Association of upper gastrointestinal toxicity of non-steroidal anti-inflammatory drugs with continued exposure: cohort study.

OBJECTIVES: To determine the profile of risk of upper gastrointestinal toxicity during continuous treatment with, and after cessation of, non-steroidal anti-inflammatory drugs. DESIGN: Cohort study with a prospectively constructed, population based, record linkage database containing details of exposure to all community dispensed non-steroidal anti-inflammatory drugs and also all admissions to hospital for upper gastrointestinal diagnoses. SETTING: The population of Tayside, Scotland. SUBJECTS: 52,293 subjects aged 50 and over who received one or more non-steroidal anti-inflammatory between 1 January 1989 and 31 December 1991 and 73,792 subjects who did not receive one during the same period (controls). MAIN OUTCOME MEASURES: Admission to hospital for upper gastrointestinal bleeding and perforation, and admission for other upper gastrointestinal diagnoses. RESULTS: About 2% of the non-steroidal anti-inflammatory cohort were admitted with an upper gastrointestinal event during the study period compared with 1.4% of controls. The risk of admission for upper gastrointestinal haemorrhage and perforation was constant during continuous non-steroidal anti-inflammatory exposure and carried over after the end of exposure. The results were similar for admissions for all upper gastrointestinal events. CONCLUSION: This study provides evidence that non-steroidal anti-inflammatory toxicity persists with continuous exposure. There seems to be carryover toxicity after the end of prescribing. These findings have implications for the management of patients requiring non-steroidal anti-inflammatory drugs.

Acquired ocular visual impairment in children. 1960-1989.

OBJECTIVE: To describe the causes, sites, and types of eye anomaly and associated handicaps in children identified in the last 30 years with ocular visual impairment of 20/200 (6/60) or worse in the better eye with correction. DESIGN: Trend study. STUDY POPULATION: Children in British Columbia younger than 19 years with visual loss diagnosed between January 1960 and December 1989 who were referred for multidisciplinary assessment. RESULTS: The incidence of acquired ocular visual impairment has decreased from 0.6 to less than 0.2 per 10,000 people aged 19 years or younger during the last 30 years. The most common cause was a genetic cause, followed by tumor, injury, infection and autoimmune disorders. Optic nerve atrophy and retinal disorders together resulted in more than 90% of all ocular lesions. Gender distribution revealed more males than females to be affected. Sixty-six percent of children had enough sight to read. The percentage of affected children with neurologic disabilities has increased overall in the last 30 years because more children with profound brain damage have survived. CONCLUSIONS: Acquired ocular visual impairment is rare. The incidence of such impairment has been reduced by two thirds in the last 30 years. This decline has had little impact, however, because most cases of blindness are due to congenital conditions. The number of cases of acquired blindness is only one fourth that of congenital blindness, which has begun to increase again owing to the reemergence of retinopathy of prematurity.

An evaluation of the Brüel and Kjaer monitor 1304.

A laboratory evaluation was performed on the Brüel and Kjaer multigas monitor 1304, incorporating a pulse oximeter. The instrument was tested for accuracy, stability, response and delay times, frequency response and the effects of water vapour, alcohol, cyclopropane and sevoflurane. The instrument's performance was found to be within or very close to the manufacturer's specifications for accuracy, stability and response and delay times. It was unaffected by water vapour and alcohol and the effect of cyclopropane on the vapour channel was lower than has been reported for other analysers. The response to sevoflurane was of the same order as that of the other vapours. A 90% response to square wave changes of gas composition was maintained up to 60 breaths.min-1 for CO2, O2, and N2O and up to 40 breaths.min-1 for the vapours when the nafion sampling tube was used.

Misoprostol--a logical therapeutic approach to gastroduodenal mucosal injury induced by non-steroidal anti-inflammatory drugs?

Misoprostol is a synthetic analogue of naturally occurring prostaglandin E1. The basis of the damaging actions of non-steroidal anti-inflammatory drugs (NSAIDs) on the gastrointestinal (GI) tract is believed to be a consequence of two events: a direct damaging action on mucosal integrity and depletion of endogenous mucosal prostaglandins (PGs). Due to the latter effect, and because current evidence indicates that PGs play an important role in maintaining the integrity of the GI tract, misoprostol has been developed as a logical therapy to prevent and heal gastric and duodenal damage caused by NSAIDs. The purpose of this review is to consider the need for such a therapy, to describe its pharmaceutical development, to review its pharmacology and to review its efficacy compared with other available agents.

Traumatic rupture of the pulmonary artery.

Traumatic rupture of the main pulmonary artery in a surviving patient is very rare. The case history of a 37-year-old man who sustained blunt chest trauma in a motor vehicle accident is presented. A persistent, bloody right pleural effusion led to the diagnosis of a ruptured right main pulmonary artery, which was surgically repaired using cardiopulmonary bypass. Points of diagnostic interest and therapeutic decision making are discussed.

Changing pattern of retinopathy of prematurity: a 37-year clinic experience.

A retrospective analysis was done of multi-disciplinary neurodevelopmental assessments in 70 children who were legally blind because of cicatricial retinopathy of prematurity. The subjects lived in British Columbia and were born during a 37-year period between 1951 and 1987. The purpose of the study was to investigate changes in the perinatal characteristics and to evaluate the associated handicaps. All patients were assessed at least once in the Visually Impaired Program, British Columbia Children's Hospital. In the majority, the visual loss was profound. Since 1951, blinding retinopathy of prematurity has become a disease of progressively smaller and less mature infants. Since 1981, it has been almost entirely confined to infants of birth weight less than 1,000 g in British Columbia. The diagnosis of mild spastic diplegia was made more commonly in patients born after 1980 but, despite the progressive reduction in birth weight and gestational age during the study period, the number of patients without other associated handicaps remained constant (approximately 30%) during each successive decade.

Congenital ocular blindness in children, 1945 to 1984.

A total of 676 children born in British Columbia with congenital ocular blindness during the years 1945 through 1984 were studied. The birth prevalence rate of congenital blindness has decreased from eight per 10,000 live births in the late 1940s to three per 10,000 live births. Retinopathy of prematurity was replaced by genetic ocular disorders as the leading cause of congenital blindness, although the former is reemerging. The rate of congenital rubella infection also declined. There has been a significant increase in the rate of births with optic nerve lesions during the past 15 years, while the rate of births with lesions of the lens fell, reflecting the decline in the rate of maternal rubella infection. There are fewer children with congenital ocular legal blindness who have no light perception today, and they also have fewer associated handicaps.

Clinical profile and prevalence of fetal alcohol syndrome in an isolated community in British Columbia.

The authors were invited by the band council to carry out a study to determine the prevalence of alcohol embryopathy among children in a native Indian community in British Columbia. The mothers of the 123 children aged 18 years or less who lived in the community were interviewed. In addition, educational screening was carried out for children in grades 1 through 12, and 116 of the children underwent medical examination. A diagnosis of fetal alcohol syndrome or fetal alcohol effects (FAS/FAE) was made in 22 children aged 3 to 18 years. Each of these children was matched for age and sex with an unaffected child in the same community, and both groups underwent psychoeducational testing. The children with FAS/FAE showed a generalized depressed level of functioning compared with the unaffected children. The finding that two thirds of the children with FAS/FAE were mentally retarded points to a major health and education problem.

Maternal age and congenital optic nerve hypoplasia: a possible clue to etiology.

The maternal age of two groups of children with congenital handicaps, cerebral palsy and fetal alcohol syndrome (FAS), were examined and compared with a group of mothers of children with congenital optic-nerve hypoplasia (CONH). The maternal age of children with CONH was significantly less than for the cerebral-palsied children which, in turn, was significantly less than for the FAS children. In addition, about one-half of the children with CONH had associated handicaps which clustered into four progressively more severe combinations. Maternal age and the occurrence of endocrine problems did not differ significantly among the clusters.

An economic study of cost savings on a care-by-parent ward.

Alternatives to inpatient care that improve quality of care and save money are desirable during periods of restraint on hospital budgets. One such alternative is the care-by-parent unit (CBPU) in which a parent's stay on the ward can reduce costs by resuming nursing tasks, limiting unnecessary procedures, and encouraging early discharge. This study measured costs per case treated in the CBPU compared with the costs for similar patients treated in the inpatient nursing unit (NU). Average costs per episode were lower in the CBPU--33 per cent for general pediatrics, 13.5 per cent for tonsils and adenoids and 29 per cent for other surgery. These savings are capable of considerable expansion because more than half of the admissions to NU meet the criteria for admission to CBPU. If CBPU facilities were expanded, however, the savings estimated above would not follow automatically. New CBPU facilities must substitute for NU, not add to total utilization.

Surgical day care: measurements of the economic payoff.

A careful and detailed cost analysis that measured all the costs, direct and indirect, generated in the course of an episode of surgical care demonstrated that there are very large savings from the substitution of surgical day care for inpatient care. Surgical day care appears to be an ideal alternative to inpatient care, from the points of view of those who pay for medical care (governments) as well as those who provide it (hospitals and health professionals) and those who receive it (patients). From an economic perspective the potential savings have not been achieved, and present policies provide no incentives to encourage these savings. These problems, together with strategies to encourage cost savings, are discussed.

Mallory-Weiss: suture plication without gastrotomy.

A new method of surgical treatment is described for the Mallory-Weiss tear that is not controlled by conservative measures. This technique uses a team approach combining endoscopy with simultaneous laparotomy to plicate the Mallory-Weiss tear without opening the gastrointestinal tract. We believe this method offers equal or better vision of the lesion than gastrotomy and will significantly lower the morbidity and perhaps the mortality associated with violating the integrity of the gastrointestinal tract.