The provision of CME meetings for physicians.

1. A large number of meetings on a wide variety of topics are available for a majority of consultant physicians. 2. Many meetings consist of lectures or presentations; more diverse and participatory learning methods are required. 3. The pharmaceutical industry provides sponsorship for 45% of all meetings, much more in some medical specialties. 4. It should be possible and easy to obtain information about approved educational events from a WEB page.

'Relapse' of chronic active hepatitis--not always what it seems.

Immune chronic active hepatitis is a disease notorious for its unpredictability. In a patient with chronic hepatitis who has already suffered relapses a search for a second cause of jaundice is not usually necessary. This report emphasises the essential role of liver biopsy.

Neurological complications of celiac disease: a rare but continuing problem.

Neurological complications are a recognized but unusual manifestation of celiac disease. We present here our experiences with four current cases. Age of patients at presentation with neurological signs varied from 7 to 67 yr. In one patient, the neurological disability developed before the diagnosis of celiac disease, whereas, in the other three, it occurred from months to 16 yr after the diagnosis had been established. One patient died of rapidly progressive neuromyopathy. The other three patients had combinations of cerebellar and posterior and lateral column abnormalities. All four patients developed neurological complications despite a strict gluten-free diet. In three of four patients, there was no improvement in duodenal histology on this diet. Treatment with vitamin B12, folic acid, or vitamin D failed to reverse the changes. No other nutritional deficiencies were found. Vitamin E levels were normal in two of three patients. One patient had no response to treatment with immunosuppressive drugs. The mechanisms responsible for these neurological complications are poorly understood, although patients whose duodenal histology fails to improve on a gluten-free diet may be at greater risk. There have been no real advances in the understanding of this condition since the original description nearly 30 yr ago.

CME and the role of the Journal of the Royal College of Physicians of London. Results of a survey of consultant and trainee physicians.

AIM: To assess (a) the views of Members and Fellows of the College on the role of reading general medical journals in continuing medical education (CME); (b) the place of the Journal of the Royal College of Physicians of London (JRCPL) in relation to seven other general medical journals; (c) the possible need for change in the content of the JRCPL and the demand for a systematic series of articles designed specifically for CME; (d) the extent of home ownership and use of computers and of readers' readiness for interactive teaching and electronic books and journals. METHOD: Distribution of a questionnaire to all Fellows and Collegiate members of the College, mailed with the JRCPL in May 1995. RESULT: Responses were received from 2,600 (26.4% home recipients and 8.4% overseas recipients). Journal reading was rated the most important form of CME. All eight journals listed play a part in CME, the three weekly journals playing the most prominent role. There was strong support for the introduction of a series of articles covering topics systematically as part of CME. Seventy-six per cent of respondents own a home computer and 40% of these have either a CD-ROM drive or full multimedia facilities. Most use their computers mainly as word-processors and few have access to the Internet or E-mail.

1895: Dr W G Grace's golden summer.

One hundred years ago there was another wonderful summer. Dr. W G Grace, England's greatest cricketer, in his 47th year, completed his "century of centuries" and scored 2346 runs. This remarkable achievement was celebrated with enthusiasm and affection by the Victorian public. In more practical terms generous testimonials raised 9073 pound sterling 8s 6d, which made it a golden summer in more ways than one.

Primary gastric lymphoma in clinical practice 1973-1992.

This study assessed the presentation, treatment, and prognosis of primary gastric lymphoma in general hospital practice and its relation to infection with Helicobacter pylori. The number of patients that would on the current recommendations have been suitable for H pylori eradication therapy was also examined. All lymphomas were graded according to a standard classification of gut lymphoma into high and low grade disease. Forty five patients (mean age 65 years) were identified. The overall five year survival was 40% with a trend in favour of an improved prognosis for low grade and stage I disease. H pylori was present in 80%. Only one of 18 patients with a low grade mucosa associated lymphoid tissue tumour had mucosal disease alone, which responded to omeprazole and amoxycillin. All other patients had bulk disease. These patients were treated by surgery, chemotherapy or radiotherapy or a combination of these treatments. In district hospital practice, most cases of primary gastric lymphoma have bulk disease at presentation. Even in patients with low grade gastric lymphoma on histological examination, many on the current evidence would not be suitable for anti-H pylori therapy alone.

Functional hyposplenism following allogeneic bone marrow transplantation.

AIMS: To investigate the incidence of functional hyposplenism in a group of patients who had undergone allogeneic bone marrow transplantation (BMT). METHODS: Splenic function was assessed by counting the number of gluteraldehyde fixed red blood cells containing pits or indentations as examined by interference phase microscopy. Normal values are < 2% whereas splenectomy patients have values of 25 to 40%. RESULTS: Twenty eight BMT recipients (17 men, 11 women) were studied at varying periods post-transplant and the results compared with 20 healthy volunteers and 10 patients who had undergone splenectomy or had splenic atrophy because of haematological conditions. Of the 28 BMT recipients, one had undergone a prior splenectomy; of the remaining 27 patients, four (15%) had evidence of functional hyposplenism with between 5.0 and 34.0% pitted cells. Of these four patients, one had active extensive chronic graft versus host disease (GvHD) which has been previously reported to be associated with functional hyposplenism following transplantation. Only one of the four patients had peripheral blood red cell changes typical of hyposplenism. CONCLUSION: These results confirm that extensive chronic GvHD is associated with hyposplenism. Intermediate degrees of functional hyposplenism may also occur following BMT in the absence of chronic GvHD and in the absence of haematological features of hyposplenism on routine blood films. This may be of significance in mediating the susceptibility to infection with encapsulating bacteria seen following allogeneic BMT.

Functional hyposplenism in alcoholic liver disease: a toxic effect of alcohol?

Functional hyposplenism, seen in some patients with alcoholic liver disease, may contribute to the increased susceptibility to infections. As hyposplenism does not complicate non-alcohol related chronic liver disease, it is probably secondary to a toxic effect of alcohol. Over a two year period the case notes of 82 patients with alcoholic liver disease, whose splenic function had been assessed by the counting of pitted erythrocytes using differential interference microscopy, were reviewed to monitor mortality and the effects of hyposplenism. Thirteen patients (seven with hyposplenism) had serial measurements of pitted erythrocyte count made to assess the effect of abstinence from alcohol on splenic function. Thirty one of the 82 alcoholic patients had pitted erythrocyte counts greater than 2%. Eighteen of 82 (16%) patients died over the two years and 11 of these had been unable to stop drinking. Only one patient died of sepsis. Five patients (6%) had pitted erythrocyte counts comparable with those in splenectomised patients. In 12 of 13 patients who had abstained from alcohol for two months, the pitted erythrocyte count fell from a median of 3 to 1.3% (mean: 8.1 to 2.6%. p = 0.01). The pitted red cell count in two patients increased. One had abstained, the other had continued to drink heavily. Short term mortality in alcoholics is high, particularly if they continue to drink heavily. Only a few of these deaths are secondary to infection. Splenic function, as assessed by these methods, improves in most patients with abstinence, suggesting that the functional hyposplenism may be a result of a direct toxic effect of alcohol on the spleen.