Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease.

It is often difficult to assess small bowel recovery in adults with coeliac disease on a gluten-free diet (GFD). This prospective study compares changes in intestinal permeability with changes in intestinal biopsy at various intervals after commencing a GFD. Intestinal permeability was measured by lactulose/rhamnose absorption from 1 week to 24 months after commencing a GFD. Intestinal morphometry was measured by villus area, crypt length and mitotic count per crypt at diagnosis and after commencing a GFD. Median intestinal permeability values decreased from 0.47 (n = 35) at diagnosis to 0.25 (n = 17) after 1 week and to 0.16 (n = 18) after 2 months of a GFD. Rhamnose absorption improved significantly at an early stage, from 6.6% (untreated) to 15.4% at 3 months of a GFD, whereas the decrease in lactulose permeation took longer: from 3.4% (untreated) to 0.8% after 12 months of a GFD. Mean villus area (n = 29) was reduced to 16% of control values at diagnosis, and improved to a maximum of 48% after 6 months on a GFD, but did not change thereafter. Mean crypt length and mitotic count per crypt were increased by 222% and 356% respectively at diagnosis, and these parameters remained elevated at 172% and 216% above control values after 6 months of a GFD. We conclude that intestinal permeability improves within 2 months after starting a GFD, but that measurable intestinal biopsy improvement requires ingestion of a GFD for at least 3-6 months, and even then remains incomplete.

Access to health care: a clinician's opinion about an ethical issue.

Is health care a social good, or is it a commodity? A trend to increase access to health care was initiated in the 1960s by the Social Security Act. The current prospective payment system has served to reverse the impact of the Social Security Act and has caused a clash between administrative and clinical decision makers. The physician's traditional pledge to place the patient's welfare first conflicts with the social reality of fiscal constraint, which is causing the rationing of patient care without public consensus. This article raises the issue of distributive justice in health care and points to the need for increased understanding of the nature of health care as a social good.

Psychological vulnerability to alcoholism: studies in internal scanning deficit.

Three studies considered the predispositional role of impaired internal scanning in alcoholism. Scanning represents the person's sensitivity to internal stimulation and the extent to which the person utilizes internally generated information. The first study found that more acute alcoholic patients displayed poorer scanning than more chronic alcoholics. This finding contra-indicates deficit scanning as an effect of alcoholism and suggests that this impairment antecedes the alcoholic disorder. Two further studies tested the possible antecedent status of deficit scanning. Adolescent wards of the juvenile court, judged to be more at risk for alcoholism, were poorer scanners than their counterparts with fewer drinking-related problems. Male college students with a greater number of alcohol-related problems also proved to be poorer scanners. It is proposed that limited scanning contributes to alcoholic vulnerability by depriving the person of information vital to the control of drinking behaviour.