Showing papers in "BMJ in 1976"

The Framingham study.

Abstract: Background and Purpose We sought to modify existing sex-specific health risk appraisal functions (profile functions) for the prediction of first stroke that better assess the effects of the use of antihypertensive medication. Methods Health risk appraisal functions were previously developed from the Framingham Study cohort. These functions were Cox proportional hazards regression models relating age, systolic blood pressure, diabetes mellitus, cigarette smoking, prior cardiovascular disease, atrial fibrillation, left ventricular hypertrophy by electrocardiogram, and the use of antihypertensive medication to the occurrence of stroke. Closer examination of the data indicated that antihypertensive therapy effect is present only for systolic blood pressures between 110 and 200 mm Hg. Adjustments to the regressions to better fit the observed data were developed and tested for statistical significance and goodness-of-fit of the model residuals. Results Modified functions more consistent with the data were developed, and, from these, tables to evaluate 10-year risk of first stroke were computed. Conclusions The stroke profile can be used for evaluation of the risk of stroke and suggestion of risk factor modification to reduce risk. The effect of antihypertensive therapy in the evaluation of stroke risk can now be better evaluated.

Alcohol dependence: provisional description of a clinical syndrome.

Abstract: Anyone concerned with treating drinking problems must find that his patients often tell him more than is in the textbooks. Each tells a different story, but there are also repeated patterns. Much of the varied experience that is recounted can be inter preted as the patient's astute observation of the alcohol depen dence syndrome-a condition certainly far better described by the average alcoholic than in any book. To attempt a definitive description of this syndrome would be premature; much is still only at the stage of "clinical impression." Routine clinical questions may impose a pattern on patients' accounts, and patients may themselves organise their uncertain recall of events in terms of expectations given to them. To link the clinical syndrome with information on the psychobiological basis of dependence is difficult, though scientific understanding has advanced recently. Our aim here is to help further to delineate the clinical picture. This is far from the first attempt to describe the syndrome. Jellinek's classification of alcoholism into types stands supreme.' The American National Council on Alcoholism has recently analysed diagnostic criteria,'2 nd a World Health Organisation group is preparing a report that seeks to define this syndrome and examine its importance.* Furthermore, we take the term syndrome to mean no more than the concurrence of phenomena. Not all the elements need always be present, nor always present with the same intensity. No assumptions need be made about

Twelve-minute walking test for assessing disability in chronic bronchitis.

Abstract: The distance covered in 12 minutes' walking was used to test exercise tolerance in chronic bronchitis. The distance covered bore a poor relation to the forced expiratory volume in 1 second but a significant relation to the forced vital capacity and the maximum oxygen consumption and ventilation on a bicycle ergometer. The test may be a simple practical guide to everyday disability in chronic bronchitis.

Jolly fat: relation between obesity and psychoneurosis in general population.

Abstract: The relation between fatness and aspects of psychological status was investigated in a representative sample (339 men and 400 women) of a middle-aged suburban population. A significant positive relation was found between substantial obesity and low levels of anxiety (in men and women) and depression (in men).

Contribution of preterm delivery to perinatal mortality.

Abstract: A detailed retrospective analysis was made of the records of 486 preterm infants, who accounted for 5-1% of all births during 1973 and 1974. Whereas preterm delivery did not contribute to perinatal mortality in terms of stillbirth, it outweighed all other causes in terms of early neonatal deaths. Preterm birth was responsible for 85% of the early neonatal deaths not due to lethal congenital deformities. Early neonatal mortality rates were closely linked both to gestational age and birth weight and to the reason for preterm birth. Early neonatal mortality was high (97 per 1000) when preterm labour was spontaneous, whether or not associated with material or fetal disease or with multiple pregnancy, but low (27 per 1000) when preterm delivery was elective. Preventing spontaneous preterm labour would considerably reduce neonatal mortality in our community.

Hormonal profiles after the menopause.

Abstract: The endocrinological changes of the climacteric have been defined by studying the concentrations of follicle-stimulating hormone (FSH), luteinising hormone (LH), androstenedione, testosterone, oestrone, and oestradiol in 60 normal postmenopausal women of different menopausal ages. The women were studied in six groups, according to the number of years since their menopause. One year after the menopause androstenedione, oestrone, and oestradiol concentrations were reduced to about 20% of the values recorded during the early proliferative phase of the menstrual cycle. At the same time the mean concentration of FSH had risen by a factor of 13-4 and that of LH by a factor of 3-0. Concentrations of both gonadotrophins reached a peak of 18-4 and 3-4 times the proliferative phase value respectively after two to three years, and then gradually declined in the next three decades to values that were 40-50% of these maximal levels. Testosterone concentrations remained mostly in the normal range for premenopausal women but were depressed to 60% of these levels two to five years after the menopause, and the mean androstenedione levels showed a significant increase in the same group of women. The concentrations of both oestrone and oestradiol remained consistently low for 10 years after the menopause, but oestradiol concentrations inexplicably increased in the last two decades, with levels at the lower end of normal range for reproductive women in six patients.

The Distribution of the Human Blood Groups and other Polymorphisms.

Abstract: The blood groups have been a trail blazer for the study of human polymorphism. No doubt much of the impetus and progress in the investigation of them has come from their great clinical importance in blood transfusion. Their determination was, however, recognised early as a powerful tool in anthropology. At first anthropologists used characters such as skin and hair colour or skull size to classify human populations. This approach gave rise to many problems. It is notoriously difficult to classify, for example, nose, eyes, and mouth when there is much transition between different populations. With the blood groups the emotional aspects of divisions between human races became irrelevant and much more objective assessments could be made. The frequencies of the ABO blood groups were the first example. ABO blood groups are distributed all over the world, but different frequencies could be demonstrated between different populations, such as the increase in frequency of blood group B from west to east across Europe and the high incidence of blood group Ro (cDe) in Africa. It was about 22 years ago that Mourant's book first appeared. The second edition, for which Mourant has been joined by two coauthors, includes polymorphisms other than human blood groups. It is about three times the size of the first edition. During the years which intervened between the two editions three new events must be noted. They are the discovery of additional blood groups, the discovery of polymorphisms other than blood groups, and the discovery of a correlation between the incidence of some human polymorphic characters such as blood groups and certain diseases. By adding some discussion of them to this book the authors have produced a pool of information on human genetics and of genetic data which is unequalled. Perhaps the most enchanting aspects are the introductory chapters, which occupy the first 140 pages. There are also some fascinating chapters on the interpretation of blood group data from Northern and Central Europe, Southern Europe, the Near East, the AfghanistanIndian region, the indigenous peoples of Africa south of the Sahara, and the indigenous peoples of America. The rest of the book is occupied by numerous tables and references. Whether or not there will ever be such a book again is doubtful. The great value of this one is that it provides a data bank in a single volume which can be consulted at short notice in most larger laboratories. The data themselves are also illustrated by numerous maps showing, for example, the individual frequencies of ABO blood groups in the indigenous populations of the world, with similar data for the MNS blood groups and the rhesus blood group system. Polymorphisms, such as the red cell isoenzyme system of adenosine deaminase or the isoenzyme system of phosphoglucomutase, are also considered. There are detailed subject and author indices. In an attempt at a synthesis Mourant discusses the possible selective processes which may have caused mankind's diversity for blood groups. At the time this book was written it was already known that there was a much stronger association between the histocompatibility antigens of the lymphocytes and a number of diseases, some of them of obscure origin, than for red cell antigens. There is at present no example which is more striking than the fact that 9500 of all patients suffering from ankylosing spondylitis have the HLA blood group B27, whereas the general frequency of this character in Britain is only

Fetal activity and fetal wellbeing: an evaluation.

Abstract: The clinical value of the 12-hour daily fetal movement count (DFMC) as a test of antepartum fetal wellbeing was assessed. The lowest 2-5% of 1654 DFMCs recorded by 61 women who subsequently delivered healthy infants fell below 10 movements per 12 hours. This level was taken as the lower limit of normal for clinical purposes. A normal DFMC in a population at risk was associated with a satisfactory fetal outcome. A low DFMC was associated with a high incidence of fetal asphyxia, and when fetal death occurred fetal movements rapidly diminished and stopped 12 to 48 hours before death. The DFMC is a generally applicable method of monitoring fetal welfare during pregnancy which provides an inexpensive adjunct or even an alternative to the more expensive placental function tests in current use.

Breast-feeding protects against respiratory syncytial virus infections.

Abstract: Eight out of 115 infants admitted to hospital with respiratory syncytial (RS) virus infection had been breast-fed compared with 46 out of 167 controls; this difference was statistically significant. Twenty-one specimens of human colostrum were examined, and all contained RS virus neutralising activity. Specific IgA and IgG were detected in 18 specimens, whereas IgM was detected in none. The titre of IgA antibody was usually higher and correlated more closely to the titre of neutralising activity than that of IgG. Infants inhale milk feeds and regurgitate them through the nose, and the IgA collecting in the respiratory tract might protect against severe respiratory infection. Alternatively, if severe RS virus illness is a sign of hypersensitivity to the virus breast-feeding might protect the infant from an early sensitising infection.

Prevalence of primary and secondary hypertension: studies in a random population sample.

Abstract: The prevalence of primary and secondary hypertension was determined in a random sample of 7455 Swedish men aged 47 to 54 years. Three hundred and sizty-one men were undergoing treatment for hypertension. Seven hundred and ninety-eight men who had blood pressures above 175/115 mm Hg at preliminary screening were recalled for further blood pressure measurements. Those on treatment and all the untreated men whose blood pressures were still over 175/115 mm Hg then underwent extensive investigation for secondary hypertension. Renal parenchymal hypertension was found in 25 (3-6%) patients, renovascular hypertension in four (0-6%), and other forms of secondary hypertension in 11 (1-6%). The investigation led to surgical treatment in only two cases (0-3%). The low prevalence of secondary hypertension, especially surgically curable forms of hypertension, makes routine screening for these cases unnecessary, at least when patients with hypertension have been found at screening. These data must be taken into account in planning community control programmes in hypertension.

Twenty years on.

Abstract: One of the problems of moving to the USA to practise medicine is taking \"finals\" again. I don't mean the exam for an Educational Council for Foreign Medical Graduates (ECFMG) certificate, which is a one-day affair taken in the familiar surroundings of London or Edinburgh. Without the ECFMG, of course, one's chances of getting a visa to live in the USA are next to nil. But actually to practise as an independent and fully functioning doctor something more extensive is demanded. One can sit these further tests only after burning one's boats, migrating to the USA, and risking all on the three-day \"trial.\" Each State has its own regulations but all, except Alaska and Florida, take a satisfactory performance in the Federation Licensing Examination (FLEX) held only in the USA as evidence of competence. Unlike Britain, where the MB ChB degrees or royal college diplomas are themselves registerable as evidence of competence, the MD degree in the USA does not give automatic entry into the ranks of practising doctors. In addition to having the MD a newly graduated doctor has to be successful in a three-part National Board of Medical Examiners (NBME) examination or FLEX, the latter having strong clinical emphasis in each of its three parts. Usually the NBME is taken by native US graduates and FLEX is favoured by the many foreign medical graduates who come to the USA to find fortune if not fame. The FLEX is extremely thorough and lasts three days, starting at 0830 and ending at 1730 with an hour for lunch and one 15-minute break during the morning and afternoon sessions. I took the exam at the beginning of December 1975 at the McCormick Place Centre in Chicago, which is a huge, draughty, hanger-like exhibition hall overlooking Lake Michigan and Meigs Field aerodrome. The 500-odd candidates were a colourfully international crowd with only a few from Britain. The place was so cold that most people sat in their overcoats and the proctors refreshed themselves at frequent intervals from hot vacuum flasks.

Controlled trial of oxygen in uncomplicated myocardial infarction.

Abstract: Two-hundred consecutive patients thought to have suffered a myocardial infarction were admitted to a randomised, double-blind controlled trial of oxygen or air administered by MC mask throughout the first 24 hours in hospital. Forty-three patients in whom myocardial infarction was not subsequently confirmed were excluded from the analysis. The remaining air and oxygen groups were comparable except for a significantly higher PaO2 and serum aspartate aminotransferase level in the oxygen group. There was no significant difference in mortality, incidence of arrhythmias, use of analgesics, or systolic time intervals between the two groups, although a higher incidence of sinus tachycardia was found in those given oxygen. There appears to be no evidence of benefit from the routine administration of oxygen in uncomplicated myocardial infarction.

Hypertension after renal transplantation.

Abstract: The incidence of hypertension (mean diastolic pressure above 90 mm Hg) was evaluated in 85 patients with renal transplants whose follow-up ranged from 3 to 84 months. Bilateral nephrectomy had been performed in 80 recipients. The proportion of hypertensive subjects rose during the first three months, subsequently stabilised around 50-60% for up to five years, and then decreased slightly during the next two years. Over the years hypertension fluctuated so that one-third of the initially hypertensive patients became normotensive, and over one-third of the initially normotensive patients became hypertensive. The main single aetiological factor was renal failure. A significant relation between steroid dosage and blood pressure was found in only a quarter of the hypertensive patients, and in another quarter no cause could be found.

Fetal complications of obstetric cholestasis.

Abstract: Among 56 pregnancies complicated by obstetric cholestasis five intrauterine deaths and one neonatal death occurred between 33 and 39 weeks, and a further six infants required urgent delivery for intrapartum asphyxia. Eighteen spontaneous premature deliveries occurred. Five mothers required specific treatment for unexplained postpartum haemorrhage. Cholestasis of pregnancy is therefore not a condition benign to the fetus, and it may contribute to increased maternal morbidity.

Use of pressurised aerosols by asthmatic patients.

Abstract: Aerosolised bronchodilator drugs in pressurised canisters delivering metered doses are widely used, easy to carry, and apparently easy to operate. The instructions with each canister are reasonably clear, stating that each puff must be deeply inhaled and the breath held afterwards. Since the drug intake depends mostly on the patient's ability to follow the instructions, we thought it was important to find out whether asthmatics used their aerosols correctly.

Plasma nicotine levels after cigarette smoking and chewing nicotine gum.

Abstract: Plasma nicotine levels were measured over seven hours of smoking cigarettes (1-2 mg nicotine) in a single subject under standardised conditions, and were compared with the levels obtained from chewing-gum containing either 2 mg or 4 mg nicotine. Levels comparable to those resulting from smoking were not obtained with the 2-mg gum, but peak levels on the 4-mg gum averaged 40-1 ng/ml from the third gum onwards compared with 49-2ng/ml after cigarettes. Nicotine was absorbed much more slowly from the gum than from cigarettes. It took 15-30 minutes for the 4-mg gum to raise the plasma nicotine by an average of 11-9 ng/ml compared with an average increase of 27-8 ng/ml within two minutes of completing each cigarette. In a sample of 15 smokers attending a withdrawal clinic the average plasma nicotine concentration while taking 2-mg nicotine chewing-gum was only 10-8 ng/ml compared with 30-4 ng/ml two minutes after smoking a cigarette. Although plasma nicotine levels equivalent to those following cigarette smoking may be obtained by chewing at least 10 pieces of 4-mg nicotine gum daily, the slower rate of absorption may limit its therapeutic value as a substitute for cigarette smoking.

Deep venous thrombosis of the legs after strokes. Part I--incidence and predisposing factors.

Abstract: Forty out of 76 patients (53%) who had suffered a cerebrovascular accident developed deep venous thrombosis of the paralysed leg, as detected with the 125I-fibrinogen technique A further five also had thrombosis in the non-paralysed leg A study of many predisposing risk factors provided no help either in elucidating the cause of venous thromboembolism or in identifying patients at risk of DVT as a complication of cerebrovascular accidents

Preoperative prediction of postoperative deep vein thrombosis.

Abstract: A range of clinical data was obtained from 124 patients about to undergo operation and several coagulation tests were performed. No patient received prophylaxis for deep vein thrombosis, and isotopic scanning after operation showed that 20 patients had developed thrombosis. a simiple prognostic index for predicting which patients would develop postoperative deep vein thrombosis was constructed using the clinical and coagulation data obtained before operation. The five variables with the best predictive power-euglobulin lysis time, age, presence of varicose veins, fibrin related antigen, and percentage overweight-produced an equation that identfied 95% of those who developed deep vein thrombosis and misallocated only 28% of those who did not develop thrombosis. In view of the complications that low-dose heparin and dextran can cause, giving prophylaxis to under a third of the patients who will not develop deep vein thrombosis is clearly better than giving it to all.

Deviation from prescribed drug treatment after discharge from hospital.

Abstract: A study of 130 patients discharged from four hospital wards dealing mainly with acute medical cases showed that 66 deviated from the drug regimen prescribed on discharge. Of the patients, 46 did not have a clear understanding of the regimen (non-comprehension) and 20 of the remaining 84 patients understood the prescribed regimen but did not follow the instructions (non-compliance). The prescribing of complex drug regimens, and the availability of medicines prescribed before admission to hospital appeared to be the two main factors influencing non-comprehension and non-compliance.

Low-tar medium-nicotine cigarettes: a new approach to safer smoking.

Abstract: The logic of expecting people who cannot stop smoking to switch to cigarettes that have hardly any nicotine is questionable. Tar and nicotine yields of cigarettes available in Britain today correlate 0-93, and further reduction of tar intake is limited by the reluctance of smokers to tolerate similar reductions in nicotine. A new approach would be to aim at lowering tar yields of cigarettes from the present average of 18 mg to around 6 mg but maintaining nicotine yields at around 1-0 to 1-2 mg, which would be acceptable to most smokers. This approach requires that emphasis be placed on tar: nicotine ratios as well as on the absolute yields. These ratios for brands on sale in Britain today average 14-2 and range from 9-6 to 20-8. They provide an additional guide for comparing the relative harmfulness of different brands. For example, 35% of cigarette smokers in Britain smoke either Embassy Filter or Players No 6 Filter; by changing to John Player Carlton King Size they could reduce their tar intake by more than 20% without having to suffer any nicotine deprivation.

Endotoxaemia and renal failure in cirrhosis and obstructive jaundice.

Abstract: An investigation into the possible role of endotoxins in the pathogenesis of renal failure in cirrhosis and obstructive jaundice showed the two to be closely related. None of the patients with cirrhosis who had endotoxaemia had other evidence of Gram-negative infection at the time of the study, and the endotoxaemia was therefore probably due to impaired hepatic clearance of toxins normally absorbed from the gastrointestinal tract. In contrast, bacteriological evidence of Gram-negative infection was found in most of the patients with obstructive jaundice and endotoxaemia.

Myocardial infarction: a comparison between home and hospital care for patients.

Abstract: To compare the results of home and hospital treatment in men aged under 70 years who had suffered acute myocardial infarction within 48 hours 1895 patients were considered for study in four centres in south-west England. Four-hundred-and-fifty patients were randomly allocated to receive care either at home by their family doctor or in hospital, initially in an intensive care unit. The randomised treatment groups were similar in age, history of cardiovascular disease, and incidence of hypotension when first examined. They were followed up for up to a year after onset. The mortality rate at 28 days was 12% for the random home group and 14% for the random hospital group; the corresponding figures at 330 days were 20% and 27%. On average, older patients and those without initial hypotension fared rather better under home care. The patients who underwent randomisation were similar to those whose place of care was not randomised, except that the non-randomised group contained a higher proportion of initially hypotensive patients, whose prognosis was poor wherever treated. These results confirm and extend our preliminary findings. Home care is a proper form of treatment for many patients with acute myocardial infarction, particularly those over 60 years and those with an uncomplicated attack seen by general practitioners.

Beta-cell function improved by supplementing basal insulin secretion in mild diabetes

Abstract: Insulin supplements, predominantly as a constant basal fish insulin infusion, were given to patients with mild diabetes to reduce the overnight fasting glucose level to normal. The basal plasma human insulin levels were reduced to subnormal levels by the infusion, and the insulin response to intravenous glucose was enhanced. The beta-cell in diabetes seems to be in a vicious circle in which an impaired insulin response to glucose produces hyperglycaemia, which stresses beta-cell function, making it more inefficient. A constant basal insulin supplement to induce basal normoglycaemia may benefit beta-cell function in diabetes.

Report of the Committee on Mentally Abnormal Offenders

Abstract: In the study of medical genetics it is difficult for clinicians to penetrate the boundaries of theoretical genetics andfor geneticists to understand fully the requirements of clinical practice. In recognising the importance of interaction between genetics and clinical medicine the editors have aimed to produce a textbook of human genetics which will improve communications between the two disciplines. They have selected authors with expertise in biochemistry, embryology, cytology, immunology, and statistics to describe important developments in the genetic field, and have themselves each devoted a chapter to the application of human genetics in the community at large and in disease. The result is a very stimulating book which provides a substantial framework for further study and advances in clinical genetics. It will be useful to both clinicians and students of human genetics and should succeed in the aim of encouraging interaction at the boundaries of the two specialties. Some chapters from specialists are notably useful. The chapters on population genetics and on quantitative inheritance are so simply and clearly expressed that clinical readers will surely be encouraged to think more boldly than usual about the quantitative contribution of inherited characteristics. Inevitably with several authors contributing chapters on closely related subjects there is some overlap and some artificial separation of information. The chapter on biochemical variation, dealing with a large subject, seems to touch rather lightly on biochemical syndromes, and there is some repetition in the chapters on developmental genetics and somatic cell genetics. The layout of the book is consistent, with clear chapter headings and a bibliography which is divided conveniently into references and suggestions for further reading. There is a useful glossary. A serious discouragement to buying this book is the price. It is regrettable that the publishers are now charging £9 75 for 524 pages in paperback.

Diverticular disease: three studies. Part I--Relation to other disorders and fibre intake.

Abstract: The fibre intake of 40 patients with diverticular disease was compared with that of 80 age- and sex-matched controls. The daily crude-fibre intake of the patients was significantly lower than that of the controls, and the incidence of haemorrhoids, varicose veins, hiatus hernia, gall stones, and abdominal hernias was significantly higher than in the control group. These findings suggest that a fibre-depleted diet may be a causative factor in diverticular disease and several other conditions.

Explaining the Brain.

Abstract: This is a comprehensive text whose authors are respectively a pathologist, a surgeon, and a radiologist, all practising in Edinburgh. The numerous contributors mostly also come from Scotland, and one must praise the Scottish school of medicine for yet another fine tome on pathology. The outstanding feature of this book is the close collaboration between the disciplines of pathology, surgery, and radiology so that the clinical features of the diseased patient are closely correlated with the x-ray appearances of the condition and its morbid anatomy. The opening chapters concern such general topics as wound healing, cancer, injury and burns, haemostasis, thromboembolic disease, and tissue transplantation, all of which are covered adequately, if perhaps a little erratically. But the bulk of the book is regional special pathology of a very high order of excellence, in which few omissions can be cited. All the organs of the body, including the skin and subcutaneous tissue, the breast, and the female genital tract, are covered, and there is a fine section on the central nervous system, but the authors have wisely omitted the special sense organs. The book is copiously illustrated; the radiographs are uniformly excellent, and so are many of the pictures of gross specimens, but some of the photomicrographs are of poor quality. It is a large book, and its considerable weight seems to have outdistanced the outer hard binding; my copy at least showed a partial drift of the main contents from the covers. This is probably the finest textbook on surgical pathology by British authors at present on the market, and it can be recommended most heartily, as the authors intended, to surgeons. Pathologists will gain less from it because of the brief histological descriptions and the variable quality of the photomicrographs, but they may nevertheless find it useful in their routine work. It will help radiologists to gain greater insight into the diseases they so often meet in front of the x-ray screen. The considerable price of the book is not unreasonable. M S ISRAEL