In a three-year controlled trial of subcutaneous catheter tunnelling as a method of reducing total parenteral nutrition (TPN) catheter sepsis 99 silicone catheters (52 tunnelled, 47 untunnelled) were inserted into the subclavian (94%) or jugular (6%) veins under aseptic conditions. The influence of a nutrition nurse, who joined the nutrition team after 18 months, on catheter sepsis rate was also documented. Catheter sepsis was confirmed in 13 of 47 (28%) untunnelled catheters and only 6 of 52 (11.5%) tunnelled catheters (p less than 0.05). A nutrition nurse reduced sepsis rate from 33% (tunnelled 6, untunnelled 11) to 4% (0 tunnelled; 2 untunnelled) (p less than 0.001). There was no significant difference between tunnelled and untunnelled catheters in sepsis rates after the arrival of the nutrition nurse. Although 85% patients had concurrent internal sepsis, the pathogens implicated in catheter sepsis came from superficial sites in 16 of 19 cases (p less than 0.01). Rigorous aseptic nursing care is thus the most significant factor in the reduction of TPN catheter sepsis, but tunnelling can reduce sepsis rate when nursing care is suboptimum.

12 patients with troublesome hot flushes after orchidectomy (as a primary treatment for prostatic carcinoma) were treated with cyproterone acetate or placebo in a double-blind cross-over trial. The frequency of hot flushes was significantly reduced during the three weeks that cyproterone acetate (100 mg three times a day) was given. 5 patients complained of lassitude while on cyproterone acetate, but in none was it necessary to discontinue treatment.

The role of sclerotherapy in long-term management after oesophageal variceal bleeding was assessed by comparing repeated sclerotherapy by means of a rigid oesophagoscope in 37 patients with control medical management in 38 patients. Varices were eradicated in 21 of the 22 patients analysed (95%) in the sclerotherapy group, but recurred in 13 of the 21 patients (average 21.5 months). Varices persisted in 13 of 14 surviving controls. The sclerotherapy patients had fewer recurrent bleeds than control patients (43 versus 73); the majority occurred before variceal eradication and were mild. However, there was no difference in survival in the two groups. The commonest cause of death was liver failure (37 patients). 32 complications occurred in 24 patients during 258 injections. Repeated sclerotherapy failed to improve survival in this trial, although varices were eradicated and recurrent variceal bleeds were prevented with adequate follow-up.

The efficacy of a heat-inactivated hepatitis B vaccine, 3 micrograms of surface antigen (HBsAg), given at 0, 1, 2, and 5 months, was evaluated in 401 haemodialysis patients in 18 centres by a placebo-controlled, double-blind, randomised trial. The attack-rate of hepatitis B virus (HBV) infections in the control group was 18% over 435 days. The protective efficacy rate of the vaccine was 78% against all HBV infections in the entire study (p = 0.00016), and 94% against HBsAg-positive hepatitis more than 3 months after day 0. Those patients in whom HBV developed showed no evidence of vaccine-acquired anti-HBs. Among 152 similarly randomised staff members receiving three monthly injections, all 5 HBsAg-positive infections occurred in the placebo group (p = 0.022). The vaccine induced anti-HBs in 88% of the patients and 100% of the staff. Immediately after the fourth injection, anti-HBs levels were as high in responding patients as in staff. There were no serious side effects. In the four-dose schedule the vaccine provides dialysis patients with protection of the same order as that given by other hepatitis B vaccines to normal subjects.

Although osteomalacia is known to be common in some sections of the elderly population, the disease is often subclinical and there is uncertainty about the point at which treatment is necessary. Identification and treatment of osteomalacia are inseparably bound; the response of varying degrees of subclinical disease to treatment with vitamin D or alfacalcidol is described here. The response is assessed in relation to a simply derived reference range based on standard biochemical measurements together with a Jamshidi needle biopsy of the iliac crest. Although this technique does not define a truly normal range it identifies a treatable abnormality which could form the basis of further study of the problem of subclinical osteomalacia in the elderly.

Vasoactive intestinal peptide (VIP) caused significant bronchodilatation in seven asthmatic volunteers when given intravenously at the rate of 6 pmol/kg/min for 15 min during a double-blind study. Tachycardia and cutaneous flushing were observed during the infusion. VIP also ameliorated histamine-induced bronchoconstriction in all subjects. VIP may be an important natural bronchodilator in man and this has implications for the pharmacotherapy of asthma.

A double-blind randomised trial was carried out in 60 infants with a birth-weight of less than 1500 g or a gestational age below 31 weeks. 30 infants received phenobarbitone (20 mg/kg) within 4 h of birth and 30 infants received a placebo. The two groups of infants were similar in birth-weight, gestational age, frequency of vaginal delivery, sex, Apgar scores, ventilator dependence before the injection, pneumothorax, hypercapnia, and acidosis. Cranial ultrasound scans were carried out daily for 14 days. 12 out of 30 phenobarbitone-treated infants and 11 out of 30 placebo-treated infants had PVH, with parenchymal haemorrhages in 2 of the placebo group. Plasma phenobarbitone was over 15 micrograms/ml in 28 out of 30 of the phenobarbitone-treated infants during the first 72 h. 7 out of 17 spontaneously breathing infants became ventilator-dependent within 12 h of the phenobarbitone injection, whereas only 1 of 18 spontaneously breathing placebo-treated infants became ventilator-dependent within 12 h of injection. Although the possibility of protection against parenchymal haemorrhages may justify further investigation, there is no justification for administration of 20 mg/kg of phenobarbitone to all infants below 1500 g.

A randomised blind controlled trial of hepatitis B immune globulin (HBIG) plus hepatitis B vaccine for the prevention of the perinatally transmitted HBsAg carrier state was conducted in Taipei. Infants of e-antigen-positive HBsAg carrier mothers were given HBIG immediately after birth, and then one of three schedules of vaccination. There was no difference in efficacy between the three schedules; the combined efficacy was 94%, compared with that of HBIG alone (71%) or of vaccination alone (75%). Persistent HBs antigenaemia developed in only 9 (6%) of the 159 infants receiving prophylaxis, but in 88% of the controls. Antibodies developed in all those who did not become antigenaemic and presumably will provide long-term protection from hepatitis B virus infection. HBIG should be given as soon as possible after birth and need not be given again if the infant is subsequently vaccinated. With HBIG coverage from birth, the timing of the start of vaccination does not seem to be of importance within the first month of life, but to maximise compliance and minimise costs hepatitis B vaccination should be initiated during the confinement.

101 patients with Clostridium-difficile-associated diarrhoea or colitis were prospectively randomised to 10-day oral courses of metronidazole, 250 mg four times a day, or vancomycin, 500 mg four times a day. 7 did not complete the protocol and were dropped from analysis. Pseudomembranous colitis (PMC) was diagnosed after endoscopy in 33 patients. Of the remaining patients without PMC, 38 had both C difficile culture and cytotoxin and 23 had only culture evidence of C difficile. 52 evaluable patients received vancomycin and 42 received metronidazole. There were two treatment failures with metronidazole and none with vancomycin (p = 0.20); and two relapses with metronidazole versus six with vancomycin (p = 0.17). Treatment in 1 patient in each group was discontinued because of drug intolerance. Response and relapse rates of the 33 patients with PMC were no different from those of the remaining patients. Pharmacy cost for the dosage used was $387.48 to $520.00 for vancomycin and $11.84 for metronidazole. Metronidazole and vancomycin have equivalent efficacy and relapse rates and are tolerated to a similar extent by patients with C-difficile-related diarrhoea and colitis, but metronidazole is considerably more economical.

The effectiveness of two rubella vaccines (RA 27/3 and Cendehill) in women vaccinated post partum was compared. Significantly more women who received RA 27/3 gave satisfactory seroconversion responses than women who received Cendehill (97.6% vs 82.2%). This difference was reflected in the geometric mean titres (43.6 vs 17.0). More women who received RA 27/3 had minor side-effects, but the difference was not significant. The serological response to both vaccines was not affected by the concurrent administration of anti-D immunoglobulin. In view of these findings, the replacement of Cendehill vaccine with RA 27/3 vaccine for women vaccinated post partum should be considered.

In a multicentre trial conducted in eight European centres, 232 recipients of cadaveric renal allografts were randomly allocated to receive either cyclosporin (117 patients) or azathioprine and steroids (115 patients) for immunosuppression. All patients have now been followed up for at least a year. 1-year graft survival was 72% in the cyclosporin group and 52% in the control group. 24 of the 84 patients in the cyclosporin group with functioning grafts at 1 year had been changed to azathioprine and steroids, and 1 patient had had prednisolone added to cyclosporin therapy; the other 59 patients were receiving cyclosporin as their sole immunosuppressive agent. 16 patients on cyclosporin treatment never received steroids. 1-year patient survival was 94% in the cyclosporin group and 92% in the control group. There was no difference between the two treatment groups in the prevalence of infection. Lymphoma did not develop in any patient. At 1 year post-transplantation, renal function was poorer in patients on cyclosporin than in those on conventional therapy. Thus the 1-year graft-survival rate is higher with cyclosporin alone as a first-line immunosuppressive agent than with azathioprine and steroids.

34 very low birthweight babies (mean 1143 g) in incubators were randomly assigned to be continuously nursed on lambswool (n = 17) or ordinary cotton sheets (n = 17). The weight gain for the periods when babies were well was significantly larger for the wool group, 22.7 g/day vs 18.6 g/day for cotton control (p less than 0.02). The overall weight gain (which included weight change during periods of illness) revealed a similar picture in favour of the wool group, 21.5 g/day vs 18.2 g/day (p less than 0.05). Movement patterns for the two groups showed no differences, but for all babies a strong correlation was noted between moving and lying suspine (p less than 0.001), having eyes open (p less than 0.001), a cooler incubator (p less than 0.01), and faster weight gain (p less than 0.01). Lambswool seems to have advantages over cotton sheets as a bedding material for very low birth weight babies.