A new approach to scoring systems to improve identification of acute medical admissions that will require critical care.

Removal of the intensive care unit (ICU) at the Vale of Leven Hospital mandated the identification and transfer out of those acute medical admissions with a high risk of requiring ICU. The aim of the study was to develop triaging tools that identified such patients and compare them with other scoring systems. The methodology included a retrospective analysis of physiological and arterial gas measurements from 1976 acute medical admissions produced PREEMPT-1 (PRE-critical Emergency Medical Patient Triage). A simpler one for ambulance use (PREAMBLE-1 [PRE-Admission Medical Blue-Light Emergency]) was produced by the addition of peripheral oxygen saturation to a modification of MEWS (Modified Early Warning Score). Prospective application of these tools produced a larger database of 4447 acute admissions from which logistic regression models produced PREEMPT-2 and PREAMBLE-2, which were then compared with the original systems and seven other early warning scoring systems. Results showed that in patients with arterial gases, the area under the receiver operator characteristic curve was significantly higher in PREEMPT-2 (89·1%) and PREAMBLE-2 (84.4%) than all other scoring systems. Similarly, in all patients, it was higher in PREAMBLE-2 (92·4%) than PREAMBLE-1 (88·1%) and the other scoring systems. In conclusion, risk of requiring ICU can be more accurately predicted using PREEMPT-2 and PREAMBLE-2, as described here, than by other early warning scoring systems developed over recent years.

Effects of atenolol withdrawal in patients on triple antihypertensive therapy.

The objective of this study was to examine the contribution of beta-blockade to antihypertensive treatment regimens including an angiotensin converting enzyme inhibitor or a calcium antagonist. The effects on BP control, adverse events, and plasma active renin concentration of removing atenolol from standard triple therapy (bendrofluazide and atenolol together with captopril or nifedipine) were assessed in a double-blind, randomised, parallel-group study, of eight weeks' duration in 46 patients from the Glasgow Blood Pressure Clinic. Blood pressures rose in patients randomised to placebo-atenolol compared with those who continued active-atenolol although the difference did not achieve statistical significance. However, the proportion of patients with controlled blood pressure (supine systolic BP < 140 mmHg plus supine diastolic BP < 95 mmHg) fell from 31% to 0% over the study period in patients given placebo-atenolol. There was a trend for BP control to deteriorate most when atenolol was withdrawn from nifedipine treated patients, but the 95% confidence intervals for the difference from captopril-treated patients were wide. Few side-effects were seen and these did not differ quantitatively between the study groups. Plasma active renin concentration was initially higher in captopril-treated patients, and increased on withdrawal of atenolol in both groups. Our findings suggest that beta-blockers make a clinically relevant contribution to treatment regimens including angiotensin converting enzyme inhibitors or calcium antagonists when given as part of standard triple antihypertensive therapy.

Comparison of captopril, hydralazine and nifedipine as third drug in hypertensive patients.

The antihypertensive, biochemical and adverse effects of captopril, hydralazine, nifedipine and placebo were compared in 160 patients with BP inadequately controlled by atenolol 100 mg daily plus bendrofluazide 5 mg daily. Treatments were given for up to 12 weeks. Beta-blocker and thiazide were continued unchanged. All three active drugs reduced supine BP relative to placebo; mean BP changes attributable to active treatment (95% confidence intervals): captopril 13.4/10.3 mmHg (0.6/4.0 to 26.2/16.6), hydralazine 15.0/10.0 mmHg (1.7/3.4 to 28.3/16.6), nifedipine 16.8/8.1 mmHg (4.0/1.8 to 29.6/14.4). There were no significant differences between the agents. Results for erect BP were similar. Target BP (< 140/95 mmHg) was achieved more frequently on captopril (33%), hydralazine (29%) and nifedipine (17%) than on placebo (10%). Compared with the other treatments captopril increased serum potassium concentration (P = 0.01), and hydralazine reduced serum cholesterol concentration (median changes: captopril -0.2 mmol/l, hydralazine -0.8 mmol/l, nifedipine -0.2 mmol/l, and placebo +0.2 mmol/l, P < 0.001). Overall, side-effects did not differ significantly between the groups; withdrawals resulting from adverse reactions: captopril 15%, hydralazine 24%, nifedipine 22%, and placebo 3% (chi 2 = 8.2, P = 0.04). Captopril, hydralazine and nifedipine did not differ significantly in efficacy and tolerability when added to atenolol and bendrofluazide. However, there were trends in favour of captopril, on which drug the highest proportion of patients had their BP controlled and the lowest proportion were withdrawn because of side-effects. Thus, of the drugs tested, captopril appears to be the best option as third drug in hypertension.

Candoxatril, a neutral endopeptidase inhibitor: efficacy and tolerability in essential hypertension.

OBJECTIVE: To examine the efficacy and tolerability of the neutral endopeptidase inhibitor, candoxatril (UK 79,300) as monotherapy in essential hypertension. DESIGN: Double-blind, placebo-controlled, parallel-group study of 28 days' duration. SETTING: Three hospital outpatient departments participating in the Glasgow Blood Pressure Clinic (Glasgow, UK). PATIENTS: Forty patients with essential hypertension with diastolic blood pressure 95-114 mmHg after a 2-4 week placebo run-in period. INTERVENTIONS: Twenty-eight days' treatment with candoxatril 200 mg twice daily or matching placebo capsules. MAIN OUTCOME MEASURES: Changes in supine and erect blood pressure, and volunteered side effects during double-blind treatment. RESULTS: When measured at the end of the dose interval, the fall in supine blood pressure following candoxatril was not significantly greater than that after placebo. Compared with placebo, a significant effect for candoxatril was seen only for systolic blood pressure in the erect posture; the fall in erect diastolic blood pressure attributable to candoxatril was insignificant. Median plasma atrial natriuretic peptide concentration increased in candoxatril-treated patients and decreased in the placebo group. No stimulation of the renin-aldosterone axis was seen. There was a non-significant trend towards greater urinary excretion of cyclic guanosine monophosphate after candoxatril. Mean plasma concentration of candoxatril at (UK 73,967--the active metabolite of candoxatril) reached a peak of 1010 +/- 437 ng/ml after acute dosing, and 1328 +/- 405 ng/ml after chronic dosing; time to maximum concentration was 2 h in each case. Candoxatril was well-tolerated; numbers of adverse events did not differ between active treatment and placebo. CONCLUSIONS: Although atrial natriuretic peptide levels were significantly increased, candoxatril 200 mg twice daily for 28 days did not produce a clinically relevant fall in blood pressure. Our results cast some doubt upon the role of neutral endopeptidase inhibition in the treatment of unselected hypertensive patients.

Antibody to Coxsackie B virus in diagnosing postviral fatigue syndrome.

OBJECTIVE: To study the association between coxsackie B virus infection and the postviral fatigue syndrome and to assess the immunological abnormalities associated with the syndrome. DESIGN: Case-control study of patients with the postviral fatigue syndrome referred by local general practitioners over one year. SETTING: General practitioner referrals in Dunbartonshire, Scotland. PATIENTS: 254 Patients referred with the postviral fatigue syndrome (exhaustion, myalgia, and other symptoms referable to postviral fatigue syndrome of fairly recent onset--that is, several months) and age and sex matched controls obtained from same general practitioner; 11 patients were rejected because of wrong diagnoses, resolution of symptoms, and refusal to participate, leaving 243 patients and matched controls. MAIN OUTCOME MEASURES: Detailed questionnaire (patients and controls) and clinical examination (patients) and blind analysis of blood sample at entry and after six months for determination of coxsackie B virus IgM and IgG antibodies and other variables (including lymphocyte protein synthesis, lymphocyte subsets, and immune complexes). RESULTS: Percentage positive rates for coxsackie B virus IgM at entry were 24.4% for patients and 22.6% for controls and for coxsackie B virus IgG 56.2% and 55.3% respectively; there were no significant differences between different categories of patients according to clinical likelihood of the syndrome nor any predictive value in a fourfold rise or fall in the coxsackie B virus IgG titre in patients between entry and review at six months. The rates of positive antibody test results in patients and controls showed a strong seasonal variation. Of the numerous immunological tests performed, only a few detected significant abnormalities; in particular the mean value for immune complex concentration was much higher in 35 patients and 35 controls compared with the normal range and mean value for total IgM was also raised in 227 patients and 35 controls compared with the normal range. CONCLUSIONS: Serological tests available for detecting coxsackie B virus antibodies do not help diagnose the postviral fatigue syndrome. Percentage positive rates of the antibodies in patients simply reflect the background in the population as probably do the raised concentrations of total IgM and immune complexes.

Adult celiac disease (celiac sprue), pernicious anemia and IgA deficiency. Case report and review of the relationships between vitamin B12 deficiency, small intestinal mucosal disease and immunoglobulin deficiency.

A 24-year-old man with addisonian pernicious anemia, adult celiac disease and selective IgA deficiency is presented to emphasize the differential diagnosis of vitamin B12 deficient megaloblastic anemia in association with small intestinal mucosal abnormalities and the relationships between immunoglobulin deficiency, pernicious anemia, and adult celiac disease.

Aspirin and bile acid induced gastric mucosal damage: protection by prostaglandins and antacids.

The importance of bile acids in causing gastric mucosal haemorrhage and the protective effect of prostaglandins and antacids has been studied in a series of studies using an animal model. Bile acids alone did not damage the gastric mucosa, but conjugated bile acids together with aspirin and hydrochloric acid may cause gastric mucosal haemorrhage. The prostaglandin analogue 15(R)15-methyl-E2 methyl ester protected the gastric mucosa against damage caused by conjugated bile acids together with aspirin or hydrochloric acid. Gastric mucosal protection was also achieved with antacids, but this effect appeared to be mainly on the aspirin rather than on the bile acid component of the damage. Bile acid binding, if it did occur, did not prevent the bile acid from increasing aspirin-induced gastric mucosal damage.

Coeliac disease associated with recurrent aphthae.

Fifty patients presenting sequentially with a history of recurrent aphthae were investigated for evidence of nutritional deficiencies and coeliac disease. In the group, two patients were found to have coeliac disease and their recurrent aphthae cleared soon after starting a gluten free diet. This study confirms the presence of an increased prevalence of nutritional deficiency and of coeliac disease in aphthous patients. However, it is recommended that jejunal biopsy be carried out in these cases only where there is evidence of malabsorption.

Small-intestinal changes induced by an elemental diet (Vivonex) in normal rats.

1. Rats were fed with the elemental diet Vivonex for 1 or 3 months and their jejunal histology was compared with that of an equal number of rats fed on a normal diet. 2. After 1 month of Vivonex feeding a significant reduction in the ratio of crypt height: villus height (CH:VH) was found in the Vivonex-fed rats (n = 4) compared with the control rats (n = 4) (P less than 0.05). 3. After 3 months the CH:VH ratio was also reduced in the Vivonex-fed rats (n = 18) compared with control rats (n = 18) (P less than 0.002). Villus height was significantly increased (P less than 0.002) and crypt height decreased (P less than 0.05). 4. Jejunal protein content, alkaline phosphatase and disaccharidase activity were also determined in 12 control and 12 Vivonex-fed rats from the 3 months study. 5. Alkaline phosphatase activity was increased from a control value of 201 +/- 8 to 243 +/- 15 munits/cm in the Vivonex-fed rats (n = 12) (P less than 0.05) but no significant changes in lactase, sucrase or maltase activites were found. The observed decrease in the CH:VH ratio suggested an improved survival of the mature enterocyte population during elemental diet feeding.

Cyclical release of vasoactive intestinal polypeptide (VIP) from a pancreatic islet cell apudoma.

A patient is described who presented with the classical symptomatology and profound electrolyte disturbance of the Verner-Morrison syndrome due to a pancreatic apudoma secreting vasoactive intestinal polypeptide (VIP). Diagnosis was confirmed by plasma VIP as measured by a radio-immunoassay technique now available. It is suggested that the cyclical nature of the symptoms in this case was due to cyclical release of VIP from the tumour in response to an unknown stimulus. Perfusion studies confirmed the excess secretory state of water, sodium and chloride in the small intestine. Symptoms were completely abolished by surgery and the progress is being monitored by means of serial plasma VIP estimations to detect any early recurrence of metastatic disease.

Cimetidine and prostaglandin: evidence for different modes of action on the rat gastric mucosa.

We have previously shown that the prostaglandin analogue 15(R)15 methyl-prostaglandin E2 methyl ester (Me-PGE2) when administered at a dose of 50 microgram per kg significantly inhibits aspirin-induced gastric mucosal erosions in the rat. In this study we have investigated the effect of cimetidine under similar circumstances. Cimetidine in a dose of 50 mg per kg significantly inhibited gastric mucosal erosions induced by aspirin (192 mg per kg) in the rat, reducing the incidence from 70% of 20 rats to 9.5% of 21 rats, the mean lesion score was reduced from 9.3 +/- 2.1 (mean +/- SEM) to 0.4 +/- 0.3. We then compared the effect of the above doses of Me-PGE2 and cimetidine on gastric erosions induced by aspirin (192 mg per kg) with the hourly addition of 160 mM HCl. The incidence of erosions in the aspirin + HCl group was 100% of 20 rats (mean lesion score 27.4 +/- 2.4). This was not significantly reduced by cimetidine, the incidence being 90% of 20 rats (mean lesion score 19.7 +/- 3.4). The incidence of erosions in the presence of Me-PGE2 was significantly less than that in both the other groups, 13% of 23 rats, (mean lesion score 3.1 +/- 0.8) P less than 0.01 in both instances. These results suggest that, whereas cimetidine protects the gastric mucosa through acid inhibition, Me-PGE2 appears to have a protective effect independent of acid inhibition.

Use of an elemental diet (Vivonex) in the management of bile acid-induced diarrhoea.

The effect of a low fat containing elemental diet (Vivonex) on faecal bile acid excretion was studied in six patients with cholerheic diarrhoea, two normal controls, and four patients with non-cholerheic diarrhoea. The total faecal bile acid excretion for the patients with bile acid-induced diarrhoea was significantly reduced fron 6-37+/- 1-64 mmol/24 h (mean +/- SEM) to 2-70 +/- 1-12 mmol/24 h during Vivonex treatment (p less than 0-05). A marked improvement in the diarrhoea of these patients occurred; the number of stools per day decreased and there was less urgency associated with the diarrhoea. No significant reduction in faecal bile acid excretion was observed for the control and non-cholerheic diarrhoea groups. An elemental diet of this type may be of value in the management of patients with bile acid-induced diarrhoea unresponsive to other forms of therapy, and may be of particular value in patients with Crohn's disease.

The effect of the synthetic prostaglandin analog 15 (R) 15 methyl-PGE2 methyl ester on gastric mucosal hemorrhage induced in rats by taurocholic acid and hydrochloric acid.

The incidence of mucosal hemorrhage induced in rats by the oral administration of taurocholic acid (TCA) and hydrochloric acid (HCl) both singly and in combination was investigated. The effect of prostaglandin 15 (R) 15 methyl-PGE2 methyl ester (Me-PGE2) on the occurrence of hemorrhage induced by TCA with HCl was also studied. The incidence of hemorrhage induced by TCA (10 mM) alone and HCl (160 mM) alone was minimal and not different from that induced by the control solution. The combination of TCA (10 mM) and HCl (160 mM) produced bleeding in 67.7% of animals. The addition of 15 (R) 15 methyl-PGE2 methyl ester (9.9 micronM, corresponding to 50 microng/Kg) significantly reduced the incidence of hemorrhage induced by the combination of TCA with HCl from 67.7% to 31.3%. This suggests that this synthetic prostaglandin may be of value in conditions thought to be associated with reflux of bile into the stomach.

Alcohol and absorption from the small intestine. 1. Impairment of absorption from the small intestine in alcoholics.

An absorption screen was performed in 10 chronic alcoholic patients within a few days of admission due to an acute alcoholic episode. Impaired absorption of d-Xylose was noted in three patients and low leucocyte ascorbic acid and serum folate levels in five. No abnormality was detected in jejunal histology. The absorption of water and electrolytes from the jejunum was studied in these patients using a triple-lumen tube perfusion system. The mean rate of absorption of water in the alcoholic subjects (50-0 +/- 2-3 ml/h) was significantly lower (P less than 0-001) than the mean value in 14 healthy control subjects (205 +/- 15-9 ml/h). A significant reduction of Na+ and Cl-absorption was also demonstrated in the alcoholic subjects. These results indicate that patients with acute-on-chronic alcoholism may have a function impairment of water and electrolyte absorption from the jejunum. This may, in part, account for some of the nutritional deficiencies in such patients and for symptoms such as diarrhoea which may be present.

Alcohol and absorption from the small intestine. 2. Effect of ethanol on ATP and ATPase activities in guinea-pig jejunum.

After the exposure of isolated segments of guinea-pig jejunum to 2% ethanol for one hour, a significant reduction (P less than 0-001) in the adenosine triphosphate content (ATP) was observed when compared with levels found in segments perfused with Krebs' solution. However, no alteration was noted in the activity of adenosine triphosphatase (ATPase). The chronic administration of 50% ethanol in a dose of 2-5 g/kg for two weeks did not affect either the ATP content or ATPase activity in jejunal mucosa.

Effect of prostaglandin 15(R) 15 methyl-E2 methyl ester on aspirin and taurocholic acid-induced gastric mucosal haemorrhage in rats.

The effect of orally administered prostaglandin 15(R)15 methyl-E2 methyl ester on aspirin and taurocholic acid-induced gastric mucosal haemorrhage has been studied in rats. The incidence of haemorrhage induced by aspirin (26-7 mM), 64 mg/kg, together with taurocholic acid (2-5 mM), was significantly reduced from 53-6% to 19-5% by the addition of the prostaglandin (9-9 muM), P less than 0.01. The incidence of haemorrhage induced by aspirin alone (53-3 mM), 128 mg/kg, was significantly reduced from 80% to 20% by the addition of prostaglandin (9-9 muM), P less than 0.002. These results indicate the possible use of synthetic prostaglandins in the prevention of aspirin-induced gastric pathology.