In 28 of 53 patients with a palpable abdominal mass computed tomography (CT) was used as the initial imaging technique, and conventional imaging was used in the remaining 25 patients. The diagnosis was established more quickly in the CT group, and the period of inpatient investigation was shorter. The cost of imaging investigations was higher for the CT group, but this difference was small when compared with the difference in cost of inpatient stay. CT seems accurate in the investigation of a palpable abdominal mass and particularly useful in excluding a pathological cause. The need for the latter is emphasised by the fact that no lesion could be found in 23 of the 53 patients.

In a placebo-controlled, cross-over study, thirty-seven puerperal women with inadequate production of breast-milk were treated with 5, 10, or 15 mg of metoclopramide three times a day for 2 weeks. Doses of 10 or 15 mg significantly raised maternal serum prolactin; they also increased breast-milk secretion by 42.5 +/- 34.7 (SD) ml and 50.0 + 35.9 ml per feed, respectively. This effect was unrelated to the phase of the puerperium during which treatment was started. The increase in milk secretion was associated with a decreased need for supplementary feeds, and 33% of the infants of these mothers needed no supplementary feeds during treatment. 5 mg doses did not stimulate prolactin milk secretion. Although placebo had no objective effect on the milk yield, 24% of the women judged its effect to be good, and 89% of women on metoclopramide reported a good effect. Seven women on metoclopramide and three women on the placebo complained of slight side-effects. No adverse effects upon the infants were observed. Metoclopramide therapy may be useful for improving poor lactation.

Twelve patients with the dumping syndrome took on one occasion oral hypertonic glucose and on another a similar glucose drink to which pectin was added. After glucose alone eleven patients had symptoms; after glucose with pectin, six had no symptoms and in five symptoms were reduced. Plasma volume changes were significantly less after glucose with pectin, and the hypoglycaemia at 120 min after glucose alone did not occur after glucose with pectin in patients in whom symptoms were abolished. Gastric emptying was prolonged, and serum insulin levels were lower, after glucose with pectin. In those patients to whom gastric emptying rate reverted to near normal with pectin, symptoms were abolished, but symptoms were only reduced in number when gastric emptying, although slowed, remained rapid. The findings suggest that pectin and similar substances may be useful in the day-to-day management of patients with dumping symptoms.

The imidazole derivative UK-37 248, a thromboxane synthetase inhibitor, reduces the in-vitro formation of thromboxane B2 and hydroxyheptadecatrienoic acid by washed platelets, and this is compensated for by an increased production of prostaglandins E2 and F2 alpha; arachidonic acid challenged platelets pretreated with UK-37 248 also stimulate the production of prostacyclin by aspirin pretreated cultured endothelial cells. In a double-blind placebo controlled study to examine the in vivo properties of UK-37 248, human volunteers ingested 200 mg of the compound. Their serum thromboxane B2 levels dropped and their plasma 6-keto-prostaglandin F1 alpha values rose. Arachidonic acid induced platelet aggregation was completely inhibited whereas that elicited by adenosine-5'-diphosphate was unaffected. By reducing formation of pro-aggregatory tromboxane A2 and increasing production of anti-aggregatory prostacyclin, thromboxane synthetase inhibitors may be better than aspirin as antithrombotic agents.

Four treatments for sciatic symptoms--traction, exercises, manipulation, and corset--were assessed in a randomised controlled trial in 322 outpatients. The design was factorial. There were thus sixteen treatment groups, enabling a comparison of combinations of methods as well as of individual methods. Treatment lasted for four weeks. Patients were reviewed at the end of this period and at four and sixteen months after entry to the trial. Progress was measured by the patient's account of symptomatic improvement or deterioration and by return to work or normal activities. At four weeks each of the treatments was associated with a small degree of benefit over and above the high rate of spontaneous improvement. For manipulation, the benefit was statistically significant on one of the scales used to measure progress. There was a significant increase in symptomatic improvement with increasing numbers of treatments used in combination. This was complemented by a clear tendency for those who had received fewer types of treatment during the trial to have further treatment in the ensuing three months. There were no beneficial effects of treatment detectable at four or sixteen months. In the short-term, active physiotherapy with several treatments appears to be of value in the outpatient management of patients with sciatic symptoms, but it does not seem to confer any longer-term benefit.

30 patients with active classical rheumatoid arthritis affecting the knee took part in a 12-week double-blind trial in which intra-articular injections of orgotein (4 mg/week for 6 weeks) were compared with intra-articular aspirin 4 mg/week for 6 weeks. After 12 weeks clinical and biochemical assessments showed that orgotein was superior to aspirin. Clinical response was measured in terms of the cumulative rheumatoid activity index (RAI) which was based on scores for morning stiffness, range of flexion, pain and 25-foot (7.5 m) walking time. Treatment with orgotein resulted in significant improvement of the RAI; the improvement correlated with findings on knee-joint scanning which showed reduced mean uptake of 99mTc-pyrophosphate. After intra-articular orgotein injections, synovial fluid IgM and IgG rheumatoid factor levels fell significantly; so did prostaglandin E2 formation and lactate dehydrogenase activity. The changes in the synovial fluid suggest that the anti-inflammatory properties of orgotein may lie in its effect on proliferating synovia.

The capacity of venous tissue for prostacyclin synthesis was determined in 68 patients undergoing surgery for removal of varicose veins. A single dose of aspirin (81 mg or 300 mg) taken 14 h preoperatively strongly inhibited its synthesis, and the effect of 300 mg was still evident 48 h after ingestion. A single dose of 40 mg aspirin taken 14 h preoperatively had no effect on prostacyclin synthesis. The capacity of blood platelets to synthesise thromboxane (measured as malondialdehyde) was determined in volunteers before and at various times after ingestion of 300 mg or 40 mg aspirin. Both doses had an inhibitory effect that lasted for at least 96 h. The length of time for which the amount of thromboxane synthesised was insufficient to support platelet aggregation and the platelet release reaction depended on both the donor and the dose of aspirin. If prostacyclin and thromboxane are important in the pathogenesis of thrombosis, then doses of aspirin much lower than those used previously should be tested. The long-lasting effect of 300 mg aspirin on both venous tissue and platelets indicates that this dose is unlikely to produce a favourable prostacyclin/thromboxane balance.

In a multicentre trial to compare the ability of a combination of acetylsalicylic acid and dipyridamole (1050 mg + 150 mg/day, group A) to prevent recurrence of transient ischaemic attacks (TIA) with that of pentoxifylline (1200 mg/day, group B), 36 patients received the combination and 30 pentoxifylline. There was no statistically significant difference between the groups as regards age, sex, blood pressure, site of origin of TIA, and incidence of other risk factors. The incidence of recurrent TIAs during 1 year of follow-up was 28% in group A and 10% in group B; this difference was significant (p less than 0.05). The incidence of permanent strokes was similar in the two groups but distinctly lower (4.5%) than that usually reported after untreated TIA.

Placebo or propranolol was given randomly of two groups of 12 adults with cirrhosis who had recently held from oesophageal or gastric varices or from acute gastric erosions. During three months' follow-up 5 patients in the placebo and none in the propranolol group had recurrent gastrointestinal bleeding.

The effect of oxygen on breathlessness and exercise tolerance was examined in "pink and puffing" patients with fixed airways obstruction. When breathing oxygen, patients were less breathless and walked further. This was true whether the cylinder was carried by the patient or by an assistant. It was not possible to identify those patients who would benefit most. The best method of assessing improvement was by comparing breathlessness on a standardised progressive exercise test on a treadmill. Four patients had a greater than 30% reduction in breathlessness on submaximum exercise when breathing oxygen. Breathing oxygen for five or fifteen minutes before exercise but not during exercise (predose) resulted in a similar improvement in exercise tolerance. For short periods of exercise predosing with oxygen provides a convenient alternative to continuous oxygen. For longer periods of exercise the benefits of portable oxygen in selected patients have been previously underestimated.

In a multicentre study in eighteen European cities 3175 patients were treated with photochemotherapy (PUVA) for severe psoriasis and data obtained during a period of 39 months were analysed. A response better than marked improvement was obtained in 88.8% of patients; twenty exposures and a total cumulative UVA dose of 96 J/cm2 were required for clearing, the duration of the clearing phase being 5.3 weeks. A comparison of the results of this study with those of a similar multicentre study in the United States on 1300 patients and using a different treatment protocol, revealed that while treatment results and the number of individual treatment sessions were similar the European protocol requires only half the time and less than half the total cumulative UVA dose for clearing of psoriasis. When patients in the European study who received continuous maintenance treatment were compared with patients who received no maintenance treatment the probability that a patient would remain in remission for a period of 80 weeks was the same, irrespective of whether patients received maintenance treatment or not. This study confirms the dramatic efficacy of PUVA in clearing psoriasis and contains two important messages for the reduction of possible long-term hazards of this treatment. Firstly, the total UVA energy requirements for clearing psoriasis strongly depend on the treatment schedule and can be kept low if an individual approach aimed at rapid clearing of psoriasis is used. Secondly, maintenance therapy may not significantly prevent recurrences for prolonged periods of time and may thus not be necessary in most patients.