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SUMMARY Seven cases of diffuse interstitial lung disease (DILD) are reported with an unequivocal temporal relationship between the development of the lung disease and treatment with gold (6 cases) and penicillamine (1 case). They were characterised clinically by the sudden onset of dyspnoea and crepitations and radiologically by diffuse bilateral pulmonary shadowing. Most showed evidence of hypersensitivity such as eosinophilia, a raised serum IgE level in response to gold, proteinuria, thrombocytopenia, or an immediate postinjection reaction. DILD is a serious complication of treatment with gold and penicillamine that is commoner than generally realised.

SUJMMARY In a randomised, double blind, parallel group study in patients with symptomatic gastric ulcer (94% >-5 mm diameter), 102 received omeprazole 20 mg om and 87 cimetidine 400 mg bd. After four weeks 73% and 58% (p<0 05) respectively had healed (eight weeks: 84% and 75%, ns). After four weeks, a greater proportion (81%) of omeprazole treated patients was symptom free than of those receiving cimetidine (60%; p<001). Over the first two weeks, patients receiving omeprazole had less day pain, less night pain and took fewer antacids than those receiving cimetidine (all p<0 05). The difference between omeprazole and cimetidine was not appreciably affected by age, smoking, size of the ulcer and trial centre. Tolerability was similar in the two treatment groups. In the treatment of symptomatic gastric ulcer, omeprazole relieves the symptoms more quickly than cimetidine and heals a greater proportion of ulcers within four weeks.Omeprazole specifically inhibits HK -ATPase, the 'proton pump' in the parietal cell' thereby effectively controlling gastric acid secretion.' Whilst 20 mg om omeprazole has been shown to heal a greater proportion of duodenal ulcers within two and four weeks than H2-receptor antagonists, there have been fewer studies in patients with gastric ulcer.4 One' showed similar efficacy of omeprazole and ranitidine but included small ulcers which healed quickly on both regimens; two others5" showed that omeprazole 20-40 mg healed gastric ulcers more quickly than ranitidine 150 mg bd.The present study was designed to compare omeprazole 20 mg om with cimetidine 400 mg bd on both the healing and the relief of symptoms of gastric ulcer. Particular attention was directed to the time course of the relief of symptoms with the two drugs. The trial was a randomised double blind parallel group comparison of omeprazole 20 mg om and cimetidine 400 mg bd in 16 centres in the UK and the Republic of Ireland. Details of recruitment are given at the end of the paper: 13 centres were in the gastroenterology units of district hospitals and three involved local general practitioners in the treatment (but not endoscopic assessment) of patients. Blindness was maintained by the 'double dummy' technique: patients took either one active 20 mg omeprazole capsule each morning and one placebo tablet morning and evening or one placebo capsule each morning and one 400 mg cimetidine tablet morning and evening. At randomisation, patients were stratified by age (<65; :65) and smoking (current smoker; non-smoker) for prospectively defined subgroup analyses; separate sets of drug packs were used for each of the four subgroups.

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Data on clinical chemistry test use and revenue expenditure per admission or per outpatient visit, were supplied monthly to three consultant physicians.3 The data were provided as eight histograms on four sheets of A4 paper. The first sheet compared clinical chemistry use and expenditure among the physicians on inpatients for that month. The other sheets provided data for the previous 12 months comparing each physician's use and expenditure with the mean of the other four physicians. These data were separated into within hours and out of hours for inpatients and for outpatients. Two consultant physicians who received no information served as controls. Unknown to the physicians, we also collected data on their haematology requests throughout the study period and on their clinical chemistry requests and costs after feedback had stopped. A request was defined as any number of samples taken from a patient at any one time and sent to the laboratory for one or more analyses (tests).Changes in the feedback and control groups were assessed by comparing laboratory use and expenditure before (baseline) (01.11.88 to 30.04.89), during (intervention) (01.05.89 to 30.04 90), and after (follow up) (01.05.90) to 31.10.90) the feedback using the Mann-WXhitney U test. P values of < 0 05 were regarded as significant. ResultsThe numbers of emergency admissions and new outpatient visits in the intervention (92% and 21%, respectively) and control (88% and 10%, respectively) groups remained unchanged throughout the three study periods.In the baseline period the variation in the physicians' clinical chemistry requests on inpatients was 1 5-fold and 3-6-fold on outpatients.In the one year intervention period, there was an immediate and sustained decrease of 15%, 27%, and 21% in clinical chemistry requests (p < 0 01), tests (p < 0-001), and expenditure (p < 0-001), respectively, and a 10% reduction in haematology tests (p < 0-05) per outpatient visit in the intervention group. These changes persisted in the six months after the feedback had stopped (tables 1 and 2). There were no significant decreases for inpatients in the intervention and control groups (tables 1 and 2).The cost of providing the feedback was £530 a year. The corresponding annual savings in revenue expenditure and cash (consumable costs) achieved through a reduction in out-248 on 11 May 2018 by guest. Protected by copyright.

Hubert WT, Rosen MN. Pasteurella multocida infection. II. Pasteurella multocida infection in man unrelated to animal bite. AmJ7 Public Health 1970;60:1/09.

In a 1 year prospective study we evaluated the effect of feedback of laboratory data on the requesting behaviour of physicians in general medicine. Data on within-hours and out-of-hours clinical chemistry laboratory usage and revenue expenditure for inpatients and outpatients, expressed in terms of clinical workload, were supplied monthly to a group of three consultant physicians in general medicine. With these data the physician could monitor his performance over a period of time and compare it with that of his peers. Two consultants in general medicine who received no information served as controls. Over a period of 6 months, there was a 25%, 13% and 18% decrease in tests (P less than 0.01), requests (P less than 0.05) and revenue expenditure (P less than 0.01) per outpatient visit, respectively, in the intervention group of physicians following the introduction of feedback when compared to their baseline period and to the control group. The decrease (P less than 0.01) was in the commonly requested and 'seemingly cheap' tests. There was no significant change in laboratory use and expenditure on inpatients. The feedback of laboratory data was acceptable to the physicians, raised their awareness of laboratory usage and costs and decreased laboratory workload and expenditure.

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