The value of hyperbaric oxygen in the treatment of acute carbon monoxide intoxication was assessed in 629 adults who had been poisoned at home in the 12 h before admission to hospital. In patients without initial impairment of consciousness (group A) the effect of 6 h of normobaric oxygen (NBO) (group A0, n = 170) was compared with that of 2 h of hyperbaric oxygen (HBO) at 2 atmospheres absolute (ATA) plus 4 h NBO (group A1, n = 173). At the 1 month follow-up 66% of A0 and 68% of A1 patients had recovered. In patients with initial impairment of consciousness the effect of one session of HBO (group B1, n = 145) was compared with that of two sessions (group B2, n = 141); all group B patients also received 4 h of NBO. At 1 month of follow-up 54% group B1 and 52% group B2 patients had recovered. The 7 patients left with neuropsychiatric sequelae (3 B1, 4 B2) and the 4 who died (2 B1, 2 B2) had all presented with coma. HBO was not useful in patients who did not lose consciousness during carbon monoxide intoxication, irrespective of their carboxyhaemoglobin level, nor were two sessions of HBO in patients who sustained only a brief loss of consciousness. The prognosis is poorest for those presenting with coma; the trial needs to be pursued in this group of patients until the power of the study is sufficient to demonstrate the value or otherwise of HBO.

The routine recommendation to women to count fetal movements daily during late pregnancy for the prevention of antepartum late fetal death in normally formed singletons has been evaluated. 68,000 women were randomly allocated within thirty-three pairs of clusters either to a policy of routine counting or to standard care, which might involve selective use of formal counting or informal noting of movements. Antepartum death rates for normally formed singletons were similar in the two groups, regardless of cause of prior risk status. Despite the counting policy, most of these fetuses were dead by the time the mothers received medical attention. The study does not rule out a beneficial effect, but at best, the policy would have to be used by about 1250 women to prevent 1 unexplained antepartum late fetal death, and an adverse effect is just as likely. In addition, formal routine counting would use considerable extra resources.

In a randomised cross-over study, six patients with recurrent sustained ventricular tachycardia (VT) were treated with 3 regimens--amiodarone, amiodarone plus metoprolol, and amiodarone plus xamoterol. All patients had poor left ventricular function and were resistant to multiple drugs. Xamoterol (a partial beta-agonist) was more effective than metoprolol as adjuvant therapy to amiodarone in the control of recurrent sustained ventricular arrhythmias and was not associated with any clinical deterioration of ventricular function. Xamoterol was also more effective than metoprolol for suppression of VT at programmed stimulation and as effective as metoprolol for suppression of VT on exercise. Exercise tolerance was significantly greater during treatment with xamoterol/amiodarone than during treatment with metoprolol/amiodarone or with amiodarone alone.

The effect of posture on central venous pressure (CVP) was studied in 16 patients with circulatory volume depletion before and after fluid replacement. At presentation, measurement of CVP when supine did not reflect circulatory volume depletion, with a mean (SEM) of 0.1 cm H2O (0.6), but when sat at 45 degrees the CVP showed a striking fall in all patients to -9.7 cm H2O (1.1). After fluid replacement, the CVP was 2.3 cm H2O (0.4) when supine, and -0.4 cm H2O (0.4) at 45 degrees. In the assessment of circulatory volume depletion, CVP should be measured with the patient sat at 45 degrees, if possible: measurement of CVP in a supine patient may not detect or severely underestimate circulatory volume depletion.

The value of the Acute Physiology and Chronic Health Enquiry (APACHE-II) score, the Simplified Acute Physiology score, and the Medical Research Council (MRC) sepsis score were compared with clinical assessment and Ranson and Imrie scores in the evaluation and monitoring of acute pancreatitis in 290 attacks. Attacks were graded mild (231) if uncomplicated, or severe (59) when major organ failure or a pancreatic collection occurred. Only APACHE-II scores were available at the time of admission; they correctly predicted outcome in 77% of attacks and identified 63% of severe attacks, compared with 44% achieved by clinical assessment. After 48 h, APACHE-II was most accurate, and correctly predicted outcome in 88% of attacks, compared with 69% for Ranson and 84% for Imrie scores. APACHE-II predicted 73% of pancreatic collections at 48 h, compared with 65% for Ranson and 58% for Imrie scores. In acute pancreatitis, APACHE-II may facilitate rapid selection of patients for intensive therapy or clinical trials, improve comparison between groups of patients, and indicate that a pancreatic collection is probable.

In a multicentre study 711 patients were randomised to a group receiving calcium-heparin, 12,500 U, subcutaneously (360), or to a group receiving no heparin (351), beginning within 24 h of the onset of symptoms. 433 of these patients, admitted within 6 h, were given intravenous streptokinase (SK). Results were analysed for the in-hospital period. Calcium-heparin had no significant effects on the frequency of electrocardiographically documented ischaemic episodes or non-fatal reinfarction in the whole series; in the subgroup receiving SK, transient ischaemic episodes recurred in 14.2% of those treated with heparin vs 19.6% of the controls (p = 0.08). Mortality was significantly lower in the calcium-heparin treated patients, both in the overall groups (21/360 vs 35/351, p = 0.03) and in the SK subgroups (10/218 vs 19/215, p = 0.05). In 200 patients with first anterior myocardial infarction, it was possible to assess the effect of heparin on left ventricular mural thrombosis. On predischarge two-dimensional echocardiography, the prevalence of thrombus was significantly lower in the heparin group than in the control group (19/107 vs 34/93). Heparin also greatly reduced the incidence of thrombus formation in those who were thrombus-free on admission. Complications of heparin treatment were few.

To examine the potential role of fish oil supplementation in the prevention of restenosis after coronary angioplasty (PTCA), a randomised double-blind trial was conducted in 204 patients. The treatment group received 6 g/day of n-3 fatty acids, beginning 5.4 (SD 3.2) days before PTCA, and continuing for 6 months; the control group received olive oil placebo. Compliance was assessed by pill count and plasma levels of eicosapentaenoic acid (EPA). Restenosis was identified by symptoms and exercise testing and confirmed by angiography. PTCA was successful in 186 patients (93%). The incidence of angiographic restenosis was 34% in the fish oil group and 23% in the control group (relative risk 1.7, 95% CI 0.9-3.4). The lack of benefit of fish oil was not influenced by length of pretreatment, compliance with study medication, or the concentrations of plasma EPA achieved.

In a prospective study, 105 infants aged 3-12 months with acute otitis media were randomly assigned to one of three treatment groups: amoxycillin/clavulanate ('Augmentin') alone (36 patients), myringotomy plus placebo (35 patients), or augmentin plus myringotomy (34 patients). The last two groups were double-blinded. Bacterial pathogens, mainly Haemophilus influenzae (of which 20% were beta-lactamase producers) and Streptococcus pneumoniae, were isolated from 60% of the ear exudates and all isolates were sensitive to augmentin. Most of the infants improved clinically within 3-6 days irrespective of the treatment protocol. As judged by otoscopy, 60% of the patients receiving augmentin, with or without myringotomy, recovered completely compared with 23% of patients treated with myringotomy plus placebo. Treatment with augmentin was also more effective than myringotomy with regard to persistence of ear infection. In the myringotomy plus augmentin group closure of the incision and resolution of the discharge from the incision site was faster than in the myringotomy plus placebo group. The addition of myringotomy to augmentin did not seem to affect either the persistence of the infection after treatment or the residual middle ear effusion.