Diagnosis Of Peptic Ulcer Research Articles

Is Helicobacter pylori Infection an Occupational Hazard for Anesthesiologists?

In the process of doing their daily job, anesthesiologists are exposed to the secretions of the upper airways and stomachs of their patients. These secretions may carry pathogens, which can lead to clinically significant infections. Among these pathogens is Helicobacter pylori (formerly Campylobacter pylori) [1]. First described in 1983, H. pylori has been implicated as the major etiological factor in chronic type B gastritis [2]. In addition, there seems to be a strong association between the presence of H. pylori and peptic, as well as gastric, ulcers. Furthermore, infection with H. pylori has been linked to an increased risk of developing gastric carcinoma [3]. The mode of transmission of this organism is unclear: both oral-oral and fecal-oral routes have been postulated. Epidemiological studies of H. pylori indicate an increased prevalence with age, lower socioeconomic status, and being born outside the United States [4]. Of concern to anesthesiologists, studies have shown that gastroendoscopists and nurses seem to have an increased prevalence of H. pylori antibodies, which may be suggestive of an occupational hazard [5-7]. In contrast, dentists do not seem to be at increased risk [8]. The purpose of this study was to determine the prevalence of H. pylori antibodies among a group of practicing anesthesiologists. Methods This study was reviewed and approved by our human investigation committee. The clinical faculty members and residents of the department of anesthesia at Yale University were approached and asked to participate in this study. Each subject completed a self-administered survey form. The survey included the following items: age, gender, country of origin, years of clinical practice (including residency training), race, any history of chronic dyspepsia, use of antacids or H2 blockers, previous diagnosed H. pylori infections, and previous diagnosis of peptic or gastric ulcer. The presence of immunoglobulin G antibodies to H. pylori was determined by using the AccuStat[trade mark sign] H. pylori test (Boehringer Mannheim, Indianapolis, IN). The test kit uses a qualitative immunochemical membrane assay. The two investigators (KHS and ASH) performed all testing. Quality control testing was performed as suggested by the manufacturer. According to published studies, this test has a sensitivity of 83%-89% and a specificity of 78%-91% compared with biopsy-proven disease [9-11]. Subjects were given their results and counseled as necessary. Data were analyzed using descriptive and comparative (chi squared) statistics and are reported as mean +/- SD. Results Fifty-three practicing anesthesiologists were tested in 1998. Although general medical clearance is required for hospital appointment, H. pylori testing is not routinely performed. The mean (range) demographics of the group were age 39 +/- 7.9 (28-56) yr, years of clinical practice 9 +/- 7.5 (1-30), male 67%, and American-born 47%. Fifteen (28%) reported chronic dyspepsia and 12 (23%) reported using antacids or H2 blockers over the last month. Of this group, two subjects (4%) tested positive. Our results were then compared with two published controlled groups from the eastern United States. The first control group was from Charlottesville, VA, and its data were collected in 1988 [6]. It consisted of 510 healthy blood donors (age 41 [20-77] yr). Using an enzyme-linked immunoadsorbent assay (ELISA) (Pylori Screen; New Horizons Diagnostics, Columbia, MD), the authors found that 72 (14%) individuals were seropositive to H. pylori. The second control group consisted of 441 volunteer blood donors (age 42 [20-91] yr). The samples were collected in 1992 in Tennessee [5]. This group was tested using a different ELISA made by Biomerica Inc (Newport Beach, CA). Using this assay, 114 (25%) of the donors were found to be seropositive. The percentage of H. pylori positivity among the anesthesiologists, 4% (2 of 53), differed significantly from that of the combined control groups: 19% (187 of 951) (P < 0.01). There was no association found between H. pylori antibody status and age, gender, country of origin, or years of clinical practice among the group of tested anesthesiologists. Discussion Intrinsic to the care of patients is the potential of exposure to pathogens. Anesthesiologists spend extended time in close proximity to their patients. In addition, they are often exposed to body fluids while performing endotracheal intubations and starting IV lines [12]. The low detected prevalence among this group of anesthesiologists was surprising given the high percentage of subjects born outside the United States, a well described risk factor. The low prevalence may be due to a number of factors, including higher socioeconomic status (compared with the general population), contact with low-risk patients (compared with gastroenterologists), and the controlled environment of the operating room (compared with the gastrointestinal clinic). In conclusion, H. pylori infection does not seem to be an occupational hazard for anesthesiologists.

Economic constraints in the diagnosis of peptic ulcer disease

The discovery of Helicobacter pylori and its role in upper gastrointestinal disease has changed the outlook on diagnosis of peptic ulcer disease. To address the questions of what types of diagnostic tests and how many of each type are needed to diagnose among patients with dyspepsia as many ulcers as possible at least cost. Bayes' formula and a decision tree were used to follow the outcomes of alternative test combinations for ulcer diagnosis. Assuming unlimited resources, only endoscopy of all subjects results in the correct diagnoses of all ulcers, but costs $5600 per diagnosis. Barium swallow followed by endoscopy is less expensive ($2980), but misses 5% of all ulcers. Serology for H. pylori followed by endoscopy or barium meal provides relatively high diagnostic yields (85 or 81% of all ulcers detected) at lower costs ($2900 or $1050 per ulcer diagnosis, respectively). In general, a higher number of ulcers is found at a lower cost if the cheap tests are used to screen patients before subjecting them to the more expensive tests. The ideal work-up depends on the urgency of a correct diagnosis, the willingness to miss some ulcer diagnoses and the availability of resources. H. pylori serology followed by endoscopy or barium meal represents two cost-effective strategies.

The quality of care for medicare beneficiaries with peptic ulcer disease: A multistate quality improvement project

Purpose: There are approximately 600,000 individuals each year discharged from US hospitals with a diagnosis of peptic ulcer disease. In 1994, the NIH disseminated guidelines recommending that all patients with documented ulcers be tested for H. pylori infection and treated if present. In addition, NSAID use has been identified as the cause of up to 50% of ulcers in the Medicare population. The purpose of this study is to examine state-wide and interstate variation in the process of care, and to evaluate the quality of care for hospitalized Medicare beneficiaries with peptic ulcer disease. Methods: Five Peer Review Organization (PRO) Quality Improvement collaborators (Colorado, Connecticut, Georgia, Oklahoma and Virginia) used 1995 Medicare claims files to select state-wide samples of inpatients with a principal diagnosis of peptic ulcer during the period from January, 1, 1995-June, 30, 1995. Each collaborator selected 100% of the claims until 550 cases were selected in each state. Quality of care indicators were developed by a multi-state group with content experts and include: the percent of ulcer patients screened for H. pylori, the percent of patients who had a biopsy who received a tissue test, the percent of H. pylori positive patients who received appropriate therapy, the percent screened for pre-admission NSAID use, and the percent counseled about the risks of NSAID use. Statistical analysis was performed using Pearson's Chi-squared test. Results: 2,621 patients were eligible for medical record review. There was a median age of 78, with 43% of the sample male. Inter-rater reliability testing for chart abstraction resulted in a mean Kappa value of .81. Only 57% of hospitalized Medicare beneficiaries with PUD were screened for H. pylori, and only 73% of those testing positive were treated with appropriate anti-H, pylori therapy. 84% of patients who had endoscopic biopsies taken received a tissue test for H. pylori. 74% of patients were screened for pre-admission NSAID use, but only 24% and 2% were counseled about NSAID use and the specific ulcer risks of NSAID use respectively. There was statistically significant regional variation for four of the six quality indicators: H. pylori screening, screening for non-steroidal anti-inflammatory drug use, counseling about NSAID use, and counseling about ulcer risks associated with non-steroidal anti-inflammatory drug use. Conclusions: Well accepted guidelines for the management of NSAID and H. pylori related PUD exist, but are not always observed. There is an opportunity to improve the quality of care by improving screening for H. pylori in hospitalized Medicare beneficiaries with PUD. Substantial opportunities also exist to improve counseling about NSAIDS and their ulcer risks. Improving H. pylori screening and treatment in those infected may prevent hospital admissions, ulcer recurrences and complications of ulcer disease.

Time Trends for Peptic Ulcer Disease in Denmark, 1981-1993: Analysis of Hospitalization Register and Mortality Data

Background: Since the mid-1980s there has been great improvement in the available diagnostic tools and treatments for peptic ulcers. The aim of this study was to determine whether these improvements have been paralleled by decreasing age- and sex-specific hospitalization and death rates for peptic ulcers in Denmark. Methods: The study was based on all discharges from Danish somatic hospitals as registered in the National Hospital Discharge Registry and all the death certificates as registered in the Danish National Board of Health from 1981 through 1993, when a diagnosis of peptic ulcer was recorded. The age- and sex-specific and age-adjusted hospitalization and death rates were estimated. Results: In men the age-adjusted hospitalization rate for all types of peptic ulcers decreased by 0.88, but the mortality increased by 1.19. In women the age-adjusted hospitalization and mortality increased for all types of peptic ulcers. The increasing mortality was mainly due to bleeding and perforated duodenal ulcers. The analysis of the age-specific hospitalization and mortality for peptic ulcer complications showed that the increasing trends mainly occurred among the elderly. Conclusion: The improved medical treatment of peptic ulcers has not been paralleled by decreasing hospitalization or death from complicated peptic ulcers in Denmark. On the contrary, we found an increasing hospitalization and mortality from peptic ulcer complications, particularly in elderly Danish people.

Heartburn and dyspepsia: the utility of symptom analysis

SUMMARYPatients presenting with dyspepsia and heartburn are a heterogeneous group and a more precise identification of the cause of the symptoms is a prerequisite for a rational treatment. The patient's history is the basic diagnostic tool. Therefore it is important to evaluate the utility of symptoms as a predictor of any organic disease, like peptic ulcer, or as a predictor of a favourable symptomatic response to a specific drug treatment, such as omeprazole. When the history alone was used to discriminate between peptic ulcer and non‐ulcer dyspepsia half of the patients with endoscopically‐confirmed active ulcer were misdiagnosed as not having ulcers. Furthermore, in two‐thirds of the patients in whom a clinical diagnosis of peptic ulcer was made, this was not confirmed at endoscopy. Heartburn is recognized as a symptom of reflux oesophagitis, but most patients complaining of heartburn have no visible mucosal lesion at endoscopy. The predictive value of heartburn depends on its severity; one‐half of patients with severe heartburn, in fact, have oesophagitis. When symptoms of reflux oesophagitis are used in a scoring system, the diagnostic sensitivity is about 50% while the specificity is 34–85%, depending on the severity of symptoms. When a complete patient history is used as a predictor, the diagnostic value increases significantly. Patients with endoscopy‐negative dyspepsia and heartburn are a common problem and acid inhibitory drugs are widely used to manage the disease. The rationale for prescribing an acid inhibitor in this situation is the assumption that the symptoms are acid‐related, but this is only the case for a subgroup of these patients. Identification of those patients who have acid‐related symptoms is possible using omeprazole as a diagnostic tool, either in an open design or in a placebo‐controlled single‐subject trial. When heartburn is a predominant symptom, 50% of the patients respond to the acid inhibitory treatment, while this is the case for only one‐third of patients when heartburn is not the dominating symptom. It is important to identify symptoms that, when present, significantly reduce the likelihood of a specific diagnosis or condition. This is the case with the symptom of loose stools in patients with dyspepsia, where it reduces the likelihood of a symptomatic improvement during treatment with omeprazole. In conclusion, symptoms do not reliably predict the underlying disorder, whether this is an organic disease or endoscopy‐negative dyspepsia. Clusters of symptoms or the more global clinical judgement seem to have a higher discriminative value compared with a single symptom.

Lack of gender and racial differences in surgery and mortality in hospitalized Medicare beneficiaries with bleeding peptic ulcer.

Determine the relation of race and gender to outcome from bleeding peptic ulcer. Retrospective cohort study. All acute care hospitals in the United States. A 100% sample of hospitalized Medicare beneficiaries older than 64 years (n = 82,868) with a primary discharge diagnosis of peptic ulcer with hemorrhage. Surgical treatment was performed in 6.9% of patients, 30-day mortality was 8.5%, and average length of stay was 9.4 days. Surgery was somewhat more common in men than women (7.3% vs 6.5%, p < .001), and in whites than African Americans (6.9% vs 6.3%, p < .001), but neither race nor gender was associated with surgery in multivariable analysis adjusting for potentially confounding factors. Mortality rates were similar in African Americans and whites (8.5%), and somewhat higher in men than women (10.7% vs 9.3%, p < .001). In multivariable analysis, there was no difference in mortality across gender and racial groups. Although unadjusted and adjusted lengths of stay were longer for African Americans and shorter for men, the differences were modest (i.e., 16% increase and 6% decrease in multivariable analysis, respectively, p < .0001). In this national sample, there is no significant gender or racial difference in therapy and outcome for patients with hemorrhagic peptic ulcer. The findings raise the possibility that studies that have shown race and gender differences in management of coronary artery disease and cancer may not be generalizable to other common diagnoses.

Interobserver agreement on endoscopic diagnosis of bleeding peptic ulcers

Background: The aim of this prospective study was to evaluate the interobserver agreement of stigmata of recent hemorrhage of bleeding peptic ulcers. Methods: Sixty-one consecutive adult patients were enrolled in the study and nine (three junior and six senior) endoscopists reviewed standardized video recordings of endoscopic examinations. Interobserver agreement was evaluated using the kappa (κ) index, intraclass correlation coefficient, and proportion of agreement. Observer bias and poorly trained observers were investigated. Results: Interobserver agreement was very good for oozing (κ = 0.68), good for clot (κ = 0.51), poor for spurting (κ = 0.29) and visible vessels (κ = 0.33), and excellent for the absence of stigmata (κ = 0.82). Observer bias sometimes occurred and the number of poorly trained observers was low. The κ indexes were significantly better in senior than in junior investigators: 0.48 ± 0.16 versus 0.37 ± 0.26, respectively, p < 0.05. The agreement between the in vivo evaluation and video tape recordings (intraobserver agreement) was good (κ = 0.60 ± 0.19). There was no training phenomenon between the first and the second half of the patient group. Conclusions: The endoscopic classification of bleeding ulcers might be simplified by limiting grading to a few classes. Special attention should be paid to the training of endoscopists.(Gastrointest Endosc 1997;46:27-32)

Management of haematemesis and melaena.

Upper gastrointestinal bleeding remains a common medical emergency with high morbidity and mortality. High risk patients are best managed in specialised units. Endoscopy is the procedure of choice for diagnosis and haemostatic therapy of peptic ulcers, reducing deaths and the probability of rebleeding, as well as the need for surgery; for acute variceal bleeding, pharmacotherapy followed by endoscopic ligation is recommended.

Nonulcer Dyspepsia in a Dutch Working Population and Helicobacter pylori

There is considerable debate about whether Helicobacter pylori infection is important in causing nonulcer dyspepsia. Many studies assessing this relationship have been performed in selected patient populations and included patients with a history of peptic ulcer. General population-based data with attention to ulcer history are needed to clarify this relationship. A questionnaire on ulcer history and dyspeptic symptoms during the preceding 3-month period was obtained from apparently healthy employees who underwent a periodic medical examination in the Netherlands. In addition, serum samples were analyzed for anti-H pylori IgG antibodies. A total of 427 men and 73 women, aged 22 to 69 years, participated in the study. None of the women but 27 men (6%) had a previous diagnosis of peptic ulcer. Among 19 unoperated-on men with verified duodenal (17 subjects) and gastric (two subjects) ulcer, 89% were H pylori positive, while 74% had frequent dyspeptic symptoms in the 3 months before the study. Among the 400 men and 73 women without an ulcer history, the 3-month period prevalence of frequent dyspepsia was 13% and 21%, respectively. The rate of H pylori positivity was 25% in subjects with nonulcer dyspepsia and 29% in all others. The H pylori infection rate increased with age and with a lower occupational level but was independent of gender. In the male population, various differences in symptoms between H pylori-positive and H pylori-negative subjects could be detected when the 27 subjects with a history of ulcer were included, whereas these differences disappeared when these subjects were excluded. In the Dutch working population, nonulcer dyspepsia is not related to H pylori infection, whereas for duodenal ulcer the relationship is clear. The apparent association between dyspeptic symptoms and H pylori infection is entirely accounted for by subjects with an ulcer history.

The natural course of peptic ulcer disease and its predictors.

Little is known about today's natural course of peptic ulcer disease (PUD). A follow-up study based on a structured telephone interview was attempted in 728 patients with an endoscopic diagnosis of peptic ulcer in 1980-84. Seven patients (1%) died because of PUD during the 8- to 10-year follow-up period. Of the 441 interviewed patients 15.2% had experienced no further clinical manifestations of PUD, 10.9% had had bleeding and 0.7% perforation, and 17.5% had been operated on. The operated patients reported fewer symptoms (p < 0.01) during the last 2 weeks before the interview than those not operated on. On an average the unoperated patients had had symptoms and had used histamine-2-receptor antagonists (H2RA) 12 and 10 weeks per year, respectively. Long-term treatment with H2RA was reported by 18%. More than one-third (36%) of the unoperated patients stated that the symptoms had had a significant negative impact on their lives. Age at onset of disease and index ulcer, family history, use of anti-inflammatory drugs and alcohol, bleeding, and another chronic disease were found to be significant predictors of the course. In more than one-third of the patients with PUD the course is still burdened with many symptoms and complications.

Anti-Helicobacter pylori antibodies prevalence and gastric adenocarcinoma in Portugal

Evidence from large cohort studies has established an increased risk of gastric cancer for individuals infected with Helicobacter pylori (HP). In low incidence countries, like the United Kingdom and Sweden, case-control studies suggested that the prevalence of anti-HP antibodies in gastric cancer patients (at the time of cancer diagnosis) is greater than in control populations. We present results from a case-control study of the prevalence of IgG anti-HP antibodies in gastric cancer patients and a control population in a country with a high incidence of gastric cancer. Sera were studied from 80 gastric cancer patients (GC group) admitted consecutively to our department in 1990/91, and from 80 controls (CT group) matched by age and sex. IgG anti-HP was determined by ELISA. Patients' files were reviewed for evidence of previous diagnosis of peptic ulcer, gastric surgery, tumor localization and histopathological classification. Controls were submitted to a questionnaire for past history of peptic ulcer and gastric surgery. Positive results for anti-HP were: gastric cancer patients, 70.0%; control group, 81.5% (NS). However, the median optical densities (OD, a measure of antibody concentration) were significantly lower in the gastric cancer group than in controls: gastric cancer patients, 0.720 +/- 0.424 OD; control group, 0.906 +/- 0.443 OD (P = 0.004). There were no differences concerning past history of peptic ulcer or surgery. The proportion of positives for cancer of the cardia (66.7%) was lower than for the other tumour localizations (70.4%) (NS). Anti-HP positivity was lower in patients with gastric cancer associated with intestinal metaplasia than in controls (P = 0.14).(ABSTRACT TRUNCATED AT 250 WORDS)

Pneumogastrogram in the diagnosis of perforated peptic ulcer.

Early diagnosis and surgical intervention is important in the management of peptic ulcer perforation. This study looks at the value of a pneumogastrogram in the diagnosis of patients suspected of having a perforated peptic ulcer. One hundred and twenty-nine patients were studied. Pneumogastrogram increased the diagnostic yield of pneumoperitoneum from 66% following plain erect X-ray examination to 91%. The procedure was free of complications.

Perforated peptic ulcer in the Hunter region: a review of 174 cases.

A review of 174 consecutive patients admitted with a diagnosis of perforated peptic ulcer to eight Hunter Region hospitals during 1979-86 is presented. Among the female admissions, the proportion of patients greater than 70 years of age was twice that in males. One-third of all perforations were in females who accounted for two-thirds of all perforated gastric ulcers. Multivariate analysis revealed that perforations located in the stomach and older age were both significant independent variables adversely affecting outcome following surgery. In contrast, shock at presentation and delay in operating were not statistically significant independent risk factors.

Acid peptic disease in adolescents

Acid peptic disease in adolescents may be more common than previously recognized. However, appropriate medical attention is often delayed because of misdiagnosis and undertreatment. Thorough questioning of adolescent patients is important to elicit a complete description of symptoms. Endoscopy or intraluminal pH monitoring may be necessary to establish a diagnosis of gastroesophageal reflux disease or peptic ulcer. Therapy with histamine receptor antagonists, especially ranitidine (Zantac), is recommended. Antireflux surgery may be needed to prevent potential long-term gastrointestinal damage. Patients with duodenal ulcer should also be advised to make life-style changes to avoid recurrence of disease later in life.

Diagnostic approaches and treatment of peptic ulcer at Chulalongkorn University Hospital, Bangkok

Gastroscopy is the main investigative tool in the diagnosis of peptic ulcers in Thailand. In spite of its potential diagnostic value, endoscopic biopsy for histologic diagnosis is reserved only for suspected malignant gastric ulcers. Regarding treatment, duodenal ulcers can be treated satisfactorily with either low-dose antacid or one of the various H2-blockers, while gastric ulcers show a fairly good healing response to site-protective agents. Further trials using potent acid inhibitors, antibiotics against helicobacter pylori and plaunotol are being investigated.

Acid Peptic Disease in the Elderly

Research in epidemiology and related fields highlights three factors contributing to a high prevalence of complications of ulcer disease in the elderly, namely anti-inflammatory drugs (aspirin and NSAIDs), type B gastritis due to H. pylori infection, and smoking; these factors also increase the prevalence of both GU and DU. The major dangers with ulcer disease arise from continued exposure to the causative risk factors, absent or insidious symptoms, difficulties in diagnosis, late presentations, high rates of complications (often the presenting features), high preoperative and perioperative mortality, and serious postoperative morbidity (especially in smokers). Empiric therapy and the use of diagnoses such as nonulcer dyspepsia invite additional hazards. Once diagnosed and adequately treated, ulcers in the elderly behave similarly to those in younger subjects matched for risk factors, and they respond well to treatment. In high-risk elderly patients without previous or active ulcer disease, misoprostol may be used to prevent gastric ulcers; other benefits of the drug await clarification. In those with previous or active ulcer disease, H2-antagonists given long-term in higher doses appear preferable. Side effects of antiulcer drugs are rarely serious and are easily managed by dose reductions or changes in products. The major benefits to the management of ulcers in the elderly come from increased vigilance on the part of physicians.

Endoscopic Diagnosis of Gastric Peptic Ulcer Penetrating into the Liver

A 61-year-old man was admitted with upper gastrointestinal bleeding. Endoscopy showed a large gastric peptic ulcer with a pseudotumoral mass protruding from the ulcer bed. Histological examination of biopsies taken from the mass revealed distorted hepatic tissue and inflammatory changes. Hepatic penetration was diagnosed as the cause of bleeding. Surgery findings confirmed the endoscopic diagnosis.

Incidence of Duodenal Ulcer in the Northern Savannah of Nigeria

In 4 years, 200 patients were admitted to the University of Maiduguri Teaching Hospital, in the Northern Savannah of Nigeria, with a clinical diagnosis of peptic ulcer; 60 had the diagnosis of duodenal ulcer confirmed on barium meal or at operation, giving an incidence of 6/1000 adult admissions (excluding obstetrics). There were no gastric ulcers. Forty-four patients had a 'simple ulcer', 10 presented with gastric outlet obstruction, five with peritonitis following perforation and one with haematemesis. There were 44 males, and 16 females, with a mean age of 34 years and mean length of history of 44 months. Contrary to previous published reports improved diagnostic facilities have shown duodenal ulcer to be relatively common in the Northern Savannah of West Africa.

Peptic ulcer among urban bus drivers in Denmark

As part of a survey on the work environment of bus drivers, 2045 (83%) of 2465 male bus drivers in the three major cities in Denmark in 1978 answered a postal questionnaire on health and working conditions. In order to evaluate the relative occurrence of peptic ulcer among the bus drivers, a follow-up study was also conducted. All hospital discharges with a peptic ulcer diagnosis among the bus drivers were registered from the Danish National Patient Register. All Danish men were used as reference group. On the basis of the 1978-questionnaire association between occupational and psychosocial factors and subsequent hospital discharge with a peptic ulcer diagnosis was studied. The prevalence of abdominal pain alleviated by food intake was 12% among bus drivers and 6% in the reference group. The incidence of hospital discharge with duodenal ulcer among younger bus drivers was twice the incidence among Danish men in the same age group. The incidence of all manifestations of peptic ulcer disease among bus drivers did not differ from the incidence among Danish men. Of occupational and psycho-social factors, wage dissatisfaction and smoking showed statistically significant association with hospital discharge with PU in a 6 3/4-year period. Job dissatisfaction, stress symptoms and lack of some social network factors tended to increase the risk of hospital discharge with PU.

Generalised linear models and excess mortality from peptic ulcers

The paper applies the methodology of generalised linear models to the assessment of the level of extra mortality experienced by insured lives who were identified at the date of proposal as then having peptic ulcers. The approach used here is to analyse the force of mortality (or hazard rate) relative to the base-line force of mortality, which is assumed known. This ratio is then represented as a function of several covariables including, for example, age at entry, policy duration, medical status at entry and calendar year of entry, when data are available for a cohort of lives being followed up over time. Various models of this kind are fitted using data from the impaired lives investigation of one major British insurance company together with the statistical package, GLIM. The data set comprises the followup experience of 34,631 male policyholders with a diagnosis of peptic ulcer. One of the objectives of the paper is to illustrate the potential for analysing mortality data (and related data involving decremental or transition rates) using generalised linear models and the statistical package GLIM.