Review article: controversy in the therapy of gastro-oesophageal reflux disease—long-term proton pump inhibition or laparoscopic anti-reflux surgery?

The treatment of gastro-oesophageal reflux disease is controversial. Whilst medical treatment is successful in patients with mild to moderate disease, the threshold of severity above which an operation should be contemplated remains a matter for debate. Laparoscopic anti-reflux surgery may be lowering this threshold, as this form of therapy provides several advantages over its open counterpart, but it is not without risk, and few long-term results are available. This article reviews treatment options for reflux disease and examines the relative position of current medical and surgical therapies.     

Detection of ambulatory ischaemia is not of practical clinical value in the routine management of patients with stable angina: A long-term follow-up study

It has been reported that medically treated patients with stableangina and positive exercise test for ischaemia have an adverse1–2 year outlook if they are shown also to have transient,and predominantly silent, ischaemic episodes detected by ambulatoryST segment monitoring during their daily activities: it hasbeen suggested that this investigation could be used to identifypatients more likely to benefit from early investigation andtreatment. We assessed the long-term (up to 65 months) prognosticsignificance of transient iscliaemic episodes during daily activitiesin 172 patients routinely attending cardiac outpatients withmedically treated stable angina who had undergone exercise testingand 48 h of ambulatory ST segment monitoring between February1988 and August 1989 for this purpose. A positive exercise testfor ischaemia was not a prerequisite for inclusion. One hundred and four patients (60.5%) had a positive exercisetest for iscliaemia and 72 (42%) had transient ischaemia duringdaily activities (63 had both tests positive). Over a median50-month follow-up period 54 patients suffered at least onecardiac event (primary event: cardiac death n=7; non-fatal myocardialinfarction n=11; unstable angina n=18; elective CABGIPTCA n=18).Two further patients suffered non-cardiac death. Cardiac events,either objective (cardiac death or non-fatal myocardial infarction)or subjective (unstable angina or revascularisation) were nomore likely to occur in those with transient ischaemia duringdaily life when compared with those without, at follow-up timesup to 65 months. The detection of transient ischaemia during daily life is oflimited practical clinical value in the management of ‘lowrisk’ medically treated patients with stable angina, anddoes not appear to help identify subgroups at increased riskof an adverse outcome at follow-up to more than 5 years.     

A comparison of non-invasive continuous finger blood pressure measurement (Finapres) with intra-arterial pressure during prolonged head-up tilt

Simultaneous intra-radial and non-invasive (Finapres, Ohmeda)blood pressures were compared during prolonged head-up tilt,in eight patients (mean age 49 years) with malignant vasovagalsyncope. Twelve tilts were performed, of which eight resultedin vasovagal syncope. The mean bias (difference between Finapresand intra-arterial pressures) for systolic pressure was +0.7mmHg (standard deviation 11.3 mmHg) and for diastolic pressurewas +5.4 mmHg (standard deviation 7 mmHg). The within-tilt precision(standard deviation of the bias) of the non-invasive measurementsvaried between 2.9–12.4 mmHg (median 4.5 mmHg) for systoliccomparisons, and 1.6–8.4 mmHg (median 4.4 mmHg) for diastoliccomparisons. In all but one tilt highly significant positiveincreases in both systolic (median 7.1 mmHg) and diastolic bias(median 81 mmHg) occurred on tilt with respect to resting pre-tiltlevels. Independent of the absolute level of agreement, thenon-invasive measurements followed changes in intra-arterialpressure closely, with 89% of beat-to-beat changes in systolicpressure, and 95% of beat-to-beat changes in diastolic pressurefollowed to within ±2 mmHg. This study suggests thatthe Finapres is well suited for use during diagnostic tilt testing,demonstrating an acceptable within-tilt precision and closelyfollowing pressure changes during vasovagal syncope.     

NASPE POLICY STATEMENT The NASPE* BPEG** Defibrillator Code

BERNSTEIN, A.D., et al .: The NASPE/BPEG Defibrillator Code. A new generic code, patterned after and compatible with the NASPE/BPEG Generic Pacemaker Code (NBG Code) was adopted by the NASPE Board of Trustees on January 23, 1993. It was developed by the NASPE Mode Code Committee, including members of the North American Society of Pacing and Electrophysiology (NASPE) and the British Pacing and Electrophysiology Group (BPEG). It is abbreviated as the NBD (for NASPE/BPEG Defibrillator) Code. It is intended for describing the capabilities and operation of implanted cardioverter defibrillators (ICDs) in conversation, record keeping, and device labeling, and incorporates four positions designating: (1) shock location; (2) antitachycardia pacing location; (3) means of tachycardia detection; and (4) antibradycardia pacing location. An additional Short Form, intended only for use in conversation, was defined as a concise means of distinguishing devices capable of shock alone, shock plus antibradycardia pacing, and shock plus antitachycardia and antibradycardia pacing. (PACE, Vol. 16, September 1993)     

DISCORDANT SERUM α-SUBUNIT AND FSH CONCENTRATIONS IN A WOMAN WITH A PITUITARY TUMOUR

We have studied a women who presented at the age of 51 with a large FSH and alpha-subunit producing pituitary adenoma. Following insertion of ventriculo-peritoneal shunts and external pituitary irradiation there was no change in the elevated serum concentrations of FSH, and alpha-subunit over a four year period although she developed both ACTH and TSH deficiency. Various drugs, however, did alter the FSH and alpha-subunit concentrations and these changes suggest possible mechanisms controlling FSH secretion. Ethinyloestradiol 0.03 mg daily for three weeks suppressed serum FSH to 77% of the basal level (240 +/- 35 i.u./l to 184 +/- 20 i.u./l) but alpha-subunit rose to 130% of basal level (281 +/- 50 ng/ml to 366 +/- 40 ng/ml). On ethinyloestradiol 0.1 mg daily, FSH suppressed to 17% of basal (40 +/- 11 i.u./l) with no change in alpha-subunit concentration, while on 0.2 mg daily suppression of FSH was similar but alpha-subunit fell to 59% of basal (190 +/- 28 ng/ml). Dexamethasone, 3 mg daily for one week reduced FSH to 53% of the initial concentration and alpha-subunit to 74% while bromocriptine 7.5 mg daily for three months, reduced FSH to 39% and alpha-subunit to 66% of basal. Neither thyroxine, 0.2 mg daily for four weeks, nor an LHRH analogue, (Buserelin, Hoechst) 200 micrograms, three times daily for three months elicited any effect. Chromatography on Sephadex G100 showed that serum FSH and alpha-subunit both had Kav values somewhat lower than those of their standard counterparts (FSH, 0.20 vs 0.25; alpha-subunit 0.35 vs 0.45).(ABSTRACT TRUNCATED AT 250 WORDS)     

THE MUCOSAL IMMUNE RESPONSE IN THE NEONATE

Hanson LÅ, Brinton C, Carlsson B, Dahlgren U, Mellander L, Sutton A and Söderström T. (Departments of Clinical Immunology and Paediatrics, University of Göteborg, Sweden, Bureau of Biologies, FDA, Bethesda, and Department of Life Sciences, University of Pittsburg, USA). The mucosal immune response in the neonate. Acta Paediatr Scand, Suppl. 296:53, 1982. — Human infants are relatively deficient in the IgA system defending mucosal membranes, but are provided via the maternal milk with considerable amounts of SIgA directed against microbes and food antigens to which both mother and infant are exposed. It is possible that serum antibodies may support the mucosal defense as do the lactoferrin, lysozyme and other defense factors present in the milk.