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Background/aims: Prospective studies from the Far East and Alaska have shown an increased mortality from cirrhosis and/or hepatocellular carcinoma in asymptomatic hepatitis B virus (HBV) carriers. The magnitude of this risk in apparently healthy North American carriers remains undefined., Methods: The outcomes of 317 asymptomatic hepatitis B surface antigen-positive carriers from the Montreal area were examined after 16 years of follow-up. A majority of carriers were of French Canadian origin, were positive for antibody to hepatitis B e antigen, and had normal serum transaminase levels; institutionalization in orphanages as infants or children was the most important epidemiological risk factor, suggesting horizontal transmission of HBV during childhood., Results: At follow-up, mean age was 46 +/- 8 years; 3 carriers had died of HBV-related cirrhosis, 1 of alcoholic cirrhosis, and 9 of causes unrelated to liver disease. No carrier died of hepatocellular carcinoma; had the risk of hepatocellular carcinoma been similar to that reported from the Far East and Alaska, 17 cases of hepatocellular carcinoma-related deaths would have been expected. During follow-up, the annual negativation rate for hepatitis B surface antigen was 0.7%., Conclusions: In asymptomatic HBV carriers from Montreal, a majority are "healthy" carriers and remain asymptomatic after 16 years of follow-up and the risk of death from HBV-related cirrhosis and/or hepatocellular carcinoma is low.

The evolution of 118 children treated for acute lymphoblastic leukemia between 1976 and 1984, and followed until 1991, was reviewed. Maintenance chemotherapy consisted of daily 6-mercaptopurine (6-MP), weekly methotrexate (MTX), and monthly vincristine and prednisone. Eighty-two children took 6-MP and MTX in the morning, and 36 took them in the evening. Disease-free survival, as determined by Kaplan-Meier analysis, was better for children on evening chemotherapy. Regression analysis (Cox proportional hazards model, with evening versus morning schedule as exposure variable, and age at diagnosis, leucocytosis at diagnosis, and sex as covariates) showed that for those surviving free of disease for longer than 78 weeks, the risk of relapse was 2.56 times greater for the morning schedule than for the evening one.

Data collected during postnatal visits were used to study the risk of low birthweight (LBW) and prematurity among foreign-born mothers and mothers born in Canada. 2,913 singleton live births were included in the analysis. Odds ratios (OR) and 95% confidence intervals (CI) for LBW and prematurity were estimated using a logistic regression model. Foreign-born mothers did not have a higher risk of LBW or prematurity as compared to native-born mothers (OR = 1.1, 95% CI = 0.8-1.5; OR = 1.0, 95% CI = 0.7-1.4, respectively). For both LBW and prematurity, women in the intermediate category of length of stay (1-3 years) had a somewhat lower risk and women with the shortest length of stay (less than one year) had a slightly higher risk than women with the longest length of stay (more than 3 years). However, none of these results was statistically significant. Results of this study suggest that foreign-born mothers do not have a higher risk than Canadian-born mothers of bearing a LBW or premature infant. This finding differs from the widespread perception that immigrant mothers are at high risk for adverse birth outcomes.

Most elderly persons with dementia are cared for at home, usually by the spouse or an adult child. The objective of the present study was to determine whether there is an excess of psychological and physical health problems among family caregivers (CGs) of elderly persons with dementia. Data were obtained by interview from close family members of dementia patients (CGs), and from a comparison group made up of close family members of patients undergoing cataract surgery (non-caregivers, NCGs). CGs had significantly higher levels of depression and physical symptoms than NCGs. The association between caregiving and the health variables was stronger among subjects who were the patient's spouse than among those who were the patient's child. Furthermore, greater behavioral disturbance in the demented patient was associated with higher levels of morbidity in the CG. The results suggest that CGs might benefit from careful monitoring of their health status, and from greater access to specialized support services.

We assessed the agreement between 2 methods of data gathering of particular interest in urology: patient questionnaire and examination vs. frequency-volume charts. One hundred consecutive patients consulting our out-patient clinic were chosen for this study; 88 completed the study. Urinary frequency and bladder capacity were evaluated in each patient by using the above methods. The agreement between different methods of measurement was assessed by determining whether the 2 methods were interchangeable, a condition occurring if results of both methods fall within predetermined limits of variability. The results showed poor agreement between subjectively estimated urinary frequency and chart-determined urinary frequency. Moreover, different methods of measuring bladder capacity (endoscopic vs. chart) gave different results. Since chart-determined data are probably a more valid indication of urinary habits, we suggest that frequency-volume charts should be used more often in the investigation and follow-up of patients with micturition disorders.

The objective of this study was to assess survival and the prognostic influencing survival of compensated silicotic patients. All workers compensated for silicosis in the Province of Quebec from 1938 to 1985 (n = 1,165) were included. Clinical data were those collected during the exam that led to a compensation decision. Due to missing data, a subcohort of 961 patients was used for multivariate analysis of clinical prognostic factors with the Cox proportional hazards model. The following factors made an independent contribution to survival: age at compensation, smoking, dyspnea, expectoration, abnormal breath sounds, radiographic appearance, and vital capacity. On the basis of the model, patients with small opacities alone on their chest radiograph and who did not have dyspnea, expectoration, or abnormal breath sounds had a survival similar to the average Quebec man; other patients had a poorer survival. We conclude that it is possible to identify at the time of compensation, silicotic patients who are likely to have a life expectancy similar to that of the general population. Symptoms and physical signs as well as radiographic and lung function abnormalities appear to be useful prognostic indicators in compensated silicotic patients.

Background: Lupus anticoagulants and anticardiolipin antibodies are antiphospholipid antibodies that have been associated with fetal loss, but they have not been shown unequivocally to be a risk factor for this event., Methods: To estimate the risk of fetal loss in association with these antibodies, we conducted a hospital-based case-control study of 331 women with spontaneous abortion or fetal death (case patients) and 993 controls. The subjects were included in the study only if they reported that they had had no previous spontaneous fetal loss. Each control was a pregnant woman who, in the same period of pregnancy as a case patient, had not had a fetal loss. Lupus anticoagulants were identified in blood samples through a series of coagulation tests, and IgG anticardiolipins by an enzyme-linked immunosorbent assay. Each subject was interviewed in person to obtain information on potential confounding variables, such as sociodemographic characteristics and medical conditions., Results: Lupus anticoagulants were found in blood from 17 case patients (5.1 percent) and 38 controls (3.8 percent). The crude odds ratio for the association between lupus anticoagulants and fetal loss was 1.36 (95 percent confidence interval, 0.75 to 2.43); the odds ratio adjusted for confounders was 1.42 (95 percent confidence interval, 0.72 to 2.80). An IgG anticardiolipin level of 5 units or more was found in 4 case patients (1.2 percent) and 15 controls (1.5 percent). The crude and adjusted odds ratios for fetal loss were 0.80 (95 percent confidence interval, 0.26 to 2.41) and 1.28 (95 percent confidence interval, 0.38 to 4.21), respectively., Conclusions: There is not apparent justification for considering lupus anticoagulants or IgG anticardiolipins to be risk factors for fetal loss among women who present with spontaneous abortion or fetal death and have had no previous spontaneous fetal loss.

Study Objective: The aim was to investigate the association between mothers' occupational exposure during pregnancy and the incidence of acute lymphoblastic leukaemia in children., Design: The study was a case-control investigation. A face to face interview was used to assess exposures at work and relevant confounding variables., Setting: The study was community based and was carried out in five provinces of Spain., Subjects: 128 cases less than 15 years of age were interviewed (91% of those eligible). Controls (one for each case) were chosen from the census lists and were matched on year of birth, sex and municipality., Measurements and Main Results: Children of mothers working at home had a relative risk (RR) of 7.0 (95% CI = 1.59-30.79) of developing acute lymphoblastic leukaemia. Exposure to organic dust was associated with a RR of 5.5 (95% CI = 1.21-24.8). There was a statistically significant interaction between exposure to organic dust and working at home. The majority of women working at home were hired by local industries to sew different types of tissues (cotton, wool, synthetic fibres) on a machine., Conclusion: A similar association has not been reported before: if confirmed, this finding may suggest a new health concern.

One of the main problems in selecting a control group in community based case-control studies is the availability of an appropriate source of the same geographical area. In Spain, the Municipal roll consists on a list of inhabitants being a potential source to obtain representative samples of general population. The structure of the Municipal roll is described with its contents in districts and census tracts. The strategy of the Municipal roll utilization in performing a childhood leukemia case-control study is also described. Its limitations are compared with those founded in the methods used currently in other countries like random digit dialing and birth certificates. Finally and given the current structure of the spanish Municipal roll, we discuss the usefulness of different approaches to obtain a random sample from this source and the problems which arose from using a method of matching by municipality, which is a cheap and quick procedure.

We conducted a population-based descriptive study of medical visits and surgical interventions for otitis media among 3- and 7-year-old children from the Montreal, Canada, area over the period 1981 to 1983. The number of children seen annually for otitis media increased over that time. An increase in the event rate of otitis was observed; there was also an increase in the rate of myringotomy with ventilatory tube insertion. The rate of surgery reached a level, among 3-year-old children in particular (25.0 per 1000 cases of otitis among boys, 23.9 per 1000 cases of otitis among girls), that some authors have termed "epidemic." Comparison of the trends in the rates of surgical interventions and the rates of medical consultations for otitis suggest that most of this so-called surgical epidemic for middle ear effusion is related to a higher frequency of the underlying condition and not to more aggressive patterns of therapy during the years studied.

We examined the usefulness of technetium-99m-phytate (99mTc-phytate) hepatic scintigraphy in the evaluation of hepatic function, and the assessment of prognosis in patients with cirrhosis. Ninety-four patients with biopsy-documented cirrhosis had, at the time of entry into the study, a scintigraphy with 99mTc-phytate complexed with calcium in vivo. Extrahepatic uptake (EHU) of 99mTc-phytate on scintigraphy was graded from 0 (absent EHU) to 5 (important EHU) according to the relative distribution of the radiotracer between the liver, the spleen and the bone marrow. The severity of liver disease was also assessed according to the index of Child and Turcotte as modified by Pugh et al. Mean follow-up was 2 yr. EHU was correlated to the Pugh score (r = 0.73) and to survival. Survival at 2 yr was 97% for an EHU equal or inferior to 2.5, 62% for grades 3-4.5, and 31% for grade 5. In conclusion, hepatic imaging with 99mTc-phytate, in addition to its diagnostic value, also contains valuable prognostic information in patients with cirrhosis.

The decision to regionalize obstetric services in the Montreal metropolitan area was designed to improve the efficiency of the system. Changes in types of birth between 1981 and 1984 in this area were studied in order to evaluate the effects of this decision on cesarean section rates. Results show a sudden increase in cesarean rates, coinciding with the regionalization decision. Hypotheses put forward are linked to the characteristics of hospitals remaining after this measure, as well as the organisational disturbances which it may have caused.

A randomized controlled trial was performed to determine whether a telephone support system could reduce the frequency of ambulatory physician encounters. A total of 182 elderly persons were enrolled in the study. The experimental group was regularly called by a public health nurse and could call the nurse every weekday during normal working hours. The control group received no intervention. A year later, the experimental group reported 7.40 ambulatory encounters with a physician (SD = 4.94) and the control group reported 8.61 encounters (SD = 6.85). The difference between the groups, after adjusting for various prognostic factors, was 1.20 (95% confidence interval, -0.84 to 3.24). Although the difference did not achieve statistical significance, the results suggest that telephone support may bring about a substantial decrease in medical care utilization. Further research assessing the cost-advantage ratio for this type of intervention is recommended.

The process of well child care in public health clinics was evaluated using a peer review approach based on explicit criteria formulated by the peers themselves. The criteria defined what should be done in order to ensure good preventive care during a client-provider encounter. The data from this study suggest that the traditional goals of public health are being pursued, but that a broader spectrum of preventive care, including attention to the child's psychosocial development, is still lacking.

A 48-year-old man presented with the first symptoms of myasthenia gravis one month after a general anesthesia and a second dose of hepatitis B plasma vaccine. Whether either event may have acted as a nonspecific challenge to the patient's immune system is speculative, but the case is described to discover similar observations, if any.

A survey was conducted among 160 persons aged 64 year or more in Montreal who were receiving home care. They answered at home a questionnaire on their use of health care services and drugs, and showed the interviewer all the drugs they were taking. In comparison with similar data from elsewhere, the use of health care services (an average of 8.0 encounters with a physician per person per year) and of drugs (an average of 5.3 per person) by this group seems high. Perhaps this group of people was obviously sicker than others of the same age, but this remains to be shown. Moreover, despite the reported frequency of health problems, it is uncertain whether such use of services and drugs was necessary. The question is raised whether the home care system is doing for the patient what it was intended to do.

The course of 118 children with acute lymphoblastic leukaemia who had achieved complete remission with a standard induction protocol and had also received meningeal prophylaxis with intrathecal methotrexate (MTX) and cranial irradiation was reviewed. Maintenance chemotherapy consisted of daily 6-mercaptopurine (6-MP), weekly MTX, and monthly vincristine and prednisone. 82 children took 6-MP and MTX in the morning and 36 in the evening. Disease-free survival as determined by Kaplan-Meier analysis was better for children on evening chemotherapy. Regression analysis (Cox proportional hazards model, with evening vs morning schedule as exposure variable, and age at diagnosis, leucocytosis at diagnosis, and sex as covariates) showed that, for those surviving free of disease for longer than 78 weeks, the risk of relapsing was 4.6 times greater for the morning schedule than for the evening one.

The results related to the controls response rate in a case-control study are presented. The study was designed to learn about the relationship between the occupational exposure to toxic products in the parents and the development of acute leukemia in childhood. 128 cases were enrolled in the study and each case was matched by sex and age (less than 15 years) to a control. Controls were selected from the Municipal roll of the same city or town in which the case has been living during the diagnosis. We contacted the control's mother by phone or by personal visit. The response rate was 47.9% and near to a half of non responses was due to errors in the addresses registered in the Municipal roll. The validity of this source of controls in Spain can be questioned in the light of the high percentage of errors. We also discuss the potential selection bias introduced in the study due to the way we selected controls.

Review of the literature reveals sporadic but true increases in the prevalence and death rates for asthma over the past 25 years. Although changes in hereditary, allergic and environmental factors must be considered as possible causes of this increase, its suddenness points to risk factors that change rapidly. Such is the case with atmospheric pollutants, notably nitrogen dioxide and particles, both of which have been shown to have adverse effects on the tracheobronchial tree. These pollutants tend to concentrate inside homes, especially since the early 1980s, when the energy crisis brought about changes in the home environment.

Hospital admission rates for childhood asthma have increased markedly in many countries since the beginning of the 1970s. Prevalence of asthma, as reported by parents or children in occasional surveys, has also increased during this period. In Montreal, 7.2 per 1000 3-year-old children were admitted to the hospital with a diagnosis of asthma in 1980-1981, whereas the rate was 11.9 per 1000 in 1984-1985. For 7-year-old children, these rates were 3.2 per 1000 and 4.8 per 1000, respectively. On the other hand, the length of hospital stay decreased steadily during this period, and the mean number of admissions per child did not show a tendency to increase. For 3- and 7-year-old children together, the prevalence of asthma, determined from health insurance data, increased by 71%, from 3.76% in 1980 to 6.45% in 1983. Prevalence of other medical conditions also increased in this community, but much less than for asthma. An increase in the incidence of the disease cannot be excluded as the cause for the changing prevalence of asthma.

Data collected during postnatal visits were used to study the risk of low birth weight (LBW) among unmarried women living alone and among unmarried women living with a partner or another adult, using married women living with their husbands as the reference group. Information on 1,627 singleton live births was included in a binomial regression, controlling for seven potential confounding variables: mother's age, education, gestational weight gain, parity, smoking status, and presence of medical problems preceding or during pregnancy. Unmarried women living alone were at greater risk of bearing a LBW infant than married women living with their husbands (RR = 2.0, 95% Cl = 1.2-3.4). Unmarried women living with a partner had a slightly lower risk of LBW than married women (RR = 0.6, 95% Cl = 0.3-1.3) and unmarried women living with another adult had a slightly increased risk (RR = 1.3, 95% Cl = 0.6-3.0), although neither of these results was statistically significant. On the basis of these findings, we suggest that public health interventions should target women according to their household structure rather than their marital status.

All patients 65 years and older who had been living in an institution for at least six months had a measurement of red blood cell folate (RBCF), serum folate (SF), vitamin B12, hemoglobin, and mean corpuscular volume. Twenty-two percent of the 97 studied subjects were found deficient in RBCF, although only 6% had anemia. Length of stay at the institution was significantly associated with deficiency in RBCF and this association was uncon-founded by age. The proportion of RBCF deficiency among the studied subjects attributable to length of stay is 80%. The prophylactic administration of folate among long-term nursing home type of patients should be considered.

In 1984, the authors undertook a major study on the multiple interrelations between unemployment and health. Tlie methodology in use is prospective, longitudinal, with a control group. Their presentation consists of a synthesis of work carried out so far followed by corresponding results. These results are in compliance with the four hypotheses developed through a priori reasoning. However, these results are not definitive. The analysis continues.

Women experienced in cervical self-palpation recognize fertile characteristics when the cervix is high, open, soft, and straight; this happens under estrogenic influence. The cervix is said to show infertile signs when it is low, closed, firm, and lying against the vaginal wall; that change occurs quickly under progesterone influence. The objective of this study was to assess the time relationship among changes in the cervix observed by self-palpation, changes in cervical mucus as observed by women, and the shift in basal body temperature during ordinary cycles. A total of 215 symptothermal charts from natural family planning users were analyzed. The duration of the change from the maximum fertility characteristics to the postovulatory return to definite signs of infertility was measured. This duration ranged from 1 to 7 days, with a mean of 2.65. The timing of maximum fertility signs in the mucus was compared with that of maximum fertility signs in the cervix: it varied from 3 days before to 6 days after, with a mean of 0.48 day. The timing of the first high temperature was compared with that of return to definitely infertile characteristics: it varied from 6 days before to 3 days after, with a mean of -0.69 day. Some of the variation may be due to the presence of inexperienced users in the sample. However, a mean difference of half a day between the most fertile cervix and the most fertile mucus on one hand and between the first day of infertile cervix and the first high temperature on the other hand suggest that the cervical changes could be useful indicators of estrogen and progesterone actions.

We conducted a prospective, randomized single-blind trial of propranolol for the prevention of recurrent variceal bleeding. Seventy-nine patients shown to have variceal hemorrhage at endoscopy were included in the study within 72 hr following diagnosis. Fifty-seven patients had alcoholic cirrhosis, 10 cryptogenic cirrhosis, 6 posthepatitic cirrhosis, 4 biliary cirrhosis, 1 portal vein thrombosis without cirrhosis and 1 idiopathic portal hypertension. The severity of liver disease at inclusion was assessed according to the Pugh modification of the Child-Turcotte classification: 9 (11%) had Class A; 41 (52%) Class B, and 29 (37%) Class C disease. Patients were randomly assigned by sealed envelope to the propranolol group (42 patients) or the placebo group (37 patients). Propranolol dosage was titrated in order to produce plasma concentrations of propranolol of 50 to 150 ng per ml. beta-blockade was also confirmed by isoproterenol testing. The cumulative percentages of patients free of rebleeding 1 and 2 years after inclusion were 31 and 21% in the propranolol group, and 25 and 17% in the placebo group; both differences were not significant. Cumulative 1 and 2 years survival were also comparable: 64 and 54% in the propranolol group vs. 70 and 63% in the placebo group. There was no evidence for a therapeutic effect of propranolol after adjusting for potential confounding variables by multiple logistic regression. We conclude that propranolol is not effective for the prevention of variceal rebleeding, when administered early following the initial bleed, in cirrhotics unselected with respect to the severity of the liver disease.

Emergency portacaval shunt for variceal bleeding is associated with a high operative mortality, particularly if used as a last resort. Because of this, a strong case has been made against emergency shunt. This report describes an experience with emergency portacaval shunt for the treatment of variceal bleeding when used systematically after hemodynamic stabilization and control of the bleeding episode with balloon tamponade, if necessary, in patients with mild or moderate liver disease. The population studied comprised 62 consecutive patients who rebled from varices while participating in a controlled trial of propranolol for the prevention of rebleeding. Of the 62 patients, nine died of massive hemorrhage and 53 survived the hemorrhage. Of the 53 survivors, 11 had severe liver disease and were not considered for shunt surgery. Of the remaining 42 patients with mild or moderate liver disease, 36 had emergency central portacaval shunt. The interval between endoscopic diagnosis of variceal bleeding and surgery averaged 19 +/- 3 hours (mean +/- SE). The operative mortality rate, defined as in-hospital mortality, was 19%. One- and 2-year survival rates were 78% and 71%, respectively. The incidence of postoperative hepatic encephalopathy was 36%; all patients responded favorably to protein restriction and lactulose. Thus, under specific conditions, emergency portacaval shunt results in an acceptable long-term survival rate. In patients with mild or moderate liver disease, emergency portacaval shunt should be considered when other forms of treatment for the prevention of variceal rebleeding have failed.

Men who had received compensation for silicosis in Québec between 1938 and 1985 were studied up to the end of 1986 to estimate risk of lung cancer mortality. Particular attention was paid to selection biases inherent in the study of such workers. Age-specific and calendar-year-specific mortality rates of Québec men from 1931 to 1985 were used for comparison. Risk of death from lung cancer in men who had received compensation for silicosis was more than 3 times higher than expected; silicosis may be a strong risk factor for lung cancer mortality.

Nurses and nursing aides (n = 418) currently working on a regular evening or day schedule were compared in terms of sleep disorder symptoms. The relationship between past nightwork and sleep disorder symptoms was also assessed. The prevalence of individual symptoms varied from 6 to 53%. Evening workers showed a pattern of sleep disorder compatible with sleep deprivation, whereas the pattern for day workers was more compatible with insomnia. Past nightwork was significantly associated with symptoms of day tiredness and the quantity of sleep obtained was influenced by past nightwork. The prevalence of a combination of four insomnia symptoms (initial, intermittent, and terminal insomnia and fatigue during the day) was 5.4% among current day workers but no cases were identified among evening workers. Among day workers, the trend for insomnia across levels of duration of past nightwork fell slightly short of conventional statistical significance (P = 0.09). The relationship between a combination of four symptoms was neither modified nor confounded by variables such as age, chronotype, intensity of past nightwork, and latency. In conclusion, although some sleep symptoms were associated with nightwork, a clear residual effect on a combination of symptoms could not be shown.

A framework for evaluating and conducting prognostic studies is proposed. Recently published studies on prognosis of cirrhosis of the liver are evaluated according to the proposed framework. It was found that appropriate statistical techniques were often used to analyze the results of prognostic studies of cirrhosis of the liver. On the other hand, the studies performed poorly with regards to study design, the determination of the usefulness of the data, the validity of the collected information, and the analytic strategy. It is hoped that the criteria suggested in this paper will improve the planning and the reporting of prognostic studies.

The objective of this study was to assess the prognostic value of spontaneous portosystemic shunting and liver function for survival and spontaneous hepatic encephalopathy after end-to-side portacaval shunt in cirrhotic patients. One hundred ninety-eight patients with variceal hemorrhage as shown by endoscopy were evaluated. Forty-five were excluded because of uncontrollable hemorrhage; 84 were rejected because they were poor operative risk, had portal vein thrombosis or had been previously treated with beta-blockers, sclerotherapy or surgery. The remaining 69 patients were enrolled in this prospective study. There were 43 patients with alcoholic cirrhosis, 23 with cryptogenic cirrhosis and three with primary biliary cirrhosis. The severity of liver disease was assessed according to the Pugh classification: 37 patients (54%) had Pugh's score 5 to 7, 26 (38%) had 8 to 10 and six (8%) had 11 to 12. Indocyanine green intrinsic clearance was used as a probe of preoperative liver function and lidocaine systemic availability as an index of spontaneous preoperative shunting. All the patients underwent an elective end-to-side portacaval shunt. The length of minimal follow-up was 40 months. One-year survival was 76% and 5-year survival was 46%. During follow-up, 25 patients died from their liver disease and 11 patients died from various causes unrelated to their liver disease. Spontaneous chronic encephalopathy occurred in 16 patients (23%). Age, Pugh's score, active alcoholism, indocyanine green intrinsic clearance and lidocaine systemic availability were tested as prognostic factors in a multivariate analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

The objective of this study was to assess the prognostic validity of Child-Turcotte classification with regard to short-term (1-year) survival. The Child-Turcotte classification, as modified by Pugh et al., was recorded on admission in 177 cirrhotic patients. The variables that comprise the Pugh modification are ascites, encephalopathy, serum albumin, serum bilirubin and prothrombin time. Using multiple logistic regression, we evaluated the contribution of different models to the likelihood of survival, defining different ways to use the Pugh score. The Pugh score categorized in three strata (5 to 6, 7 to 9 and 10 to 15) captured less variance in the survival than the Pugh score counted from 5 to 15. This, in turn, captured less variance than a model in which the parameters of the Pugh score were analyzed according to their original units. The prediction rule based on the last model was tested in another sample of cirrhotics. The "original unit" model was studied in both training and testing samples, using receiver-operating characteristic curves to evaluate its clinical validity (sensitivity and specificity). The prediction rule based on the "original units" Pugh score allowed for a good discrimination of patients who lived and those who died. (At the point of maximum discrimination, sensitivity and specificity reached a mean of 80%). Validity of the prediction rule was confirmed by the testing sample. The qualities of simplicity, availability, low cost and good discriminating power for a life or death outcome make the Pugh score a very useful method to estimate prognosis in patients with cirrhosis.

We set up a mutual help network among the elderly residents of a government-subsidized apartment building and evaluated its impact on their social ties, social support satisfaction, and depression. A quasi-experimental design was used, with the residents of a similar building located in the same neighborhood serving as the control group. A total of 230 individual services were exchanged, and 28 group activities were organized during the study period. There was almost no difference between experimental and control groups with respect to the change over the study period in the number of social ties with other residents of the building. Support satisfaction decreased in both groups, but the decrease was larger in the experimental group. The control group had a slight decrease in the frequency of their depressive symptoms, whereas the experimental group had a moderate increase. More research is needed on the ability of social support interventions to produce beneficial effects on mental health among individuals who are not experiencing a particular life stress.

Lupus anticoagulants (LA) and anticardiolipin antibodies have been strongly associated with recurrent abortion and fetal death. Because steroids have been reported to improve the fetal outcome of LA associated pregnancies, presumably by decreasing the levels of LA, it becomes desirable to have a simple and reliable test to monitor the levels of the putative antibody. To this effect, we assessed the capacity of the following coagulation tests to detect the presence of LA in serial dilutions of patient plasma with pooled normal plasma: kaolin clotting time (KCT), tissue thromboplastin inhibition test (TTIT), dilute Russell Viper venom time (DRVVT) and activated partial thromboplastin time with standard and high concentrations of phospholipids (SC and HCAPTT). All samples were also evaluated for the presence of anticardiolipin antibodies with an ELISA. The KCT was able to detect LA at a much greater dilution in normal plasma than any of the other clotting assays. The ELISA was comparable to KCT in its ability to detect high dilutions of LA.

A meta-analysis was performed of 15 randomized studies on the prophylaxis with cimetidine and/or ant-acids of upper GI bleeding acquired in the ICU. There were eight comparisons of a group receiving cimetidine with a control group, nine comparisons of a group receiving antacids with a control group, and ten comparisons of a group receiving cimetidine with a group receiving antacids. The incidence of upper GI bleeding ranged from 3.4% to 52.7% among 866 control patients who received either a placebo or no prophylaxis. In five of eight comparisons, cimetidine was significantly more effective than no treatment or a placebo to prevent occult and overt upper GI bleeding; the typical odds ratio was 0.32 (95% confidence interval 0.21 to 0.49). In six of nine comparisons, antacids were significantly more effective than no treatment or a placebo; the typical odds ratio was 0.12 (0.08 to 0.19). Finally, antacids were significantly more effective than cimetidine in two of ten comparisons; the typical odds ratio was 1.61 (0.97 to 2.65). However, weaknesses in the study designs, heterogeneity of treatment effects, the lack of strength of the accumulated evidence, and the fact that no utility has been shown in terms of reducing morbidity (shock, need for transfusion) or mortality, prevent any definitive conclusion in regard to compulsory use of upper GI bleeding prophylaxis for ICU patients.

Seven randomized clinical trials evaluating the effect of repeated endoscopic variceal sclerotherapy on the long-term survival of patients with variceal hemorrhage have been published in the English-language literature. In four trials, the sclerotherapy-treated patients showed an improved long-term survival (follow-up periods longer than a year) when compared with patients in the medical regimen group, whereas in the other three trials, the long-term survival did not differ between the compared groups. Sample sizes in these "negative" trials were too small to detect a true moderate effect for serial sclerotherapy. To resolve this controversy, we combined the findings from all trials using a meta-analysis and determined the overall effect of repeated endoscopic variceal sclerotherapy on the survival of patients who had previously bled from esophageal varices. An overall risk difference of -0.15 (95% confidence limits, -0.21 to -0.08; p less than 0.0005) was estimated, indicating that sclerotherapy reduced the number of deaths by 25%. The estimated overall risk difference remained negative even when all patients in the sclerotherapy group with an unknown survival status were pessimistically considered dead at the end of the follow-up period. The results of this quantitative synthesis suggest that patients with bleeding esophageal varices benefit from the inclusion of repeated sclerotherapy in their long-term management regimen.

Chromosome analyses were carried out on bone marrow cells from 43 consecutive patients with primary myelodysplastic syndromes (MDS), classified according to the French-American-British (FAB) cooperative group criteria. The objective was to evaluate the prognostic value of clonal chromosomal abnormalities and of an excess of blasts for early death from acute nonlymphocytic leukemia (ANLL) and/or bone marrow failure (BMF). Patients were subdivided into two main groups: (1) refractory anemia without an excess of blasts (RAWEB), grouping patients with refractory anemia (RA) and refractory anemia with ringed sideroblasts (RARS), and (2) refractory anemia with an excess of blasts (RAEB), grouping patients with refractory anemia with an excess of blasts (RAEB) and refractory anemia with an excess of blasts in transformation (RAEBt). There were 29 patients with RAWEB and 14 with RAEB. The median time of observation was 26 months for RAWEB and 12 months for RAEB. Ten RAWEB patients (34%) and 11 RAEB patients (78%) had clonal chromosomal abnormalities. Among the ten RAWEB patients with clonal abnormalities, one (10%) died from ANLL, while of 19 RAWEB patients with a normal karyotype, two (10%) died from ANLL or BMF. The median survival for patients with RAWEB and an abnormal karyotype was not reached. In contrast, eight of the 11 RAEB patients with clonal chromosomal abnormalities (74%) died from ANLL or BMF. The median survival in this sub-group was 7 months. By using a Cox proportional hazard regression analysis, it was determined that a karyotype abnormality was not a significant predictory of survival once the contribution of the RAWEB/RAEB variable was taken into account. Being in the RAEB group was associated with a relative risk of 10.6 of dying from ANLL or BMF (beta = 2.36, standard error (SE) = 0.68, P = .0001). We conclude that classifying patients according to an excess of blasts will lead to a better prediction of survival than determining karyotype abnormality.

The aminopyrine breath test has been proposed as a quantitative test of hepatic function, but its long-term prognostic value in patients with cirrhosis has not been determined. The aim of this study was to examine the usefulness of the aminopyrine breath test in assessing prognosis and to compare it with traditional methods of evaluating liver function. One-hundred eighty-seven patients with histologically confirmed cirrhosis were studied prospectively. An aminopyrine breath test was obtained at the time of inclusion in the study and results were expressed as per cent of the dose excreted in 2 hr. At inclusion, the severity of liver disease was also assessed according to the Pugh modification of the Child-Turcotte classification based on ascites, neurological status, serum albumin, serum bilirubin and prothrombin time. Mean follow-up was 844 days. During that period, 59 of 187 patients died of their liver disease. Two-year survival decreased with increasing Child-Turcotte classification score: survival was 98% in Child Class A patients (n = 62), 66% in Child Class B (n = 76) and 36% in Child Class C (n = 49) (chi 2 = 65.6, p less than 0.001). Two-year survival also decreased significantly with increasing degree of aminopyrine breath test abnormalities: survival was 90% in patients with aminopyrine breath test greater than 4% (n = 56); 78% in patients with aminopyrine breath test = 2 to 4% (n = 66), and 43% in patients with aminopyrine breath test less than 2% (n = 65) (chi 2 = 36.9, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)