The efficacy of Nd-YAG laser photocoagulation in the endoscopic control of haemorrhage from peptic ulcers was shown in a controlled trial. 527 patients admitted consecutively with acute upper gastrointestinal haemorrhage underwent urgent endoscopy. Peptic ulcers were seen in 260. All 138 ulcer patients with stigmata of recent haemorrhage (SRH) accessible to laser therapy were included in the trial (26 inaccessible, 96 no SRH). Patients were stratified into three groups--those with a visible vessel, those with other SRH, and those with clot that could not be washed off before therapy. Laser and control groups were well matched for other factors known to influence prognosis. Overall, 7/70 laser-treated and 27/68 control ulcers rebled (p less than 0.001). Rebleeding occurred from 6/39 treated and 23/43 control ulcers with a visible vessel (p less than 0.001); 0/17 treated and 1/13 ulcers with other SRH (NS); and 1/13 treated and 2/11 control ulcers with overlying clots (NS). 7/70 treated but 24/68 controls required emergency surgery (p less than 0.005). 1 treated patient but 8 control patients died after an episode of rebleeding (p less than 0.05).

The effect of sulindac on renal function and blood pressure was compared with those of placebo, piroxicam, and naproxen in 20 patients with primary hypertension being treated with a diuretic and a beta-blocker. Although the three non-steroidal anti-inflammatory drugs (NSAIDs) did not differ in their effect on renal function (weight, glomerular filtration rate, creatinine clearance) or on serum thromboxane and plasma 6-keto prostaglandin F1 alpha (6-keto PGF1 alpha), blood pressure was significantly lower with sulindac than with placebo, piroxicam, or naproxen. These differences were associated with less renal cyclooxygenase inhibition by sulindac (reflected by urinary thromboxane B2 and 6-keto PGF1 alpha) than by other NSAIDs. The findings suggest that the blood pressure differences reflect vasodilation due to differences in the balance between systemic and renal effects of the NSAIDs.

To determine whether health outcomes in a health maintenance organisation (HMO) differed from those in the fee-for-service (FFS) system, 1673 individuals ages 14 to 61 were randomly assigned to one HMO or to an FFS insurance plan in Seattle, Washington for 3 or 5 years. For non-poor individuals assigned to the HMO who were initially in good health there were no adverse effects. Health outcomes in the two systems of care differed for high and low income individuals who began the experiment with health problems. For the high income initially sick group, the HMO produced significant improvements in cholesterol levels and in general health ratings by comparison with free FFS care. The low income initially sick group assigned to the HMO reported significantly more bed-days per year due to poor health and more serious symptoms than those assigned free FFS care, and a greater risk of dying by comparison with pay FFS plans.

Left ventricular end-diastolic pressure (LVEDP) measured at cardiac catheterisation and simultaneous mitral flow patterns obtained by pulsed Doppler ultrasound scanning were assessed in twenty patients (fourteen males) with ischaemic heart disease. The ratio of passive and active components of mitral flow showed a significant linear correlation with LVEDP. Active (left atrial) mitral flow diminished as left ventricular end-diastolic pressures increased. Mitral flow ratios greater than 2 were always associated with LVEDP greater than 20 mmHg. This application of Doppler echocardiography provides a simple non-invasive method of estimating LVEDP.

The effect of acetazolamide (Az) on exercise performance and muscle mass in acclimatised subjects at an altitude of 4846 m was assessed in 11 subjects and compared with the effect of placebo on 10 other subjects. Exercise performance at 85% maximum heart rate fell by 37% in the Az group and by 45% in controls (p less than 0.05). Weight loss was greater in the placebo group at high altitude (p less than 0.01) and this correlated with the fall in exercise performance (p less than 0.001). During the expedition anterior quadriceps muscle thickness fell by 12.9% in the control group and 8.5% in the Az group (p less than 0.001), while biceps muscle thickness fell by 8.6% in controls and 2.3% in the Az group (p less than 0.001). Measurements of skin-fold thickness indicated a loss of 18% of total body fat in the placebo group and 5% in the Az group by the end of the expedition (p less than 0.001). Calorie intakes at altitudes above 3000 m were low and similar for the two groups. The Az group had fewer symptoms of acute mountain sickness but differences between the two groups were not statistically significant. Acetazolamide is therefore useful for climbers and trekkers who are acclimatised to high altitudes. It could be most useful at extreme altitudes, where maintenance of exercise performance and muscle mass are important.

The vast majority of adverse reactions following immunisation of children with live measles-mumps-rubella (MMR) vaccine were shown in a double-blind, placebo-controlled, cross-over study in 581 twin pairs to be only temporally but not causally related to the vaccination. The true frequency of side-effects caused by MMR vaccine, estimated from the discordance rates of individual signs and symptoms between MMR vaccinees and their placebo-injected twins, was between 0.5 and 4.0%. Moreover, respiratory symptoms, nausea, and vomiting were observed more frequently in the placebo-injected group than in the MMR vaccinated group.

In 12 pregnant mothers fetal sounds and infrasounds were recorded by means of a new compliance matched transducer and compared with a simultaneous ultrasound record of fetal activity. A defined pattern on the fetal phonograph correlated with 86% of the total fetal breathing detected with ultrasound, and a further distinctive pattern was associated with 90% of fetal movements. Examination of the fetal phonocardiogram when the fetus was breathing showed a significant increase in the short-term variability of both the systolic and diastolic times when compared with non-breathing episodes. The median amplitude variabilities for both the first and the second heart sounds were also significantly increased during fetal breathing. Measurement of fetal sounds and infrasounds with a compliance matched transducer offers a non-invasive method for assessment of fetal activity for long periods of time.

In a double-blind, placebo-controlled study, 252 prepubertal boys with 301 undescended testes were treated with luteinising-hormone-releasing-hormone (LHRH), 1.2 mg/day intranasally. After the 8-week double-blind period 10 placebo-treated (8%) and 14 LHRH-treated (9%) testes had completely descended. After a second LHRH course, involving all the subjects in an open study, 48 testes (18%) had descended completely. The lowest success rate (7%) occurred in the youngest age group (1-2 years). Of the successfully treated testes, 75% could be manipulated at least to the scrotal entrance before treatment. In comparison with age-matched controls, the cryptorchid boys' responses to LHRH and human chorionic gonadotropin before treatment did not suggest a deficient hypothalamo-pituitary-gonadal axis or deficient Leydig cell function. After treatment there was no evidence of stimulation of the hypothalamo-pituitary-gonadal axis; serum testosterone did not increase. Surgery was required in 170 patients (196 testes) revealing various anatomical anomalies.

Enalapril, atenolol, and hydrochlorothiazide were compared in a double-blind randomised parallel study in general practice. 436 patients with mild to moderate hypertension were included at 76 centres. A two-week placebo run-in period was followed by 16 weeks of monotherapy. The initial doses were: enalapril 20 mg; atenolol 50 mg; and hydrochlorothiazide 25 mg. These were doubled if treatment was not effective after 4 weeks. Adverse reactions were the main reason for withdrawal from the study (9 on enalapril, 19 on atenolol, and 8 on hydrochlorothiazide). Systolic and diastolic blood pressures were significantly reduced in all three groups. The reduction in systolic blood pressure was greater on enalapril than on atenolol. Serum potassium was reduced and uric acid increased on hydrochlorothiazide. Fasting blood sugar rose on atenolol but fell on enalapril. The frequency of adverse reactions was acceptable in all three groups. After 16 weeks on treatment significantly more adverse reactions were recorded in the atenolol group than in the enalapril group. Enalapril is effective and well tolerated in patients with mild to moderate hypertension.

In a randomised controlled evaluation of multifactorial prevention of coronary heart disease (CHD) among 60 881 men employed in 80 factories in Belgium, Italy, Poland, and the UK intervention was associated with reductions of 10.2% in total CHD, 6.9% in fatal CHD, 14.8% in non-fatal myocardial infarction, and 5.3% in total deaths, with a neutral result for non-CHD deaths. Benefit was significantly related to the extent of risk factor change. The observed reduction in total CHD was 62% of that predicted by means of a multiple logistic function summary of risk factor changes. Advice on risk factor reduction in middle-aged men is effective to the extent that it is accepted and it appears to be safe.