Incidence of awareness with recall during general anaesthesia

One thousand patients who were anaesthetised between February and April 1990 at University Hospital, Nottingham were interviewed between 20 and 36 hours after their operation. Patients under 16 years of age, those who had undergone obstetric or intracranial surgery, those who were unable to communicate and patients who were discharged from hospital before the postoperative visit were not interviewed. A standard set of questions was used to determine the incidences of recall of events and dreams during the operation. These incidences were 0.2% and 0.9% respectively, considerably lower than reported in previous comparable studies.     

The role of gastrin and cholecystokinin in normal and neoplastic gastrointestinal growth

Abstract Gastrin and cholecystokinin (CCK) act as growth factors for the gastric mucosa and the pancreas, respectively. CCK is also responsible, via the CCK-A receptor, for the pancreatic hyperplasia observed following the feeding of protease inhibitors or pancreaticobiliary diversion. Hypergastrinaemia does not increase the incidence of spontaneous gastrointestinal carcinoma, but does stimulate the proliferation of gastric enterochromaffin-like cells via the gastrin/CCK-B receptor, with a consequent increase in the incidence of gastric carcinoids. Whether gastrin influences mutagen-induced gastrointestinal carcinogenesis is still controversial, but CCK clearly enhances the induction by carcinogens of acinar tumours in the pancreas. While gastrin increases xenograft growth of 50% of gastrointestinal tumours tested, effects on the proliferation of gastrointestinal tumour cell lines in vitro have been more difficult to demonstrate, perhaps because many cell lines are already maximally stimulated by autocrine gastrin. Gastrin mRNA and progastrin, but not mature amidated gastrin, have been detected in all gastrointestinal cell lines tested. Although cell proliferation is inhibited by gastrin/CCK receptor antagonists, the spectrum of antagonist affinities is not consistent with binding to either CCK-A or gastrin/CCK-B receptors. Definition of the molecular structure of the receptor involved in the autocrine loop may lead to novel therapies for gastrointestinal cancer.     

Isotype-specific characterization of antibody responses to Onchocerca volvulus in putatively immune individuals

Isotypejsubclass-specific antibody responses to adult Onchocerca volvulus extract (OvAg) were assessed by both ELISA and immunoblotting for a group of putatively immune individuals (PIs, n = 29) from a hyperendemic area in Ecuador and for a group of infected individuals (INFs, n = 47) from the same region. As a group, the Pis have been previously shown to possess lower levels of OvAg specific IgG1, IgG2, IgG3 and IgG4 than INFs but semiquantitative analysis revealed that the relative proportions of these subclasses differs between the two groups. The IgG of the PI group contained a higher proportion of IgG3 and a lower proportion of IgG4 than the INF group. The frequency distribution of IgG3 responses was similar for the PI and INF groups. The frequency distributions for IgG1, IgG4 and IgE were significantly different between the PI and INF groups. A subgroup of the Pis were identified from frequency distributions and multivariate plots of individual isotype responses as having antibody responses (mainly IgG4) possibly indicative of cryptic infection. High IgE responses were exclusive to INF individuals, and a rare response type of high IgG3 with negligible levels of other isotypes/subclasses was seen only in the PI group. However, the majority of the Pis had negligible responses for all antibody classes. Immunoblots demonstrated no obvious differences in qualitative recognition between the PIs and INFs.     

A Multicenter Experience with a Bipolar Tined Polyurethane Ventricular Lead

A multicenter study was undertaken to determine the failure rate of a specific polyurethane bipolar tined pacing lead, the Medtronic 4012 pacing lead. Six centers in the United States and Canada implanted 1,190 Medtronic 4012 pacing leads. The study was designed to determine the probability and clinical manifestations of lead failure. Only failures compatible with an insulation problem were included. The probability of a 4012 lead failure by Kaplan-Meier analysis was 20.9% at 6 years after implantation. Failures were manifested as sensing abnormalities, failure to capture, early battery depletion, and significant decrease in measured impedance compared with the previous impedance measurements. Of the 95 definite lead failures, 16 (16.8%) were associated with symptoms similar to those experienced before pacemaker placement. The observed failure rate is unacceptable, and strong consideration should be given to replacing the 4012 pacing lead in pacemaker-dependent patients and closely monitoring nondependent patients.     

Drunkenness among police detainees

All detainees at seven police stations within the Metropolitan Police Area were observed by the authors. Continuous 24-hour cover was provided at each station for periods of 3 weeks. The number of people arrested far offences of drunkenness was noted, as was the apparent degree of drunkenness of all detainees, irrespective of arrest offence. Arrest for drunkenness in London was strongly associated with being white and with having been born in Scotland or Ireland. Within the confines of the station, being drunk was associated with aggressiveness, with the need for medical examination and with delays in implementing interview procedures. The physical condition of many chronically drunk people was very poor and evidence of long-term self neglect was common. Formal cautioning of drunkenness offenders has effectively removed such people from the courts; in the present study only 5% of those arrested for drunkenness alone were subsequently charged. Despite this the police in London must continue to arrest and detain the drunk and incapable for want of suitable alternatives.     

Referral for coronary angiography after exercise testing: traditional decision-making versus decision analysis

To audit the referral decisions made by a single cardiologistfor coronary angiography after exercise testing, we retrospectivelyreviewed the charts of 303 consecutive patients in a communityhospital. The outcomes of these decisions, in terms of angiogramsperformed and quality-adjusted life expectancy gains as predictedby a decision analysis model, were compared with the theoreticaldecisions that would have been made using the model. The 97patients sent for angiography exercised for a shorter time (5.6± 3.1 vs. 6.9 ± 3.2 min, p<0.001) had moreST deviation (2.7 ± 1.4 vs. 1.7 ± 1.0 mm, p<0.001),more angina (53.6 vs. 36.9% of patients, p<0.01) and weremore likely to have had a previous myocardial infarction (59.8vs. 33.5% of patients, p<0.001) than the 206 not referred.However, of those not referred, 137 were each predicted to gainup to 5.7 quality-adjusted life years (QALYs) from bypass surgery.The overall predicted gain from the cardiologist's decisionswas only 0.1±2.5 QALYs/patient. Had the decisions beenmade using the model, the mean gain would have been 1.9±1.3QALYs/patient, and an extra 128 patients would have been sentfor angiography. Decision analysis makes consistent decisionswith defined risks and benefits. Such decisions can be reproduced,reviewed and analysed, whereas traditional decision-making mayinconsistently reflect the clinician's beliefs and values.     

Chromosome testing in children with developmental delay in whom the aetiology is not evident clinically

A review was carried out to establish the value of chromosome testing in children with significant developmental delay, where the aetiology was not evident clinically. During 1990, 315 children had been assessed at a child development clinic and found to be significantly delayed in one or more areas of development; in 256, the aetiology was not evident clinically. Chromosome testing of these children revealed an abnormality in 10 (3.9%). Thirty children had dysmorphic features; six (20%) of these had an abnormal karyotype. Four (2%) of the 226 who had no dysmorphic features had a chromosome abnormality. One hundred and fifty-five children had intellectual disability; eight (5%) of these had an abnormal karyotype. Two (2%) of 101 who had a specific delay in their development had a chromosome abnormality. The advantages of chromosome testing in children with developmental delay in whom the aetiology is not evident clinically are discussed.