Showing papers in "BMJ in 1972"

Classification and definition of protein-calorie malnutrition.

Abstract: The Eighth Joint Expert Committee on Nutrition of FAO and WHO1 emphasized the need for an accepted classification and definition of protein-calorie malnutrition. There are two pressing reasons for this. Bengoa* summarized the available information about the frequency of protein-calorie malnutrition in different countries. There are many gaps, partly because for some countries there are no data, and partly because data which do exist are not always comparable. It is important that studies of prevalence should be extended and that the same criteria should be used everywhere. Secondly, the prevailing pattern of malnutrition in any region may give some information about the nature of the dietary deficiency and so will have a bearing on the preventive measures which are most appropriate. There are two schools of thought about this. According to what might now be called the classical theory, kwashiorkor results from a deficiency of protein with a relatively adequate energy supply, whereas marasmus is caused by an overall deficiency of energy and protein. From this it follows that where the kwashiorkor syndrome prevails, protein rich supplements would be an appropriate method of prevention. On the other hand, Gopalan and his co-workers* produced evidence that there are no quantitative or qualitative differences in the diets of children who subsequendy develop kwashiorkor or marasmus. They therefore proposed that the difference in the clinical picture reflects not a difference in diet but a difference in the capacity of the child to adapt. Whichever of these theories is correct the fact remains that according to reports in the literature the prevailing pattern does differ from one country to another.4 If the differences are real there must be some reason for them, and the first step in finding the reason is to put the observations on a firm foundation with an agreed system of classification. The need for this is urgent because an alteration in the pattern of protein-calorie malnutrition and in its age of onset has important implications for the planning of preventive policies.

Computer-aided Diagnosis of Acute Abdominal Pain

Abstract: This paper reports a controlled prospective unselected real-time comparison of human and computer-aided diagnosis in a series of 304 patients suffering from abdominal pain of acute onset. The computing system9s overall diagnostic accuracy (91·8%) was significantly higher than that of the most senior member of the clinical team to see each case (79·6%). It is suggested as a result of these studies that the provision of such a system to aid the clinician is both feasible in a real-time clinical setting, and likely to be of practical value, albeit in a small percentage of cases.

Iron-binding Proteins in Milk and Resistance to Escherichia coli Infection in Infants

Abstract: Human milk contains large quantities of iron-binding protein, of which the greater proportion is lactoferrin, though small amounts of transferrin are also present. Three samples of human milk with unsaturated iron-binding capacities of between 56 and 89% had a powerful bacteriostatic effect on Escherichia coli O111/B4. The bacteriostatic properties of milk were abolished if the iron-binding proteins were saturated with iron. Purified human lactoferrin, in combination with specific E. coli antibody, strongly inhibited the growth of E. coli, and this effect was also abolished by saturating the lactoferrin with iron.Guinea-pig milk also contains lactoferrin and transferrin. Newly born guinea-pigs fed on an artificial diet and dosed with E. coli O111 had higher counts of E. coli O111 in the intestine than suckled animals. The apparent suppressive effect of guinea-pig milk on E. coli in the intestine could be reversed by feeding the iron compound haematin. It seems that iron-binding proteins in milk may play an important part in resistance to infantile enteritis caused by E. coli.

Ferritin in the Serum of Normal Subjects and Patients with Iron Deficiency and Iron Overload

Abstract: The concentration of ferritin in serum gives a quantitative measure of the amount of storage iron in normal subjects and those with iron deficiency or overload. The mean level in normal men is 69 ng/ml, compared with 35 ng/ml in normal women. A concentration below 10 ng/ml is associated with a low transferrin saturation and iron-deficient erythropoiesis.

Cigarette smoking in pregnancy: its influence on birth weight and perinatal mortality.

Abstract: In a British population cigarette smoking during pregnancy increased the late fetal plus neonatal mortality rate by 28% and reduced birth weight by 170 g, and these differences persist even after allowing for a number of “mediating” maternal and social variables. A change in smoking habit by the end of the fourth month of pregnancy places a mother in the risk category appropriate to her changed habit. This evidence should have important implications for health education aimed at getting pregnant mothers to give up smoking.

Autonomic Disturbance at Onset of Acute Myocardial Infarction

Abstract: Of 74 patients seen within 30 minutes of the onset of acute myocardial infarction 68 (92%) had signs of autonomic imbalance. Excessive vagal activity was evident in 41 (55%) and there was sympathetic overactivity in 27 (36%). The high incidence of sudden death in the acute phase of a coronary attack probably results from the electrical imbalance caused by autonomic disturbance. This disturbance must therefore be taken into account in any prophylactic regimen against the lethal early ventricular dysrhythmias.

Treatment of Early Breast Cancer: A Report after Ten Years of a Clinical Trial

Abstract: A controlled clinical trial has been carried out to compare radical mastectomy with wide excision (extended tylectomy) in the treatment of early breast cancer. Only patients aged 50 and over were included and 370 entered the trial during a period of 10 years. Postoperative radiotherapy was given in each case. In patients with clinically involved axillary nodes there was a significantly higher incidence of local and distant recurrence in those having a wide excision, and the survival of these patients was significantly less than those who had a radical mastectomy. In patients with clinically uninvolved nodes, although there was a significantly higher incidence of local recurrence in those having a wide excision, there was no increased incidence of distant recurrence and the survival rate was similar to those having a radical mastectomy.

Beclomethasone Dipropionate: A New Steroid Aerosol for the Treatment of Allergic Asthma

Abstract: Beclomethasone dipropionate was used in pressurized aerosols for the treatment of 60 cases of chronic allergic asthma for up to 15 months. Twenty-eight out of 37 cases were transferred to this treatment after being dependent on oral steroids for up to 16 years. Nineteen out of 23 other asthmatics not dependent on steroids were also completely controlled. No biochemical evidence of adrenal suppression was found. Steroid withdrawal symptoms were often a problem, suggesting absence of systemic absorption. The precise mode of action and metabolic fate of this corticosteroid are not yet known.

Immediate Effects of Intravenous Verapamil in Cardiac Arrhythmias

Abstract: Verapamil was administered by intravenous injection to 181 patients with various cardiac arrhythmias. The automaticity of the cardiac pacemaker was slowed in sinus, idionodal, and idioventricular tachycardia. In atrial fibrillation the drug usually slowed the ventricular response and often made it regular. In some cases atrial flutter was converted to sinus rhythm, the ventricular response being reduced in the remainder. Conversion of paroxysmal supraventricular tachycardia to sinus rhythm was consistently achieved. A favourable response occurred in four patients in whom arrhythmias were associated with pre-excitation syndromes. There were no adverse clinical side effects.

The red cell.

Abstract: There is no general agreement about the best therapy of myxoedema coma. It is common practice to give thyroxine in doses of 0 05 mg daily by mouth combined with triiodothyronine 20 Fg twice daily by intramuscular injection together with hydrocortisone hemisuccinate 50 mg twice daily (in case of adrenal failure). Assisted respiration may be required if there is carbon-dioxide retention or hypoxaemia. Infections, cardiac failure, or arrhythmias should be treated vigorously and cardiac monitoring is desirable. The body temperature should be slowly raised -to normal, using a \"space blanket\" and heating pads if necessary, in a warm room.

Role of plasma carcinoembryonic antigen in diagnosis of gastrointestinal, mammary, and bronchial carcinoma.

Abstract: Our studies have confirmed that raised plasma levels of carcinoembryonic antigen (C.E.A.) occur with many but not all malignant tumours, particularly those of the gastrointestinal tract, breast, and bronchus. However, the incidence of raised values may reach 30% in diseases associated with inflammation or regeneration or both. Consequently, it cannot serve yet as a routine screening test for cancer. Effective surgical therapy results in high plasma C.E.A. levels returning to normal. Subsequent rises appear to develop with tumour recurrence or spread. At present the most useful role for C.E.A. seems to be in monitoring patients during the post-therapeutic followup period. Further basic work is required before C.E.A. can become of routine medical value.

Galactorrhoea: Successful Treatment with Reduction of Plasma Prolactin Levels by Brom-ergocryptine

Abstract: In five patients with inappropriate lactation and amenorrhoea or impotence brom-ergocryptine was found to suppress the lactation and to diminish the raised plasma prolactin levels. The responses to treatment suggest that there may be an inverse relationship between prolactin secretion and gonadotrophin secretion in man.

Outcome of investigation of patients with presenile dementia.

Abstract: Of 106 patients admitted for investigation to a neurological hospital with a presumptive diagnosis of dementia, 84 were confirmed to have intellectual impairment or loss of learning and memory function or both. A possible aetiology for the dementia was found in 36 of these 84 patients; the commonest causes discovered were intracranial mass lesions, arterial disease, and alcoholism. Fifteen of the 106 patients were found not to be demented but to have some other illness, most commonly depression. Of the whole series some 15% of the patients suffered from conditions that were amenable to treatment.

Skin Bacteria and Skin Disinfection Reconsidered

Abstract: Large discrepancies in the available data on skin microbiology stimulated investigations of the number, interactions, and location of commensals and the true efficiency of disinfection by using skin biopsy, culture of frozen sections, and other methods.Most current procedures were less than 0.5% as sensitive as the biopsy method described. This gave mean bacterial counts ranging from 4,400/cm(2) on the breast to 400,000/cm(2) in the axillae. An iodine preparation removed 95% of accessible organisms, but about 20% of bacteria were protected by follicles, crevices, and lipids. Commensals in over 20% of people produced antibiotics against a wide range of pathogens. Conversely, "satellitism" was demonstrable in 12% of people.

Relation between Age of Onset of Obesity and Size and Number of Adipose Cells

Abstract: The size and number of adipose cells in obese children and adults were compared with control data. An increase in adipose cell size was found in all the obese subjects. The total number of adipose cells was increased in those children who had become obese already by the age of 1 year and in those adults who dated their obesity to childhood.

Plasma Levels and Therapeutic Effect of 25-Hydroxycholecalciferol in Epileptic Patients taking Anticonvulsant Drugs

Abstract: Plasma levels of 25-hydroxycholecalciferol (25-HCC) were measured by a specific competitive protein-binding assay. Mean levels in both normal London adults and adolescent schoolchildren were 16 ng/ml and the mean level in a group of epileptic patients on high-dosage anticonvulsant therapy was 5 ng/ml, (difference from normals P

Spontaneous rupture of hepatocellular carcinoma.

Abstract: Forty-two cases of ruptured hepatoma with intra-abdominal haemorrhage were seen over a period of eight years in the professorial surgical unit at the Queen Mary Hospital, Hong Kong. In all, 207 cases of liver cancer were seen during this period, giving an incidence of rupture of 14.5%. There were 37 men and five women. The clinical features were the sudden onset of pain with shock and the presence of blood in the peritoneal cavity. The diagnosis was made before operation on suspicion and by a process of elimination. In cases of doubt paracentesis abdominis was performed to determine whether there was blood in the peritoneal cavity. Treatment was directed to control of haemorrhage and resection.The prognosis, although extremely poor, is no worse than the hepatocellular carcinoma that has not ruptured. There was one long-term survivor-a patient who had undergone an extensive resection. The man was alive and well after more than five years.

Prevention of Deep Vein Thrombosis by Intermittent Pneumatic Compression of Calf

Abstract: A consecutive, randomly allocated, controlled clinical trial of the prophylactic effect of intermittent pneumatic compression of the calf on the incidence of postoperative deep vein thrombosis showed that in patients without malignant disease there was a highly significant reduction in the incidence of thrombosis. In patients with malignant disease the incidence of thrombosis was higher than in those without, and there was no reduction in incidence by the application of intermittent compression. In the absence of malignant disease, severity of operation and the age of the patient were the most significant aetiological factors. We found no relation between the incidence of deep venous thrombosis and obesity, length of preoperative stay, location of hospital, or duration of anaesthesia. We suggest that intermittent pneumatic compression as used in this trial is a safe, effective, and extremely practical method of preventing postoperative deep vein thrombosis in patients not suffering from malignant disease.

Accuracy of Predictions of Survival in Later Stages of Cancer

Abstract: Though 83% of 168 cancer patients admitted for “terminal care” died within 12 weeks of admission predictions of the probable length of survival showed little relation to the actual length of survival. A total of 83% of all “errors” were in an “optimistic” direction, the patient being expected to survive longer than he actually did. No significant differences were found between the accuracy of predictions made at referral by general practitioners, by doctors at other hospitals, by hospice physicians on the day of admission, or by ward sisters and senior nurses at the same time. A week after admission predicted and actual survival correlated more closely but predictions were still optimistic. It is concluded that predictions of the length of time which a cancer patient who is at the end of active treatment can be expected to survive should be made and interpreted with the greatest caution.

Varicose veins, deep vein thrombosis, and haemorrhoids: epidemiology and suggested aetiology.

Abstract: Current concepts on the aetiology of varicose veins, deep vein thrombosis, and haemorrhoids have been examined and, in the light of epidemiological evidence, found wanting. It is suggested that the fundamental cause of these disorders is faecal arrest which is the result of a low-residue diet.

Drug Interaction: Inhibitory Effect of Neuroleptics on Metabolism of Tricyclic Antidepressants in Man

Abstract: Total urinary excretion of radioactivity after oral or intravenous administration of a test dose of (14)C-imipramine was measured in eight patients. They were tested before, during, and after treatment with neuroleptics. Excretion diminished while the patients were being treated with perphenazine, haloperidol, or chlorpromazine, though not during flupenthixol treatment.Total urinary excretion of radioactivity and plasma levels of metabolites and unchanged drug were measured in five patients after a test dose of (14)C-nortriptyline. Each patient was tested before and again during perphenazine treatment. In all patients perphenazine treatment caused: (1) decrease of total urinary excretion, (2) decreased plasma level of metabolites, and (3) increased plasma level of unchanged nortriptyline.These results indicate that neuroleptics inhibit the metabolism of tricyclic antidepressants in man.

Postoperative depression of tumour-directed cell-mediated immunity in patients with malignant disease.

Abstract: Leucocytes from 46 melanoma patients, 45 breast carcinoma patients, and 95 control donors were tested by the leucocyte migration test against the supernatants of homogenates of malignant melanomas, breast carcinomas, simple breast tumours, and breasts showing simple cystic disease. By comparison with controls inhibition of migration occurred significantly more frequently when tumour patients9 leucocytes were exposed to extracts of histogenetically similar tumours. Cell-mediated immunity to tumour-associated antigens was measured in 12 patients with breast carcinoma and 12 with malignant melanoma immediately before surgical operation and in the postoperative period. All patients tested before operation showed significant inhibition of migration on contact with extracts of histogenetically similar tumours. Postoperatively the degree of leucocyte migration inhibition was reduced in all patients with melanoma and breast carcinoma. Significant inhibition of leucocyte migration returned in most patients 6-22 days after operation.

Comparison of Surgery and Prolonged Spironolactone Therapy in Patients with Hypertension, Aldosterone Excess, and Low Plasma Renin

Abstract: The effect of prolonged preoperative treatment with spironolactone has been studied in a series of 67 patients with hypertension, aldosterone excess, and low plasma renin. In the series as a whole a highly significant reduction in both systolic and diastolic pressures was achieved, with no evidence of escape from control during therapy lasting several years in some cases. The drug was equally effective in controlling blood pressure in patients with and without adrenocortical adenomata. Occasional unresponsive patients were encountered in both groups; pretreatment blood urea levels in these were significantly higher than in the responsive patients. The hypotensive effect of spironolactone usually predicted the subsequent response to adrenal surgery.Spironolactone in all cases corrected plasma electrolyte abnormalities; significant increases in total exchangeable (or total body) potassium and significant reductions in total exchangeable sodium, total body water, extracellular fluid, and plasma volumes were seen. Plasma urea rose during treatment and there was a slight fall in mean body weight. Significant increases in peripheral venous plasma renin and angiotensin II concentrations occurred during treatment.In two patients no increase in aldosterone secretion rate was found during treatment, although plasma aldosterone rose in three of four subjects studied.Severe side effects were rare; in only two of the 67 patients did the drug have to be stopped.In addition to its routine preoperative use, spironolactone can now be advised as long-term therapy in selected patients.

Immunological responses in pregnancy and survival of fetal homograft.

Abstract: Immunological responses were studied in pregnant women and controls using as tests phytohaemagglutinin-induced lymphocyte transformation and the tuberculin reaction. Significantly reduced responses were found to both tests in the pregnant women. These results suggest that a reduction in T-cell activity during pregnancy may help protect the fetus from rejection by its mother9s immunological mechanisms.

Magnesium Deficiency in Patients on Long-Term Diuretic Therapy for Heart Failure

Abstract: Magnesium levels in serum, erythrocytes, skeletal muscle, and bone were measured in 10 patients with valvular heart disease who had received diuretic therapy for heart failure for an average of 3.3 years. Five patients were found to have diminished values for skeletal muscle, indicating significant magnesium deficit. Values for erythrocytes were low in only two of the five patients, and none had low values for serum ultrafiltrate and bone: Magnesium replacement therapy restored skeletal muscle values to normal. Clinical features consistent with the presence of magnesium deficiency were found in all five magnesium-deficient patients. These features were, with few exceptions, corrected by magnesium replacement. The latter also corrected low skeletal muscle potassium values present in all five patients with low skeletal muscle magnesium, four of whom showed clinical features of digoxin poisoning before magnesium therapy was given. Concomitant secondary aldosteronism, inadequate dietary intake, and digoxin therapy had probably augmented the magnesium loss due to diuretic therapy.

Methotrexate hepatotoxicity in psoriasis--comparison of different dose regimens.

Abstract: Liver histological appearances were studied in 44 patients treated for psoriasis with methotrexate. Cirrhosis was found in six and hepatic fibrosis in another 11. Of these 17 patients 12 had received methotrexate by a regimen of frequent small dosage, two had been treated by a regimen of intermittent large dosage, while three had been treated at different times by both methods. The prevalence of cirrhosis and fibrosis was significantly greater in patients treated by frequent small dosage than in those treated by intermittent large dosage, though the dose level (mg/month) was similar in both groups. Hepatic fibrosis, sometimes preceding cirrhosis, seems to develop invariably if treatment with small frequent dosage is sufficiently prolonged. In the few circumstances in which this drug is indicated for psoriasis intermittent large dosage is the treatment regimen of choice.

Genital Yeast Infections

Abstract: Genital yeast infection was studied in 533 women seen in a department of venereology. Yeasts were recovered in culture from 138 patients (26% of the total). Candida albicans accounted for 112 (81%) of the isolates and Torulopsis glabrata for 22 (16%); other yeasts were uncommon. There was no evidence that the presence of yeasts was related to age. 32% of the women who were taking an oral contraceptive harboured yeasts, compared with 18% of those who were not. The symptoms and signs of the women with yeast infections were compared with those with vaginal trichomoniasis and those with no evidence of genital infection. It seems that a clinical diagnosis of vaginal mycosis cannot be made with accuracy and that positive identification of yeasts is necessary; for this, cultural methods are the most satisfactory.

Unprocessed Bran in Treatment of Diverticular Disease of the Colon

Abstract: Seventy patients with diverticular disease of the colon were treated with a high-residue, low-sugar diet including unprocessed bran. Follow-up for an average of 22 months showed marked relief of symptoms in 62 patients. Bowel habit was restored towards normal and abdominal discomfort relieved. Only seven patients were unable to give up the use of laxatives. Eight patients did not tolerate the bran diet, and one of these needed surgical treatment. None of the 62 patients who took the diet needed surgery.

Amoxycillin: a new semi-synthetic penicillin.

Abstract: Amoxycillin (alpha-amino-p-hydroxybenzylpenicillin) is a new semi-synthetic penicillin with a broad spectrum of antibacterial activity similar to that of ampicillin. Penicillin-sensitive strains of staphylococci, streptococci, and pneumococci were sensitive to concentrations of 0.1 mug or less of amoxycillin/ml. Strains of Haemophilus influenzae were inhibited by a level of 0.5 mug/ml, and most strains of Escherichia coli, Proteus mirabilis, Shigella sonnei, Salmonella species, and Streptococcus faecalis were sensitive to a concentration of 5 mug or less of amoxycillin/ml. Penicillinase-producing strains of Staphylococcus aureus and strains of Pseudomonas aeruginosa, indole-positive Proteus, Klebsiella, and Enterobacter were insensitive to amoxycillin. The new penicillin was bactericidal in activity, as with other penicillins, and its antibacterial activity was not reduced in the presence of serum. After oral administration to volunteer subjects amoxycillin produced serum concentrations twice as high as those obtained with similar doses of ampicillin, and the penicillin was recovered unchanged in high concentrations in the urine. The absorption of amoxycillin was not greatly influenced by food, and administration of probenecid resulted in increased and more prolonged concentrations of amoxycillin in serum.

Infantile Overnutrition in the First Year of Life: A Field Study in Dudley, Worcestershire

Abstract: A survey of feeding patterns and nutrient intake in relation to the growth of 300 normal infants up to 1 year of age in Dudley, Worcestershire, highlights a problem of overnutrition in the group; 50 (16.7%) were found to be suffering from infantile obesity and a further 83 (27.7%) were overweight.During the first three months of life the daily energy intakes of 136 cal/kg body weight for boys and 149 for girls were markedly greater than the level of 120/kg recommended by the Department of Health and Social Security. This coincided with the early addition of solid foods to a full milk intake. 119 babies (39.7%) were offered solids before they were 4 weeks old and 280 (93.3%) before 13 weeks of age. Some babies had solids from the first week after birth. Protein intake was persistently high throughout the first year, and the mean intake of 32.7 g/day was much greater than the intake of 20 g for infants aged up to 1 year recommended by the Department of Health. Standards for fat and carbohydrate intake are not available but in comparison with the levels reported in breast-fed babies intake of fat and carbohydrate was high in the first three months and came closer to the desired level for the former and remained slightly high for the latter in the subsequent age quarters.The relation of childhood and subsequent adult obesity to infant feeding patterns is not yet clear, but there is a high correlation between obese parents and obese and overweight babies; had these babies not been overfed the condition might have been prevented.