increase in lifespan which has resulted from advances in medical science and public health should not be years of a "prison sentence" but should be enjoyed.Surely to advise elderly patients against going on holiday simply because they may fail to take some necessary medicine would be a complete trav-esty of this philosophy?
Chronic changes of ischaemia affecting the colon and small intestine have long been recognised radiologically (Lea Thomas, 1972; Windsor, 1972; Joffe et al, 1977; Bartram & Laufer, 1979). Because of its blood supply from separate arterial sources in the coeliac axis and superior mesenteric artery, the duodenum is well protected from ischaemic damage if one or other of these vessels is occluded, via the pancreatico-duodenal arcades. There have to date been no reports in the literature of radiological changes in barium studies of the duodenum resulting from athero-sclerotic arterial disease. A 47-year-old man presented in 1977 with abdominal pain which was described as typical of gall-bladder attacks. Oral cholecystography, however, was normal. Because of some weight loss, anorexia and a history of three previous cerebrovascular accidents, at a comparatively early age, from which he had made a good recovery, the question of mesenteric vascular insufficiency was raised.
The ultrasonic appearances of the kidney in images which contain grey shades corresponding to the detected echo-pulse heights have been examined. These "greyscale" images were obtained using a standard Nuclear Enterprises Diasonograph 4102B and a Varian 620/L digital computer interfaced to this Diasonograph. The computer was used to analyse and display the ultrasonograms with 16 grey shades. Both kidneys of 36 subjects were examined and compared with IVU findings. This group included patients with normal kidneys, polycystic kidneys, hydronephrosis, glomerulonephritis and neoplastic tumours. It was found possible to make sharp, grey-shaded ultrasonograms which were very useful to the diagnostician. In particular, the grey shade of the renal parenchyma was used as a standard to compare other grey-shaded structures. Also the grey shading was useful in defining the renal pelvis in transverse scans and the renal poles in axial scan.
This prospective study of 185 patients undergoing firsttime lumbar surgery compared how accurately clinical criteria and water-soluble myelography predicted the operative findings. Clinical diagnostic criteria of nerve root pain, root irritation signs, and neurologic signs of root compression supplemented by myelography were shown to be much more accurate than myelography alone, both in predicting the presence or absence of nerve root involvement and in distinguishing disc prolapse from bony entrapment. Provided the clinical criteria were clearly defined, patients with three or more of the four criteria were usually found to have a disc prolapse while bony entrapment could frequently be identified with one or two criteria. It is concluded that although lumbar disc prolapse is well-recognized, in practice clinical assessment and diagnostic criteria need to be defined more clearly to match increasingly sophisticated radiology.
Preface Acknowledgements 1. The Salivary Glands and Pharynx 2. The Oesophagus 3. The Stomach 4. The Duodendum 5. The Small Bowel 6. The Colon and Rectum 7. The Liver 8. The Gallbladder and Biliary Tract 9. The Pancreas 10. The Anterior Abdominal Wall, The Diaphragm, Peritoneal Cavity and Mesentry, Visceral Vessels and Lymph Nodes
Abstract Objective The Tight Control of Rheumatoid Arthritis study previously demonstrated that an intensive step‐up disease‐modifying antirheumatic drug (DMARD) treatment strategy targeting persistent disease activity was superior to routine care in the management of early rheumatoid arthritis (RA). We undertook this study to test the hypothesis that early parallel triple therapy achieves better outcomes than step‐up therapy within an intensive disease management regimen. Methods Ninety‐six patients with early RA (mean disease duration 11.5 months) were randomized to receive step‐up therapy (sulfasalazine [SSZ] monotherapy, then after 3 months, methotrexate [MTX] was added, and when the maximum tolerated dosage of MTX was reached, hydroxychloroquine [HCQ] was added) or parallel triple therapy (SSZ/MTX/HCQ). All patients were assessed monthly for 12 months. If their disease activity score in 28 joints (DAS28) was ≥3.2, the dosage of DMARDs was increased according to protocol, and swollen joints were injected with triamcinolone acetonide (maximum dosage 80 mg per month). A metrologist who was blinded to the treatment allocation performed assessments every 3 months. The primary outcome measure was the mean decrease in the DAS28 score at 12 months. Results Both groups showed substantial improvements in disease activity and functional outcome. At 12 months, the mean decrease in the DAS28 score was −4.0 (step‐up therapy group) versus −3.3 (parallel therapy group) ( P = 0.163). No significant differences in the percentages of patients with DAS28 remission (step‐up therapy group 45% versus parallel triple therapy group 33%), DAS28 good response (60% versus 41%, respectively), or American College of Rheumatology criteria for 20% improvement (ACR20) (77% versus 76%, respectively), ACR50 (60% versus 51%, respectively), or ACR70 (30% versus 20%, respectively) responses were seen. Radiologic progression was similar in both groups. Conclusion This study confirms that highly effective control of disease activity can be achieved using conventional DMARDs as part of an intensive disease management strategy. Within this setting, step‐up therapy is at least as effective as parallel triple therapy.
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