Showing papers in "BMJ in 1979"

Vitamin D deficiency.

Abstract: admission. This proportion could already be greater in some parts of the country and may increase if referrals of cases of self-poisoning increase faster than the facilities for their assessment and management. The provision of social work and psychiatric expertise in casualty departments may be one means of preventing unnecessary medical admissions without risk to the patients. Dr Blake's and Dr Bramble's figures do not demonstrate, however, that any advantage would attach to medical teams taking over assessment from psychiatrists except that, by implication, assessments would be completed sooner by staff working on the ward full time. What the figures actually suggest is that if assessment of overdoses were left to house doctors there would be an increase in admissions to psychiatric units (by 19°U), outpatients (by 5O°'), and referrals to social services (by 140o). So for house doctors to assess overdoses would provide no economy for the psychiatric or social services. The study does not tell us what the consequences would have been for the six patients who the psychiatrists would have admitted but to whom the house doctors would have offered outpatient appointments. E J SALTER

Effect of general practitioners' advice against smoking.

Abstract: During four weeks all 2138 cigarette smokers attending the surgeries of 28 general practitioners (GPs) in five group practices in London were allocated to one of four groups: group 1 comprised non-intervention controls; group 2 comprised questionnaire-only controls; group 3 were advised by their GP to stop smoking; and group 4 were advised to stop smoking, given a leaflet to help them, and warned that they would be followed-up. Adequate data for follow-up were obtained from 1884 patients (88%) at one month and 1567 (73%) at one year. Changes in motivation and intention to stop smoking were evident immediately after advice was given. Of the people who stopped smoking, most did so because of the advice. This was achieved by motivating more people to try to stop smoking rather than increasing the success rate among those who did try. The effect was strongest during the first month but still evident over the next three months and was enhanced by the leaflet and warning about follow-up. An additional effect over the longer term was a lower relapse rate among those who stopped, but this was not enhanced by the leaflet and warning about follow-up. The proportions who stopped smoking during the first month and were still not smoking one year later were 0.3%, 1.6%, 3.3%, and 5.1% in the four groups respectively (P <0.001).The results suggest that any GP who adopts this simple routine could expect about 25 long-term successes yearly. If all GPs in the UK participated the yield would exceed half a million ex-smokers a year. This target could not be matched by increasing the present 50 or so special withdrawal clinics to 10 000.

Intravenous N-acetylcysteine: still the treatment of choice for paracetamol poisoning.

Abstract: One hundred cases of severe paracetamol poisoning were treated with intravenous N-acetylcysteine (acetyl-cysteine). There was virtually complete protection against liver damage in 40 patients treated within eight hours after ingestion (mean maximum serum alanine transaminase activity 27 IU/1). Only one out of 62 patients treated within 10 hours developed severe liver damage compared with 33 out of 57 patients (58%) studied retrospectively who received supportive treatment alone. Early treatment and acetylcysteine also prevented renal impairment and death. The critical ingestion-treatment interval for complete protection against severe liver damage was eight hours. Efficacy diminished progressively thereafter, and treatment after 15 hours was completely ineffective. Intravenous acetylcysteine was more effective than cysteamine and methionine and noticeably free of adverse effects. It is the treatment of choice for paracetamol poisoning.

Collaborative United Kingdom-Australasian study of cancer in patients treated with immunosuppressive drugs.

Abstract: A collaborative study including centres in the United Kingdom, Australia, and New Zealand was instituted in 1970 to determine the incidence of cancer in patients treated for at least three months with azathioprine, cyclophosphamide, or chlorambucil. Follow-up of 3823 renal transplant recipients showed an almost 60-fold increase of non-Hodgkin's lymphoma together with an excess of squamous-cell skin cancer and mesenchymal tumours. A series of 1349 patients without transplants showed an excess of the same tumours, though to a less extent. These preliminary findings provide no clear evidence that immunosuppressive drugs produce the increased risk of most of the common cancers that might be expected from the simplest interpretation of impaired "immunosurveillance."

Soft-tissue sarcomas.

Abstract: SIR,-Minerva asks (22 September, p 743) \"Just how effective are the Samaritans in preventing suicide ?\"-a question impossible to answer owing to lack of controls. Many of us have personal experience of individual cases where suicide has definitely been averted by our intervention; but these cases cannot be enumerated. The following data, however, were extracted from the records of a random sample of 57 224 of the 250 740 individuals who sought our help during 1978. A total of 13 421 callers admitted suicidal thoughts or intentions, and 15 763 callers admitted no such thoughts or intentions; in 28 040 cases for various reasons this information was not available. Thus 45-9\", of the 29 184 cases in which the topic of suicide was broached (either by the caller or by the Samaritan volunteer) admitted to suicidal ideas; or, to put it another way, 23°% of the whole sample were found to be harbouring them. This gives the population a \"potential\" suicide rate of 23 453 per 100 000, whereas the official figure is only about eight per 100 000. Evidently we do attract those with a suicidal bent, but quite a lot of them think better of it. Minerva also states that the suicide rate is showing no further decrease despite our increased activity. True. It is levelling out at about eight per 100 000, having dropped steadily from 12 per 100 000 in 1963 (coincidentally the year when Samaritans Incorporated came into action). One of the possible reasons for its not falling further may be that the number of our new callers each year has increased since 1973 by 60\",, whereas the number of our volunteers has risen only 17\",'0. Many of our 170 branches are overstretched; to achieve some sort of parity with this increasing work load we need at least 6000 more volunteers-urgently.

Characteristics affecting fibrinolytic activity and plasma fibrinogen concentrations.

Abstract: As part of a study to determine the extent to which the haemostatic system is implicated in the onset of clinically manifest ischaemic heart disease, characteristics influencing fibrinolytic activity (FA) and plasma fibrinogen concentrations were examined in 1601 men aged 18-64 and 707 women aged 18-59 in several occupational groups in North-west London. In men FA noticeably decreased till the age of about 58, when there was a small rise. In women a small increase in FA between 18 and about 40 was followed by a slightly larger fall between 40 and 59. There was a pronounced negative association of FA with obesity. FA was significantly less in smokers than non-smokers, though the effect was not large. FA increased with alcohol consumption. FA in men appeared to be greatest in the lower social classes, and men on night shift had poorer FA than those on day work. FA was greater in women using oral contraceptives than in those not using these preparations. In both sexes FA increased with exercise, but there were no associations between any of the characteristics studied and the increase. Plasma fibrinogen concentrations increase with age and obesity, are higher in smokers than non-smokers, and fall with alcohol consumption. In women the concentrations are higher in those using oral contraceptives. The general epidemiology of FA and plasma fibrinogen concentrations suggests that they may well be implicated in the pathogenesis of ischaemic heart disease.

Anti-keratin antibodies in rheumatoid arthritis.

Abstract: A naturally occurring antibody that reacts with the keratinised tissue of animal oesophagus was found in the serum of 75 out of 129 patients (58%) with classical or definite rheumatoid arthritis (RA) but not in sera from 105 healthy people. Detection of the antibody, which is unrelated to rheumatoid factor, is more specific for RA than the reaction in the sheep-cell agglutination test but less sensitive.

Haemostatic variables associated with diabetes and its complications.

Abstract: To study the possible role of an "increased thrombotic tendency" in the vascular complications of diabetes several tests of haemostatic function were carried out on 91 men and 63 women with diabetes aged 35-54 years and the results compared with findings in 686 men and 393 women of the same age in the Northwick Park Heart Study. Mean values for factors VII and X, fibrinogen, and platelet adhesiveness were higher in the diabetics, but mean fibrinolytic activity and whole blood platelet counts were lower. Antithrombin III values were also higher in the diabetics, which may have constituted a protective response to other changes favouring the onset of vascular disease. Diabetics with retinopathy had higher factor VII and antithrombin III values, and those with proteinuria had higher values for factor VII, fibrinogen, and platelet adhesiveness than those without these complications. These findings suggest a potentially important association between a thrombogenic tendency and vascular disease in diabetes. Nevertheless, prospective data are needed to clarify whether the haemostatic abnormalities precede the onset of clinically manifest vascular complications or are a consequence of them.

Respiratory influence on heart rate in diabetes mellitus.

Abstract: To find a simple and accurate test of autonomic nervous dysfunction in diabetes mellitus, 41 insulin-dependent diabetics and 25 controls were investigated. The diabetics, none of whom had symptoms of autonomic dysfunction, were tested for retinopathy and sensory neuropathy. Each subject also performed maximal deep-breathing procedures while undergoing electrocardiographic recording: in normal subjects the intervals are shortened during inspiration and prolonged during expiration, and a difference in the heart rate between inspiration and expiration of 10% or less seems to indicate autonomic dysfunction. This difference was calculated as an E:I ratio of the mean of the longest R-R interval during maximal expiration to the mean of the shortest during maximal inspiration. Ten of the 18 patients found to have sensory neuropathy had abnormal E:I ratios, and among those with absent ankle reflexes the proportion was even higher (9 out of 11). The E:I ratio also seemed to be as accurate as traditional tests for autonomic dysfunction and easier to perform. Diabetics with autonomic dysfunction have an increased risk of acute cardiorespiratory death during and after surgery, and maximal deep breathing and calculation of the E:I ratio may be a useful test to perform on diabetics at risk.

Prevalence of facial acne vulgaris in late adolescence and in adults.

Abstract: A survey of 1066 healthy women and 1089 healthy men aged 18-70 years, performed to determine the prevalence of facial acne, showed that clinical acne was not confined to adolescents. Though it was more prevalent among men than women at 18, beyond the age of 23 clinical acne was more prevalent among women as the prevalence in men gradually declined. At 40-49 years 3% of men and 5% of women still had definite, albeit mild, clinical acne, and at 50-59 years 6% of men and 8% of women had physiological acne. The surprisingly high prevalence of acne in adults may be related to antibiotic treatment or, in women, to the use of oral contraceptives or cosmetics, though this survey did not study their influence. Further studies in different populations are needed to establish the prevalence of acne in the community, and its distribution.

Breast cancer in young women.

Abstract: This deplorable state of affairs, which is a cause of much wasted time and many unnecessary x-ray examinations, can be directly related to the very severe reduction in the amount of time which our medical schools allocate to the teaching and study of anatomy. In practical terms, it means that students become involved with contemplation of the abnormal before they have acquired a sound knowledge of the normal. Perhaps the tide is now beginning to turn, for, during the past year or so, there have been at least three publications affirming the importance of teaching radiological anatomy from the outset of the preclinical course. Can this really be just a coincidence ?

Diet, sunlight, and 25-hydroxy vitamin D in healthy children and adults.

Abstract: In 110 white West Midlands children serum 25-hydroxy vitamin D (25-OHD) concentrations showed a pronounced seasonal variation, the values being highest in August and lowest in February. The concentrations correlated significantly both with recorded sunlight and with seasonal ultraviolet energy of the sunlight. Children who had had a seaside holiday the previous summer had a higher mean 25-OHD concentration than those who had not had a summer holiday away from home. Correlation between vitamin D intake and serum 25-OHD concentration was not significant.

Psychosocial stress in pregnancy and its relation to the onset of premature labour.

Abstract: A modified life events inventory was presented over a four-month period to 132 consecutive women going into spontaneous labour in Hull and Manchester. Three study groups were identified according to the duration of pregnancy. The levels of psychosocial stress in pregnancy were found to be particularly high in the mothers whose babies were born preterm. Stressful events may precipitate preterm labour in some women. The concept of antenatal care may have to be broadened if the incidence of premature labour and resulting perinatal mortality are to be reduced.

Changes in coronary risk factors during comprehensive five-year community programme to control cardiovascular diseases (North Karelia project).

Abstract: A comprehensive community programme to control cardiovascular diseases (CVD) in North Karelia, Finland, was carried out during 1972-7. The central intermediate objective of the programme was to reduce the prevalence of smoking, the serum cholesterol concentration, and raised blood-pressure values among the population of the area. The effect was evaluated by examining independent representative population samples in 1972 and 1977 in both the county of North Karelia and a matched control county. Over 10 000 subjects were studied each time, the participation rate being around 90%. The decrease that occurred in the risk factors, especially in men, was in general greater in North Karelia compared with the control county. When a multiple logistic function was used for the three risk factors an overall mean net reduction of 17% among men and 12% among women was observed in the estimated risk for coronary heart disease in North Karelia. This community programme effectively reduced the levels of the three main risk factors for CVD in the population, and thus mortality and morbidity from CVD should fall. This is assessed in further studies.

The concept of disease

Abstract: The connotations of the term "a disease" were investigated by studying the ways in which both medical and non-medical people used the word. A list of common diagnostic terms was read slowly to groups of non-medical academic staff of a university, secondary-school students, medical academics, and family practitioners, who then indicated whether they thought each word referred to disease.All groups rated illnesses due to infections as diseases, but the doctors, and particularly the general practitioners, were more generous in accepting as diseases the terms for non-infectious conditions. Apart from the nature of the cause, the most influential factor in determining whether or not an illness was considered to be a disease was the importance of the doctor in diagnosis and treatment.These findings provide further evidence that there is ambiguity about the meaning of the term disease. To the layman a disease seems to be a living agency that causes illness. Doctors have obviously accepted more heterogeneous defining characteristics but remain reluctant to adopt unequivocally nominalist ways of thought. The position is not unlike that in the physical sciences, in which there is a good precedent for distinguishing between the formal scientific and the everyday uses of terms such as "force" and "power."

Minor tranquillisers and road accidents.

Abstract: In a prospective study of 43,117 people, prescriptions issued by general practitioners over two years were linked with records of hospital admissions and deaths. For 57 people injured or killed while driving cars, motorcycles, or bicycles the medicines that had been dispensed in the three months before were compared with those dispensed for 1,425 matched controls. There was a highly significant association between use of minor tranquillisers and the risk of a serious road accident (relative risk estimate 4.9). the increased risk of accidents to drivers given tranquillisers could be due to the known psychomotor effects of these drugs or to effects of the conditions being treated. Whatever the reason, patients taking drugs such as diazepam should be warned that they are at special risk.

Long-term survival of patients with breast cancer: a study of the curability of the disease.

Abstract: A retrospective analysis was made of 3878 cases of breast carcinoma first seen in Edinburgh from 1954 to 1964. During this time there was a policy to treat breast cancer by simple mastectomy and x-ray therapy, and over 90% of cases classified as international stages I and II were so treated. The mortality in these women was compared with that in an equivalent normal population using Scottish national age-specific death rates. For every year of follow-up within 20 years of initial treatment there was an excess mortality from all causes. There was an overall excess mortality of 58% among patients with breast cancer 15-20 years after initial treatment, and 20 times more deaths occurred in this period from breast cancer than in a normal population. For patients disease-free after 15 years there was still a 28% excess mortality from all causes. Factors known to be of major prognostic significance for five-year survivorship had less influence than might have been expected when the ratio of observed to expected deaths was considered for longer periods of follow-up. The effect of clinical staging (I, II, or III), though initially marked, largely disappeared by the 10th year of follow-up, and after allowing for age there was no evidence beyond 10 years of an effect on survival of the original stage of the disease. Similarly, the effect of tumour size on survival disappeared after 10 years. Women who were premenopausal at presentation still had a significant excess of deaths in the fourth quinquennium of follow-up. In the menopausal and postmenopausal groups combined there was still a small non-significant excess of deaths from all causes after 15 years but this almost disappeared when patients who had already relapsed were excluded. In terms of overall mortality only patients who have undergone the menopause before presentation and who are disease-free 15 years after primary treatment may prove to be cured by conventional techniques such as simple mastectomy and postoperative radiotherapy.

Iron-deficiency anaemia and its effect on worker productivity and activity patterns.

Abstract: The effects of iron-deficiency anaemia on workers productivity were studied in a tea plantation in Sri Lanka. The quantity of tea picked per day was studied before and after iron supplementation or placebo treatment. After one month9s treatment significantly more tea was picked when the haemoglobin (Hb) concentration was increased by iron supplementation than when it was not. The degree of improvement was greater in more-anaemic subjects (those with concentrations of 6.0-9.0 g Hb/dl). The level of physical activity of anaemic subjects in their everyday environment was also recorded for four or 24 hours continuously both before and after treatment. After three weeks these levels was significantly greater in the iron-treated than matched placebo-treated subjects. The economic implications of increased work productively with iron treatment are evident, particularly in developing countries. These results also provide strong evidence for the clinical impression that people with iron-deficiency anaemia suffer from tiredness and weakness.

Early postoperative feeding with elemental diet.

Abstract: The value of early postoperative feeding with an elemental diet was assessed in 30 patients after major gastrointestinal operations. The patients were allocated at random to conventional treatment (control group) or feeding with the elemental diet (ED group). The clinical and metabolic course of the 15 patients in the ED group was significantly better than that of the controls. Patients in the ED group lost less weight and had a shorter stay in hospital. Negative nitrogen balance was more pronounced in the control group throughout the seven postoperative days. Energy intake was higher in the ED group. Provided elemental feeding is used with caution, it may be given from the first postoperative day. Patients do better metabolically and require shorter stays in hospital.

Self-titration by cigarette smokers

Abstract: An 11-week crossover study was carried out in which 12 subjects smoked high-nicotine (1.84 mg standard yield) and low-nicotine (0.6 mg) cigarettes after an initial period of smoking their usual brands with a medium-nicotine yield (mean 1.4 mg). Plasma and urine nicotine concentrations, carboxyhaemoglobin (COHb) concentration, puffing behaviour, 24-hour cigarette consumption, and butt nicotine content were measured. The changes in plasma nicotine and blood COHb concentrations showed that the smokers compensated for about two-thirds of the difference in standard yields when switched to either high- or low-nicotine cigarettes. Thus, compared with the medium-nicotine brand, the intake of nicotine and carbon monoxide was only about 10% higher when subjects smoked the high-nicotine cigarettes, which had a standard yield 30-40% higher than the medium brands; and only about 15% lower when they smoked the low-nicotine cigarettes, which had a standard yield about 50% lower than the medium brands. But nicotine content and urine nicotine concentrations followed a similar pattern. Changes in puffing behaviour and in 24-hour cigarette consumption were only slight.The results show clear evidence of both upward and downward self-titration of nicotine and carbon monoxide (and tar) intakes when smokers change to cigarettes with standard yields that differ over the range studied.

Role of catecholamines in hypotensive response to dieting.

Abstract: The effect of dieting on blood pressure and catecholamine metabolism was assessed in 11 normotensive obese women by providing first a weight-maintenance regimen high in carbohydrate and then a low-energy diet. All dietary constituents other than carbohydrate were maintained constant throughout the 18-day study. The low-carbohydrate diet led within 48 hours to a 41% fall in the urinary output of 4-hydroxy-3-methoxy mandelate and a significant fall in systolic and diastolic blood pressure. Plasma noradrenaline concentrations also fell and the hypotensive effect of the diet continued despite a maintained total body sodium. Thus the fall in blood pressure appeared to be mediated by changes in catecholamine metabolism independent of sodium intake. This may explain both the usefulness of weight reduction in hypertensive patients and the fainting that occurs in some normotensive obese subjects taking slimming regimens low in carbohydrate.

Evaluation of the forced expiration technique as an adjunct to postural drainage in treatment of cystic fibrosis.

Abstract: Sixteen patients with cystic fibrosis were treated with conventional physiotherapy aided by an assistant. The results were compared with those produced by physiotherapy using the forced expiration technique cleared more sputum in less time than conventional physiotherapy. A sputum in less time than conventional physiotherapy. A second study showed that an assistant did not further improve the results obtained by the patient performing the forced expiration technique himself. These findings mean that patients with cystic fibrosis who have had to rely on the help of others for their home treatment may now perform more effective treatment without help. The forced expiration technique might also be helpful for patients with chronic bronchitis, asthma, or bronchiectasis.

Reduction in polypharmacy for epilepsy

Abstract: A two-year prospective study of 40 adult outpatients with chronic epilepsy was carried out in which blood drug concentrations were monitored, and anticonvulsant polypharmacy was reduced to treatment with a single drug in 29 patients (72%). In the year after the reduction of treatment the control of seizures was improved in 16 patients (55%), unchanged in eight(28%), and worse in five (17%). Mental function was improved in 16 (55%). The main reason for failure to reduce to or maintain treatment with a single drug was exacerbation of seizures during the difficult withdrawal period, especially in patients with frequent seizures, taking several drugs, or with additional neuropsychological handicaps. It is more difficult to reduce polypharmacy than to avoid it in the first place. Polypharmacy may sometimes aggravate control of seizures.

Unknown primary adenocarcinoma: incidence of overinvestigation and natural history.

Abstract: Out of 1300 patients referred to a medical oncology unit, there were 87 with metastatic cancer in whom a primary tumour site was not evident from the history and after physical examination and chest radiography had been carried out. An analysis of the investigations performed in these patients and their results showed that in only eight of the 87 patients did non-surgical investigations at presentation determine the primary site. In two patients it was identified by diagnostic laparotomy, and in a further 13 clinical follow-up led to recognition of the primary tumour site before death. Few investigations should be performed in patients in whom the primary site is known since they have a low yield, and in our population identifying the primary tumour did not improve the outcome or alter management. Treatable tumours should be excluded, and this may be done in most cases by simple blood tests, particularly those measuring acid phosphatase activity and other tumour markers.

Metabolic consequences of atenolol and propranolol in treatment of essential hypertension.

Abstract: A six-month study of triglyceride, cholesterol, free fatty acid (FFA), glucose, insulin, growth hormone, and glucagon concentrations was carried out in asymptomatic hypertensive normal-weight men randomly allocated to treatment with atenolol or propranolol. A highly significant increase in the basal plasma triglyceride concentration was observed in propranolol-treated patients after three and six months' treatment, with a smaller but significant increase in atenolol-treated subjects after six months' treatment. The changes in triglyceride concentration could not be ascribed to variations in plasma insulin, growth hormone, or glucagon concentrations. Basal FFA concentrations were reduced during the first three months of treatment in both groups but returned to pretreatment levels after six months. Plasma cholesterol concentrations were unchanged by either agent.

Diet and Crohn's disease: characteristics of the pre-illness diet.

Abstract: Thirty newly diagnosed patients with Crohn's disease were interviewed about their habitual, pre-illness diet and compared with 30 healthy controls, matched for age, sex, social class, and marital status. The patients ate substantially more refined sugar, slightly less dietary fibre, and considerably less raw fruit and vegetables than the controls. A diet high in refined sugar and low in raw fruit and vegetables precedes and may favour the development of Crohn's disease.

Antibiotic prophylaxis in total hip replacement.

Abstract: A controlled prospective trial to compare the efficacy of the antibiotics cephaloridine and flucloxacillin in preventing infection after total hip replacement was conducted at three hospitals. The antibiotic regimens began before surgery, cephaloridine being continued for 12 hours and flucloxacillin for 14 days afterwards. Over an 18-month period 297 patients undergoing a total of 310 hip replacements were entered into the trial and randomly allocated to one of the regimens. The follow-up period ranged from one to two and a half years. All operations were performed in conventional operating theatres; at two of the hospitals these were also used by various other surgical disciplines. Four patients developed deep infection, two having received the cephaloridine and two the flucloxacillin regimen. The overall rate of deep infection was therefore 1.3%. Thus three doses of cephaloridine proved to be as effective as a two-week regimen of flucloxacillin. Giving a prophylactic systemic antibiotic reduced the incidence of infection to a level comparable with that obtained in ultra-clean-air operating enclosures.

Congenital heart block and maternal systemic lupus erythematosus.

Abstract: The association between infants with congenital heart block (CHB) and the presence or later development of maternal systemic lupus erythematosus or other connective-tissue disease (CTD) was reviewed in 67 cases. In 24 cases CHB was diagnosed at or before birth. Of nine necropsies on affected infants, seven showed endomyocardial fibrosis. The results suggest that one in three mothers who deliver babies with CHB have or will develop CTD. The association is probably explained by placental transfer of a maternal antibody. Awareness of the association may lead to prevention of the birth of children with CHB and better neonatal care of affected children.

Treating irritable bowel syndrome with peppermint oil.

Abstract: The incidence of imported malaria in the UK has steadily increased during the past decade,' with 1909 cases reported in 1978. At St Thomas's Hospital P falciparunz malaria is much commoner than P vivax and is mostly acquired in tropical Africa.2 Most of the malaria reported in Asian immigrants is P vivax,5 and, although the World Health Organisation has reported an increase in the incidence of falciparum malaria in Bangladesh, India, and Sri Lanka,' we have not previously seen a falciparum infection in an Asian. Chloroquineresistant falciparum malaria has been reported in South-east Asia and South America for many years, but its occurrence in the Asian subcontinent and in East Africa is much more recent. Two cases of imported chloroquine-resistant falciparum infections have recently occurred in the UK; both were from Kenya and one was fatal.4 Our patient would appear to have shown RI resistance to chloroquine in that parasites reappeared after 23 days, although the initial course of chloroquine had apparently eradicated the infection. We made no attempt to culture the malarial parasites to confirm in-vitro resistance. This patient probably acquired her malaria from blood transfusion in Bangladesh, and there have been no reports of chloroquine-resistant P falciparum being transmitted by this route, although transfusion malaria is known to be common and underreported in the developing countries, and many cases of falciparum are described.5 Malaria in our patient was initially diagnosed by chance when blood films were being examined. The patient at this time was relatively well and afebrile, and malaria was not suspected clinically. The resurgence of the falciparum was unexpected and delayed diagnosis in view of the many other possible causes of fever in a neutropenic postoperative patient with leukaemia. Malaria was not initially entertained as a likely diagnosis because of the apparently successful treatment with chloroquine. It is of interest that the clinical response to intravenous quinine was slow, particularly defervescence, and perhaps \"quinine fever\" may have been contributory. The disappearance of parasites was also slow; indeed, the parasitaemia appeared unchanged after two infusions of quinine. Although we are unaware of the effect of severe neutropenia and immunosuppression on the clinical course of malaria, it seems likely that this patient was infected with a chloroquine-resistant strain of P falciparum.

Pandemic influenza 1918.

Abstract: We debated the exact meaning of our instructions ; but the general cut through the discussion by saying characteristically "I've got to carry the can." He promptly invited Hugh Cairns and Howard Florey to visit him again to resume discussion on the issue they had raised. Harold Bensted and I were invited to be present as witnesses to the conversation. Harold and I agreed to listen without speaking, which we did. I recall the general's exact words, which I think he had memorised because I recall his pacing to and fro reciting words to himself before the meeting. "Gentlemen," said the general, "you warned me of the political importance of the advice I should give on this matter. I accepted your warning. Consequently, I referred the issue for a political decision. I asked that this should go right to the top. We have had our answer. It is written in green ink?you know, I take it, what that means. I am now clear about my advice. It is that penicillin should be used to treat gonorrhoea among the assault troops in Algiers." The interview ended in polite exchanges and, so far as I know, there were no political repercussions. My own view is that Harold Bensted's military and political judgment was right, and that Leo Poole's way of handling the event proved that he was a wise, shrewd, and honest soldier capable of carrying any can that was handed to him.