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Endoscopic injection of N-butyl-2-cyanoacrylate appears to be both safe and effective in the treatment of bleeding gastrointestinal tract varices. The relative value of the undiluted substance versus the diluted one should be further evaluated.

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Internal medicine patients are mostly elderly with multiple comorbidities, usually chronic. The high prevalence of comorbidity and multimorbidity has a significant impact on both positive responses to treatment and the occurrence of adverse events. Clustering is the process of nosography grouping into meaningful associations with some index disease, so that the objects within a cluster have high similarity in comparison with one another. In the decision-making process it is imperative that, in addition to understanding the immediate clinical problems, we are able to explicit all the contextual factors that have to be taken into account for the best outcome of care. Cluster analysis could be leveraged in developing better interventions targeted to improve health outcomes in subgroups of patients.

SUMMARY In order to assess the oesophageal motor events associated with the occurrence of gastro-oesophageal acid reflux and those during endogenous acid exposure, we studied six healthy subjects and nine patients with symptoms and lesions of reflux oesophagitis. In the case of each subject simultaneous pressure and pH measurements of the distal oesophagus were taken both in fasting conditions and after a standardised balanced meal. Reflux episodes occurred in the absence of a lower oesophageal sphincter relaxation (34.3%, 17-7%) or in the presence of a relaxation associated (34-2%, 30.8%) or unassociated (31.5%, 51.5%) with a peristaltic sequence, in the controls and patients respectively. No significant differences were found between the two groups. During endogenous acid perfusion the distal oesophagus showed mainly a peristaltic motor activity, but the mean hourly number of peristaltic sequences was significantly lower in the patients than in the controls (33-5±27-2 vs 81-5±3-2, p<0.01). Our results show that the mechanisms of reflux are similar in controls and in patients, while the peristaltic frequency is reduced in the latter. This motor failure may be responsible for the increased reflux duration observed in patients with oesophagitis.Gastro-oesophageal acid reflux can be assessed and quantified by means of reliable techniques.1 2 Nevertheless, there is no agreement regarding the mechanisms of reflux; this is particularly true with regard to the role of the lower oesophageal sphincter. Some authors35 consider a low basal tone of the lower oesophageal sphincter a major cause of reflux, whereas others6 7 suggest that reflux may be related to sphincteric relaxations, particularly when they occur in the absence of a peristaltic sequence.Moreover, manometric studies have shown a failure of the peristaltic function of the oesophageal body in patients with oesophagitis both in basal conditions8S-" and during exogenous acid exposure of the oesophageal mucosa. 1213 Little information is available regarding oesophageal motilitT during reflux induced endogenous acid exposure.The aim of our study was to evaluate, in normal subjects and in patients with oesophagitis: (a) the oesophageal motor events at the occurrence of Address for correspondence: Dr F Baldi, III Clinica Medica, Policlinico S. Orsola, via Massarenti n. 9, 40138 Bologna, Italy. Received for publication 15 June 1984 gastro-oesophageal acid reflux, and (b) the motor activity of the distal oesophagus during acid reflux. Methods SUBJECTSWe performed oesophageal motility and pH studies on six healthy volunteers (four men, age range 23-41 years) and nine patients (six men, age range 24-59 years) with heartburn and/or regurgitation of at least six months duration and endoscopically proved erosive oesophagitis, in the absence of peptic stricture.

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