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Patients with congestive cardiac failure have elevated sympathetic activity at rest which contributes to the pathophysiology of this syndrome. In addition, the sympathetic response to exercise in these patients is abnormal. Sympathetic activity is accurately reflected by serum noradrenaline levels. In a double-blind, placebo-controlled, parallel group study, 16 patients of New York Heart Association (NYHA) functional class II, stabilised on optimum doses of diuretics were randomised into two equal groups, to receive either low-dose Lisinopril, an orally active angiotensin converting enzyme (ACE) inhibitor, or matching placebo, over a 12 week period. At the end of the 12 week treatment phase, there was no significant change in noradrenaline levels at rest (p = 0.33) mid exercise (p = 0.17), or peak exercise (p = 0.69), in the lisinopril group. Both lisinopril and placebo groups improved subjectively as assessed by change in NYHA grade, (p < 0.01 for placebo and p < 0.001 for those given lisinopril). Exercise duration improved significantly in the lisinopril group (p = 0.0296), but not in the placebo group after treatment. Low dose lisinopril is of use in congestive cardiac failure even in the absence of measurable changes in sympathetic tone.

This is a report of a patient presenting with a contained rupture of an internal iliac aneurysm following proximal ligation after abdominal aortic aneurysm repair three years earlier. The patient presented with a large pelvic mass with symptoms of urgency, frequency, dysuria, tenesmus and fevers associated with anemia. Following evacuation of the aneurysm and direct suture ligation of the distal branches of the internal iliac artery, the patient's aortic graft was covered with omentum which also filled the pelvic cavity. The importance of proximal and distal control of aneurysms and/or the importance of complete luminal control of internal iliac artery aneurysms is emphasized by this case.

Primary pulmonary hypertension is a rare disease of unknown case. Functional hyposplenism is characterized by the appearance of abnormal circulating erythrocytes despite the presence of a spleen and is associated with a variety of disease states. A case of primary pulmonary hypertension associated with functional hyposplenism is described in this report.

A study of dosage requirements undertaken among chronic OPD patients found on unnecessarily high drug dosage regimes. Basing on OPD experiences authors discuss long term treatment strategies and strongly advocate low dose intermittent oral therapy.

Sixty-four patients with severe postpartum hemorrhage (PPH) required surgical intervention during the years 1983 to 1987. Bilateral hypogastric artery ligation (HAL) was the initial surgical approach in 45% (29/64) and hysterectomy in 55% (35/64). HAL successfully controlled hemorrhage in 65% (19/29), and failed in 35% (10/29) where hysterectomy was required as a life saving procedure. Failure of HAL was more evident in atonic PPH than in other situations. Complications were more following hysterectomy; six (6/45) patients required re-exploration for intraperitoneal hemorrhage and two (2/45) patients died following hysterectomy. HAL was found to be a relatively easy, safe and successful procedure to be attempted as an initial surgical approach for all severe PPH, specially where uterine conservation was desired.

The purpose of this study was to determine whether adaptive cytoprotection of gastric mucosa could be demonstrated with concentrations of bile acid, which is normally found in the human stomach, and whether cyclooxygenase inhibition, in turn, could blunt the response. Surface epithelial cell exfoliation and ion fluxes were used as end points. A transduodenal gastric cannula was placed, and the pylorus/gastroesophageal junction was ligated in adult male Sprague-Dawley rats that had been anesthetized. In experiment 1 (N = 30), rat stomachs were exposed for 15 minutes to 5 ml of either a neutral test solution (160 mmol/L NaCl, pH 7) or 1 mmol/L acidified taurocholate (ATC) (100 mmol/L HCl, 60 mmol/L NaCl, 1 mmol/L taurocholic acid; pH 1.2). All rats were subsequently exposed for 15 minutes to 5 mmol/L ATC during which time mucosal injury was assessed by measuring net flux of H+, Na+, and K+, volume, and DNA efflux. In experiment 2 (N = 35), all stomachs were pretreated for 15 minutes with 1 mmol/L ATC before mucosal injury with 5 mmol/L ATC (15 minutes). Eighteen rats were pretreated with indomethacin (5 mg/kg) subcutaneously 75 minutes before the experiment was begun, and the same parameters were measured. Pretreatment of rat gastric mucosa with 1 mmol/L ATC significantly attenuated the mucosal injury that was seen with subsequent exposure to 5 mmol/L ATC, resulting in significantly (p less than 0.05) less luminal H+ loss (-16 +/- 4 vs -32 +/- 4 mEq/15 min) and DNA efflux (181 +/- 21 vs 270 +/- 25 micrograms/15 min) than the nonadapted group. Indomethacin pretreatment significantly attenuated the adaptive protective response, resulting in greater loss of H+ (-29 +/- 4 vs -18 +/- 3) and DNA efflux (190 +/- 35 vs 110 +/- 18, both p less than 0.05) after exposure to 5 mmol/L ATC. These studies demonstrate that adaptive cytoprotection of gastric mucosa occurs with physiologic concentrations of an irritant that is normally present in the stomach. Indomethacin blunts this effect, which suggests that adaptive cytoprotection in this setting may be mediated by production of endogenous prostaglandins.