Pulmonary hypertension developed in two women who had been taking fenfluramine for over eight months for weight reduction. On withdrawing the drug symptoms and electrocardiographic evidence of pulmonary hypertension disappeared in both cases. In one patient, however, the evidence recurred after rechallenge with fenfluramine.These findings are strong evidence that fenfluramine may cause pulmonary hypertension. Hence any patient taking the drug should report immediately any deterioration in exercise tolerance.

SUMMARY Eight hundred and four patients with persistence of the ductus arteriosus were seen in Edinburgh between 1940 and 1979. Thirty-seven of them reached the age of 50 years, and in 32 the shunt was exclusively from left to right. Fifteen of the 32 were subsequently treated surgically.None of the 32 was lost to follow-up. Duration ofclinical observation averaged 17 years and extended to over 30 years in eight patients. Their features have been correlated with those from reports of 48 comparable patients in an attempt to clarify the management of the persistent ductus in the older patient. Impairment of left ventricular function is shown as the major risk, even when the ductus is small. Bacterial endarteritis is infrequent.Surgical treatment carries greater risk than in childhood and early adult life but usually reduces heart size and restores exercise tolerance. Left ventricular dysfunction, however, occasionally vitiates the benefits; symptoms are then incompletely relieved and death from heart failure may occur months or years after operation. Experience in older patients thus emphasises the value of elective operation in childhood, however well the child, however trivial the shunt.It is concluded that in older patients, the presence or the development of symptoms or cardiac enlargement are almost always indications for surgical treatment. As age increases, especially by the eighth decade, medical treatment may be preferable. Continued follow-up of symptomless patients without cardiomegaly is important because increase in heart size usually precedes further deterioration which can then be prevented by timely surgical treatment.Most patients with persistence of the ductus arteriosus die before 50 years of age'-3 unless treated surgically.4 5 Occasional patients, however, survive with little disability and a few live a normal life span.6-9 In the majority of adults, exercise tolerance is liable to deteriorate rapidly'I and in them surgical treatment has been of great benefit, even at over 65 years of age. 1"12 Available information, however, has been based on single case reports with little long term follow-up.The Edinburgh experience of the persistent ductus since 1940, with and without surgical treatment, has therefore been analysed and correlated with earlier reports in an attempt to amplify knowledge of the clinical course and improve the management of these older patients. The 40 years, 1940 to 1979, have been selected in order to encompass periods before and after 1%1 when the first older patient with a persistent ductus was treated surgically in Edinburgh. During this time 37 patients (among a total of 804 with persistence of the ductus) had reached 50 years of age before death, surgical treatment, or their last medical assessment. Twentynine were women and eight were men. In five patients, severe pulmonary hypertension was associated with a right to left shunt. The progress of the 32 patients, in whom the shunt was exclusively from left to right, is the subject of the present study (Table). One of the...

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Ulcerative Colitis-Watts et al. BRnR= 1453The initial severity and extent of disease give a poor guide to the ultimate outcome of patients with ulcerative colitis, partly because the disease shows a tendency in many patients to extend proximally.Further analysis, however, shows that the severity and extent during each year profoundly influence the course and outcome during that year. Each patient-year in which a severe attack of colitis occurs carries a risk to life of 14%. Each patient-year in which there is total involvement of the colon and rectum carries a risk to life of 2.7%, and this risk is relatively unaffected by age or duration of colitic symptoms. It is argued that patients with total involvement should therefore be recommended to undergo elective proctocolectomy; for this form of treatment in the long run carries considerably less risk to life.We are grateful to Dr. Richard Doll for his advice and criticism in the preparation of this paper.