice (the COMIK study). The paper presents experience based on preliminary test runs using selected subsets of the data. In particular, the effect of the number of intervals into which quantitative laboratory variables are grouped has been stuied. Computer performance depends little on such grouping and, by inference, on analytical imprecision. As the grouping becomes finer, performance is even seen to deteriorate. These findings are in accord with theory and experience from other areas of pattern recognition, the problem being one of sample size. It is concluded that we are in a paradoxical situation of knowing from studies of single analytes that precision matters; yet when it comes to assembling information about a patients's condition we cannot make effective use of the precision of today's laboratories. This would seem to hold good whether data are processed by a computer, by physician, or by the two in collaboration.

Prescribing of acid suppressive therapy: interactions between hospital and primary care

BACKGROUND

Overuse of acid suppressive therapy in the hospital setting and in primary care is well documented.

AIM

To describe interactions between prescriptions of acid suppressive therapy in hospital and in primary care.

METHODS

All patients admitted to hospital over a 24-month period were identified. Details about prescription of acid suppressive therapy were retrieved. All prescriptions of acid suppressive therapy redeemed by these patients 12 months before and after discharge were retrieved from a prescription database.

RESULTS

A total of 549 of 4477 patients (12.3%) were treated with acid suppressive therapy while in hospital, but acid suppressive therapy was prescribed de novo in only 192 (35%) of these cases. Information about indication for acid suppressive therapy and planned duration of therapy were given in the discharge letter in only 25% and 17% of the cases, respectively. Among patients treated with acid suppressive therapy during admission, prescriptions on acid suppressive therapy were redeemed by 67% in the year before admission and by 74% in the year after discharge. Among patients who had the acid suppressive therapy discontinued during admission (n = 67), 48% resumed acid suppressive therapy within the following 12 months. Of all subjects treated with acid suppressive therapy in the hospital catchment area, 7.8% were seen in our department.

CONCLUSIONS

Decisions about acid suppressive therapy prescribing in hospital has little influence on prescribing in primary care.

Treatment of peptic ulcer induced by non-steroidal anti-inflammatory drugs

Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) are often associated with peptic ulcer. A consecutive series of patients with rheumatic disease treated with NSAIDs entered a clinical trial after endoscopic diagnosis of gastric or duodenal ulcer. Three objectives were pursued: comparison between the healing capacities of sucralfate and ranitidine; evaluation of the influence of continuous NSAID administration during ulcer treatment; and determination of the peptic ulcer recurrence rate during a one-year follow-up. Average healing times were identical for 25 patients given sucralfate (4.6 weeks) and 27 patients given ranitidine (4.9 weeks). Ten patients with persistent ulcers after nine weeks of treatment received ulcer therapy for a further 3-9 weeks and healing was obtained in seven cases. Thirty patients continued on NSAID, and the ulcers healed in 23, whereas NSAID was withdrawn in 32 patients, of whom ulcer healing was documented in 29 (p greater than 0.10). 14 symptomatic recurrences were observed during the follow-up period. Adverse reactions were non-significant, and there were no cases of severe gastrointestinal bleeding.

Peritoneovenous shunt in treatment of ascites in patients with cirrhosis. A preliminary report with special reference to pathophysiology

Peritoneovenous shunts (LeVeen type) were implanted in seven patients with cirrhosis complicated by ascites refractory to diuretic treatment. Three patients died of gastrointestinal bleeding and hepatic coma 1 to 7 weeks after the shunt implantation. The patients who died were those with the most severely impaired liver and kidney function. In two of the four surviving patients (observation time, 5-24 months) the shunt was patent during the observation time, and ascites disappeared. In the other two the shunt closed, in one patient repeatedly following several re-implantations. Enhanced urinary sodium excretion was observed in patients with patent shunts. After disappearance of ascites, the splanchnic venous pressures became less deranged. Long-term change in plasma volume or circulating albumin mass could not be detected. A patent shunt increases the drainage from the peritoneal cavity, but detectable increment in the overall lymph drainage was only found in a patient with a very low pre-shunt value. The findings do not support the 'overflow' theory of ascites formation but rather the 'lymph imbalance' theory. For clinical evaluation of peritoneovenous shunting in the treatment of ascites a controlled clinical trial is essential.

Differential diagnosis of jaundice: junior staff experience with the Copenhagen pocket chart

Originally published in 1984, the Copenhagen Pocket Chart for early differentiation between causes of jaundice has been tested with success in centres outside Denmark. Using a logistic discrimination model, it estimates probabilities of obstruction and non-obstruction in each case (and provides a further subdivision if desired). Here we evaluate its performance in the hands of young clinicians on a consecutive series of 173 jaundiced patients from two Danish hospitals. The chart performed as well as in the original series: confident diagnoses (probability greater than or equal to 0.80) were assigned to 124 patients; of these 115 proved correct (93%). In 46 patients diagnostic probabilities were less than 0.80, and 3 patients had an unknown cause of jaundice. There were 108 cases in which physician and chart were in agreement, both with a confident diagnosis, and only one of these cases was wrong. In one hospital, contributing 107 cases, each patient was independently examined by a medical student in addition to the physician's examination. Student performance was equally good, practically speaking, in particular when taking the scores on the chart into consideration. As to observer disagreement, the student and the physician typically differed on 0-2 of the chart's 21 items. In no case, however, did this lead to a confident obstructive diagnosis being changed into a confident diagnosis of non-obstruction, or vice versa.