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The continued use of progestational agents in attempts to achieve a normal outcome of pregnancy in women with a 'high-risk' pregnancy (previous miscarriage, stillbirth or present preterm labour) prompted this meta-analysis of randomized control trials of such therapy. Of 20 trials of a progestogen 15 had combinable data. Combined comparisons, using odds ratios with confidence intervals, were made of the rates of livebirths at term or preterm and the sum of term and preterm deliveries, miscarriages, stillbirths and neonatal deaths. All but one comparison failed to show a significant benefit. Only the preterm delivery versus the term delivery comparison approached statistical significance. There were average deficiencies of quality apparent in the studies, and a test for heterogeneity among the studies was positive, but these caveats do not diminish the conclusion that progestogens should not be used outside of randomized trials at present. If trials are done, they should include only women with demonstrated hormonal abnormalities who are carrying a live fetus as shown by ultrasonography.

To evaluate the use of antibiotics given prophylactically of colon surgery, we examined 26 trials published from 1965 to 1980 in which patients given various antibiotic regiments were compared with controls given no antibiotic treatment. In 22 (85 per cent of these trials) antibiotics reduced postoperative wound infection (p less than 0.05 in 14). Combining the results of the trials published from 1965 to 1975 reveals a 95 per cent confidence interval from the true difference in infection rates of 14 +/- 6 per cent (36 per cent for control group vs. 22 per cent for treatment group) and the true difference in death rates of 6.7 +/- 4.4 per cent (11.2 per cent for control group vs 4.5 per cent for treatment group). Yet trials employing control groups given no treatment continue to be reported. Since the use of such controls is justified only when no effective alternative therapy exists, we believe that any further trials of antibiotic prophylaxis in colon surgery should employ a previously proved standard. However, steadily increasing efficacy of treatment means that comparisons of new therapies with standard therapies will become prohibitively expensive because of the large number of patients required.

Loss of patients from clinical trials can nullify adequate randomization if the loss is unequally distributed among treatment groups. This study was designed to assess the magnitude of the problem in randomized control trials evaluating long-term therapy for survivors of myocardial infarction (MI). Only 19 of 52 trials reported having an explicit policy on withdrawals in the design stage; only 2 reported blinding the decision for withdrawal and only 7 reported accounting for withdrawals in sizing. In addition, only 16 gave the reader enough information to calculate the effect of withdrawals on trial results. In 2 of these 16 trials a p less than 0.05 result obtained by including withdrawals (intention to treat method) was reduced to p less than 0.05 when withdrawals were excluded. It is evident that many long-term trials do not contain adequate data on withdrawals. Readers of published trials are seldom able to judge whether or not withdrawals might affect the final results.

The potential spread of the human immunodeficiency virus (HIV) to childbearing women in areas of high acquired immunodeficiency syndrome (AIDS) endemicity is a major public health concern. As a private institution providing obstetric care to such a population of women, we undertook an anonymous HIV cord blood serosurvey to estimate the number of childbearing women at our institution at risk for perinatal transmission of the virus and to assess the success of our voluntary screening program to identify seropositive women. Between November 1987 and January 1988, cord blood samples from all clinic deliveries were analyzed for the presence of HIV antibody. For each sample obtained, the mother's age and site of prenatal care were known. Overall, 2.7% (six of 224) of the samples tested were seropositive; two of the 34 samples (5.9%) from teenage mothers were seropositive. All positive samples were from women who received prenatal care; none were identified through a voluntary screening program based on patient self-acknowledged risk-behavior assessment. This confirms that risk factor history elicited by personal interview is not a reliable screening tool for initiating HIV antibody counseling and testing. The high seropositive rate in teenagers is disturbing and needs further assessment.

We evaluated the treatment of asymptomatic patients with untreated syphilis of more than one year's duration (asymptomatic late syphilis) using a decision-analysis model. Two strategies were compared: treatment with 7.2 million units of penicillin G benzathine, or performing a lumbar puncture to test for asymptomatic neurosyphilis followed by penicillin and management based on cerebrospinal fluid analysis. Estimates of probabilities of disease prevalence, test sensitivity, and cure and complication rates were derived from published studies. Both strategies resulted in a cure rate of at least 99.7% using the best estimates. Although the strategy using lumbar puncture results in a 0.2% higher cure rate, its rate of complications (0.3%) exceeds its marginal benefit. We conclude that a lumbar puncture offers little additional benefit and may increase morbidity in patients with asymptomatic late syphilis.

42 homosexual or bisexual men with persistent generalised lymphadenopathy not attributable to an identifiable cause have been followed longitudinally since February, 1981. Lymphadenopathy was accompanied by fatigue, low-grade fever and/or night sweats (57%), splenomegaly (29%), leucopenia (40%), hypergamma - globulinaemia (76%), and diminished proportion and absolute numbers of helper T cells (95%). Of the 26 patients who had lymph node biopsy, all showed benign reactive hyperplasia. After 15-30 (median 22) months, 8 patients have met criteria for the diagnosis of acquired immunodeficiency syndrome (AIDS). This outcome was associated with previous heavy nitrite inhalant use, with the presence of night sweats, with leucopenia, and with the triad of constitutional symptoms, splenomegaly, and leucopenia. In addition, a lower mean absolute helper T cell count and an increased frequency of anergy to mumps intradermal antigen and of herpes simplex virus isolation distinguished these patients from those remaining in the cohort, who seem to be stable and in some cases to have improved.

A meta-analysis was performed to reevaluate the efficacy of dipyridamole for prophylaxis of angina pectoris. We found 10 articles that reported 11 randomized control trials published between 1960 and 1970. Three trials found a statistically significant benefit for the drug vs placebo, four showed a positive trend, two found no difference, and two showed a slight trend favoring placebo. When the results of all 11 trials were combined, two different statistical methods showed a statistically significant benefit from the drug. These combined results must be interpreted cautiously because of excluded patients and other methodologic variations in the studies, as well as evidence from other studies that dipyridamole may aggravate angina. Nevertheless, we conclude that there is some evidence for efficacy of the drug and believe the question should be restudied in larger and better-designed trials.

We describe a 63-yr-old man with disseminated medullary carcinoma of the thyroid and pancreatic nesidioblastosis and microadenosis with pancreatic polypeptide (PP) hypersecretion. His major symptoms were watery diarrhea, flushing, and abdominal bloating; these and the elevated plasma PP levels did not change after resection of the distal two thirds of the pancreas, which contained a 2-cm mass of nesidioblastotic tissue. Postoperatively, a long-acting somatostatin analog, SMS 201-995 (100 micrograms/day), normalized PP secretion acutely and chronically (7 months) and ameliorated his symptoms. The analog had no side-effects and did not alter glucose tolerance, calcitonin hypersecretion, or growth of the medullary carcinoma, but it did inhibit GH secretion. After withdrawal from therapy for 1 month, PP hypersecretion and all symptoms except diarrhea recurred. The coexistence of medullary carcinoma of the thyroid and PP cell nesidioblastosis represents a new variant of the overlap syndromes between multiple endocrine neoplasia types I and II. Patients with medullary carcinoma and unexplained watery diarrhea should have fasting gastroenteropancreatic hormone assays done to screen for a potential gastrointestinal or pancreatic origin for the diarrhea.

A meta-analysis was made of fourteen randomised controlled trials that evaluated the efficacy of nicotine chewing-gum in stopping patients smoking. The combined success rates in specialised cessation clinics are significantly higher with nicotine gum (27%) than with placebo gum (18%) at 6 months (n = 734), and 23% and 13% at 12 months, respectively. In contrast, success rates in general medical practices are similar with nicotine gum (11.4%) and with placebo gum (11.7%) at 6 months (n = 1022). However, in general practices, the success rates are 17% for nicotine gum and 13% for the no gum control at 4-6 months, and 9% and 5% at 12 months, a significant difference between the treatments at each time (n = 2238). The data suggest that proper use of nicotine gum in specialised clinics will increase the rate of stopping patients smoking. The use of the gum in general medical practices is questionable.

The pharmacokinetics of mezlocillin were investigated in 26 patients with alcoholic liver disease. Serum concentrations of mezlocillin were measured following intravenous administration of 3 g doses over 30 min. The mean peak serum concentration (+/- standard deviation) of mezlocillin at the end of infusion was 138.8 +/- 55.7 mg/l and the mean terminal half-life (T 1/2 beta) was 2.10 +/- 0.9 h. The 24 h urinary recovery of mezlocillin was 35.4 +/- 12.4% of the administered dose. Serum clearance was found to be inversely correlated with alkaline phosphatase and with total bilirubin. The T 1/2 beta was related to the following clinical measurements: age, SGOT and prothrombin time. This relationship suggests it may be prudent to adjust the dosage and the dosage interval of mezlocillin in patients with hepatobiliary dysfunction.

A case of pneumonia and empyema caused by Neisseria meningitidis is described in which the diagnosis was initially missed. Meningococcal pneumonia and empyema are rare. It is important to recognize unusual manifestations of meningococcal infection promptly because of the risk of spread to contacts including health care personnel and other patients.