Data from 634 patients who received HLA-identical bone-marrow transplants for acute lymphoblastic leukaemia in first or second remission were analysed to examine the influence of mode of prophylaxis against graft versus host disease on rate of relapse of leukaemia. Methotrexate was associated with a significantly lower risk of leukaemia recurrence than were other methods of GVHD prophylaxis (relative risk 0.2, p less than 0.0003, for first-remission transplants; relative risk 0.3, p less than 0.0001, for second remission transplants). The decreased risk of relapse did not seem to be mediated via an impact on incidence or severity of graft versus host disease. A direct antileukaemia effect of methotrexate is the most likely mechanism.

In 434 operations for valvular heart disease, patients were randomised to receive Björk-Shiley, Edwards-Duromedics, or Medtronic-Hall mechanical prostheses. At a median follow-up time of 37.5 months there were no differences in hazard of death or non-embolic events. In the first six postoperative months the incidence of thromboembolism was about the same for the three valves. Subsequently, however, the incidence of thromboembolism for the Edwards-Duromedics valve was 3.9 times higher than for the Björk-Shiley valve, and for the Medtronic-Hall valve 2.6 times higher than for the Björk-Shiley valve.

In a multicentre study the accuracy of echocardiography was measured in 164 consecutive patients with suspected aortic dissection. The diagnosis was subsequently proven (82 patients) on the basis of transthoracic and transoesophageal echocardiography and additional diagnostic procedures, including computed tomography (CT), aortic angiography, and surgery and/or necropsy. The sensitivity and specificity of echocardiography were 99% and 98%, respectively, with positive and negative predictive values of 98% and 99%. For CT sensitivity was 83%, specificity 100%, and positive and negative predictive values 100% and 86%, respectively. For aortography sensitivity and specificity were 88% and 94%, and the positive and negative predictive values 96% and 84%, respectively. Echocardiography, including the transoesophageal route, can provide accurate diagnosis of aortic dissection within 15 min. Diagnostic difficulties occur only in a few type II dissections, when complementary diagnostic procedures, including CT or angiography, may be needed. To clarify branch involvement angiography is required.

33 patients with refractory irritable bowel syndrome were treated with four 40-minute sessions of hypnotherapy over 7 weeks. 20 improved, 11 of whom lost almost all their symptoms. Short-term improvement was maintained for 3 months without further formal treatment. Hypnotherapy in groups of up to 8 patients was as effective as individual therapy.

235 infants of HBeAg-carrier mothers in Hong Kong were assigned to four study groups. Groups I, II, and III received hepatitis-B (HB) vaccine at birth and at 1, 2, and 6 months. Group I also received seven monthly injections of HB immunoglobulin (HBIg), and group II received one HBIg injection at birth. Group III received vaccine only and group IV received placebo for both vaccine and HBIg. At the age of 3 years, all infants of the three treatment groups were significantly protected against the HB virus (HBV) carrier state compared with the placebo group (p less than 0.0001); the protective efficacy rates in groups I, II, and III were 87%, 80%, and 65%, respectively. At all times, group I was significantly better protected than group III. In groups III and IV, infants of mothers with serum HBV DNA levels of 5 pg/ml or above were at a significantly higher risk of acquiring the HBV carrier state than those whose mothers had HBV DNA levels below 5 pg/ml. This difference was not significant in groups given HBIg. Of the 183 infants who initially escaped HBV infection, 73 (40%) had transient and 8 (4%) chronic HBV infection between 6 and 36 months. Vaccinated infants who had actively formed anti-HBs remained well protected against the HBV carrier state. However, infants in groups I and II with no active anti-HBs response to vaccine became at risk for the HBV carrier state when the passively acquired anti-HBs antibodies had disappeared. HBIg should be included in HB vaccination schedules for all infants of HBeAg-positive mothers.

30 patients (10 normotensive, 20 hypertensive) with stable angina and positive treadmill exercise tests entered a double-blind, placebo-controlled crossover trial of metoprolol, 100 mg twice daily. At the end of each treatment phase, blood pressure was monitored for 24 h and Holter and real-time electrocardiographic (ECG) monitoring were carried out and an activity diary kept for 48 h. Blood samples for catecholamine measurement were taken after 30 min supine, 60 min standing, and at the first silent ischaemic event, triggered by the real-time ECG monitor, by means of an ambulatory blood withdrawal pump. Metoprolol lowered blood pressure and heart rate in both normotensive and hypertensive subjects, and reduced the frequency and duration of silent ischaemic episodes in hypertensive subjects. Plasma noradrenaline measured during silent ischaemia while the patients were resting was significantly higher than the control supine level without ischaemia. These findings suggest that noradrenergic hyperactivity may have a role in coronary vasoconstriction and that treatment which neutralizes sympathetic tone may be especially beneficial in treatment of silent ischaemia in hypertensive patients.

111 untreated subjects (mean [SEM] age 58.4 [1.0] years; 93 male, 18 female) with diastolic blood pressure between 90 and 100 mm Hg were seen fortnightly, and after four pre-diet visits they were randomised into a low sodium intake group (53 subjects; diet containing less than 80 mmol sodium/day plus 8 placebo tablets daily) or a normal sodium intake group (55 subjects; same dietary sodium plus 8 slow-release sodium chloride [10 mmol] tablets daily). 103 subjects completed the intervention phase of 8 weeks. Urinary sodium fell significantly in the low sodium group but not in the normal sodium group. Urinary potassium excretion did not change in either group. Mean (SEM) systolic and diastolic blood pressure fell by 6.1 (1.1) and 3.7 (0.6) mm Hg, respectively, in the low sodium group, but by only 0.6 (1.0) and 0.9 (0.6) mm Hg in the normal sodium group. Multivariate analysis allowing for the effects of pre-diet blood pressure, weight, and age, reduced the effect of lowering the sodium intake on the systolic pressure from 5.5 (SEM 1.5) mm Hg to 4.8 (1.3) mm Hg (p less than 0.005) but the effect on diastolic pressure was not changed significantly.

1439 Dutch children were included in a randomised trial to evaluate the efficacy of preschool screening for otitis media with effusion (OME) by 3-monthly tympanometry. Children with bilateral OME on two consecutive occasions were referred for further investigation and then, if parents gave their consent, allocated at random to treatment or non-treatment groups. The effect of childhood screening for OME and subsequent treatment was evaluated by assessment of language performance; no benefit was found, mainly because of the large degree of spontaneous recovery.

A series of experiments showed that, on exercise of the inflamed human knee, intra-articular pressure rises above synovial capillary perfusion pressure, causing intra-articular hypoxia; and that, on cessation of exercise, there is oxidative damage to lipids and IgG within the joint. These findings are consistent with the hypothesis that persistence of synovial inflammation can be due to exercise-induced hypoxic-reperfusion injury mediated by reactive oxygen species.