Showing papers in "BMJ in 1980"

Molecular pathology of schizophrenia: more than one disease process?

Abstract: in Florence showed some symptomatic improvement with only minor side effects, but this requires confirmation in a controlled trial. Cyclosporin A does not cause bone marrow depression; but reports of the development of lymphoma in patients treated with the drug after transplantation,6 and indeed in patients treated with other immunosuppressive drugs,7 mean that immunosuppression should be used circumspectly. Another approach is based on the finding that suppressor lymphocyte activity is depressed during acute relapses in multiple sclerosis.8 This has raised the possibility of enhancing suppressor cell activity therapeutically, and is yet another potentially promising line of investigation.

Prevalence of urinary incontinence.

Abstract: The prevalence of urinary incontinence was investigated by determining the number of incontinent patients under the care of various health and social service agencies in two London boroughs and by a postal survey of the 22 430 people aged 5 years and over on the practice lists of 12 general practitioners in different parts of the country. The prevalence of incontinence known to the health and social service agencies was 0.2% in women and 0.1% in men aged 15-64 and 2.5% in women and 1.3% in men aged 65 and over. The postal survey, to which 89% of the people whose correct address was known replied, showed a prevalence of urinary incontinence of 8.5% in women and 1.6% in men aged 15-64 and 11.6% in women and 6.9% in men aged 65 and over. Nulliparous women had a lower prevalence than those who had had one, two, or three babies, but within the parity range of one to three there were no differences in prevalence. The prevalence was appreciably increased in women who had had four or more babies. Incontinence was moderate or severe in a fifth of those who reported it in the postal survey, of whom less than a third were receiving health or social services for the condition. Incontinence is a common symptom, and many unrecognised cases appear to exist. There may be considerable scope for improving its management.

Anabolic effect of human parathyroid hormone fragment on trabecular bone in involutional osteoporosis: a multicentre trial.

Abstract: After baseline studies, 21 patients with osteoporosis were treated with human parathyroid hormone fragment (PTH 1-34) given as once-daily subcutaneous injections for 6-24 months. The dose used did not cause hypercalcaemia even in the first few hours after injection. Calcium and phosphate balances improved in some patients, but there was no significant improvement in the group values. There were, however, substantial increases in iliac trabecular bone volume: the mean increase, confirmed by repeat blind measurements, was 70% above mean baseline volume. The new bone was histologically normal. Those patients who had the largest increases in 47Ca-kinetic and histomorphometric indices of new bone formation showed the greatest increases in trabecular bone volume, suggesting that treatment with human parathyroid hormone fragment caused a dissociation between formation and resorption rates that was confined to trabecular bone. Since vertebrae are four-fifths composed of trabecular bone, this hormone fragment may prove useful in treating patients with the crush fracture syndrome.

Statistics and ethics in medical research: III How large a sample?

Abstract: Whatw~r type of statistical design is used for a study, the problem of sample size must be faced. This aspect, which causes considerable difficulty for researchers, is perhaps the most common reason for consulting a statistician. There are also, however, many who give little thought to sample size, choosing the most convenient number (20, 50, 100, etc) or time period (one month, one year, etc) for their study. They, and those who approve such studies, should realise that there are important statistical and ethical implications in the choice of sample size for a study. A study with an overlarge sample may be deemed unethical through the unnecessary involvement of extra subjects and the correspondingly increased costs. Such studies are probably rare. On the other hand, a study with a sample that is too small will be unable to detect clinically important effects. Such a study may thus be scientifically useless, and hence unethical in its use of subjects and other resources. Studies that are too small

Relation of nicotine yield of cigarettes to blood nicotine concentrations in smokers.

Abstract: Blood nicotine and carboxyhaemoglobin (COHb) concentrations were studied in 330 smokers (206 women and 124 men). Blood nicotine concentrations in individual smokers varied from 25 to 444 nmol/l (4 to 72 ng/ml). The average concentration, 203 nmol/l (33 ng/ml), was the same in the men and the women, although cigarette consumption was higher in the men. Despite large differences in nicotine yield, there was no relation between blood nicotine concentration and the type of cigarette smoked: smokers of plain, untipped cigarettes (1.9 mg nicotine), cigarettes with unventilated filters (1.3 mg nicotine), and cigarettes with ventilated filters (0.8 mg nicotine) had similar blood nicotine concentrations. Cigarette consumption was also similar in these three groups. The correlation between blood nicotine concentration and nicotine yield of cigarette, though significant, was low (0.21, p < 0.001), showing that the nicotine yield of the cigarettes accounted for only 4.4% of the variation in blood nicotine concentrations. Similarly, the low correlation of 0.30 between COHb concentration and cigarette consumption suggests that cigarette consumption accounted for only 9% of the variation in the amount of smoke taken into the smokers' lungs. These results suggest that the assumed health advantage of switching to lower-tar and lower-nicotine cigarettes may be largely offset by the tendency of smokers to compensate by increasing inhalation. The findings of epidemiological studies showing lower risks with filter-tipped cigarettes may be attributable to other factors such as biases in the samples and changes in the quality and carcinogenicity of tobacco tar, rather than to reduced tar intake.

Anastomotic integrity after operations for large-bowel cancer: a multicentre study.

Abstract: Clinically evident anastomotic dehiscence was studied in 1466 patients who had undergone resection of a large-bowel adenocarcinoma. The overall incidence of anastomotic leakage was 13%, but the incidence varied between surgeons (range 0.5% to over 30%). Morbidity and mortality were significantly higher in those patients in whom the anastomosis failed to heal primarily. If these results are extrapolated to the national level, it should be possible by achieving results closer to those in patients without leakage to reduce overall post-operative mortality after resection of large-bowel cancer by 2% and to achieve an appreciable reduction in morbidity. Both factors are clinically important and, taken together, could result in appreciable saving of revenue.

Vitamin D supplements in pregnant Asian women: effects on calcium status and fetal growth.

Abstract: In a double-blind trial of vitamin D supplements in pregnant Asian women calciferol (ergocalciferol, 1000 IU/day) was administered to 59 women and placebo to 67 controls during the last trimester. The two groups had similar distributions of maternal age, height, parity, number of vegetarians, countries of origin, and sex and gestation of the infants. At entry to the trial maternal serum 25-hydroxy vitamin D (25-OHD) concentrations were low in both treatment and control groups and significantly lower in vegetarians than non-vegetarians. Mothers in the treatment group gained weight faster in the last trimester than those in the control group, and at term they and their infants all had adequate plasma 25-OHD concentrations, Mothers and infants in the control group, however, had low plasma concentrations of 25-OHD and calcium and raised plasma alkaline phosphatase (bone isoenzyme) activity. Five of these infants developed symptomatic hypocalcaemia. Almost twice as many infants in the control group were small for gestational age (29% v 15%), but there were no significant differences between the two groups of infants in antropometric measurements. Infants in the control group, however, had larger fontanelles, suggesting impaired ossification of the skull. Because of the benefits to mothers and infants in the treatment group and the absence of side effects, vitamin D supplements should be given to all pregnant Asian women in the United Kingdom.

Expired air carbon monoxide: a simple breath test of tobacco smoke intake.

Abstract: the buzzer alarm, and the figure for hospital B was 33 °'%. By far the commonest difficulty was failure to awake to the alarm. Most of these patients stopped using the buzzer altogether because of the difficulties, most of which occurred in the first week of using the buzzer alarm. The percentage of patients who could be said to have been cured of their nocturnal enuresis was only 17 % at hospital A and 41 % at hospital B. The figure compares the effectiveness of the buzzer in this study with Meadows's results.'

Mortality in relation to smoking: 22 years' observations on female British doctors.

Abstract: A total of 6194 female doctors who in 1951 replied to a questionnaire about their smoking habits were followed up prospectively for 22 years. During that time 1094 died. Ischaemic heart disease, lung cancer, and chronic obstructive lung disease were all significantly (p < 0.001) related to smoking, though the absolute excess risks were lower than in male doctors smoking equivalent amounts. Female smokers born before the first world war were less likely to describe themselves as inhalers or as having started to smoke while young than were female smokers who were born later. In these respects this younger group resembled male smokers, and as they move into their 60s and 70s their absolute risk of lung disease and relative risk of ischaemic heart disease will probably come to resemble the risks for men smoking the same numbers of cigarettes. These findings show only that cigarette smoking causes lung cancer, chronic obstructive lung disease, and heart disease in women as in men. Whether the proportional increase in mortality from these diseases is as great in women as in men might be estimated directly from new case-control studies on men and women born since 1920.

The natural history of childhood asthma to adult life.

Abstract: A randomly selected group of 331 children who had started to wheeze in childhood and a control group of 77 children were prospectively studied clinically and physiologically from 7 to 21 years of age. Most subjects improved during adolescence and about 55% of those whose wheezing had started before 7 years and stopped before adolescence remained wheeze free. Forty-five per cent of subjects who had apparently ceased to wheeze at 14 years had minor recurrences of wheezing between 14 and 21 years of age. Fewer than 20% of those with persistent symptoms in childhood had become totally wheeze free during adolescence, although there was amelioration in symptoms. Girls did less well during adolescence than boys, so that there was no longer an increased preponderance of boys with increasing severity of asthma. Normal growth was achieved in all grades despite the persistence of symptoms in many cases. At 21 years of age features of airways obstruction were often found during an interval phase, especially in those who had more persistent symptoms.

Progestogens and cardiovascular reactions associated with oral contraceptives and a comparison of the safety of 50- and 30-microgram oestrogen preparations.

Abstract: Progestogens probably have metabolic effects that may contribute to the increased risk of cardiovascular reactions associated with combined oestrogen-progestogen oral contraceptives. This possibility was investigated by a study of nearly 2000 reports to the Committee on Safety of Medicines from 1964 to 1977. The reports concerned preparations in which norethisterone acetate in doses of 1.0, 2.5, 3.0, or 4.0 mg was combined with 50 microgram of ethinyloestradiol and those in which levonorgestrel in doses of 150 or 250 microgram was combined with 30 microgram of ethinyloestradiol. Observed and expected numbers of reports were compared, using retail pharmacy purchase figures as a measure of the use of different preparations. There was a significant positive association between the dose of norethisterone acetate and deaths from stroke and ischaemic heart disease (IHD); this association was also found for all cases of these two conditions, fatal plus non-fatal. There were no associations of dose of norethisterone acetate with hypertension or venous thrombosis. The higher dose of levonorgestrel was associated with a possible excess of deaths, non-venous plus venous, and an excess of strokes. There was no association between dose of levonorgestrel and hypertension or venous thrombosis. The reports were also used to assess the relative safety of 30-microgram and 50-microgram oestrogen preparations. Those with 30 microgram of oestrogen were associated with significantly fewer reports of death and IHD (both fatal, and fatal plus non-fatal) than those with 50 microgram of oestrogen. In view of the large-scale move towards preparations with progressively lower oestrogen doses, there are no grounds for major changes in oral contraceptive practice. Within the range of preparations currently in use, however, there is a case for minimising the dose of progestogen to reduce the chances of thromboembolism.

Gastroscopic evaluation of anti-inflammatory agents.

Abstract: Gastroscopy was performed in 164 patients with rheumatoid arthritis (RA) and 85 with osteoarthritis (OA) to assess the effects of anti-inflammatory agents on the stomach. The main criterion for entry into the trial was the absence of active gastric lesions on pretreatment endoscopy. The patients were divided into groups to receive one of 12 anti-inflammatory drugs or combinations of these. Gastroscopy repeated at three to six and at 12 months disclosed gastric lesions in 78 cases (31%), patients in both disease categories being similarly affected. Lesions occurred in 41 of the 177 patients (23%) receiving a single drug and in 37 of the 72 (51%) receiving combined treatment. All the anti-inflammatory drugs caused gastric damage, the greatest offender being aspirin (13 out of 26 patients) and the least sulindac and diflunisal (two out of 19 (11%) and two out of 20 (10%) patients respectively). Corticosteroids caused gastric damage in only three out of 21 patients (14%), a lower incidence than expected.The indiscriminate prescribing of anti-inflammatory drugs to patients with OA is to be deplored. A lack of correlation between the patients' subjective complaints of gastric discomfort and the gastroscopic findings emphasises the unreliability of patients' complaints and the importance of gastroscopy in assessing gastric tolerance. It was not possible to assess minimal prescribing doses or minimum periods of treatment below which gastric damage may be guaranteed not to occur.

Relation between extent of coronary artery disease and blood viscosity.

Abstract: Blood viscosity (shear rate 100/s) and its major determinants (packed cell volume, plasma fibrinogen concentration, and plasma viscosity) were measured before coronary angiography in 50 men aged 30-55 and related to the extent of coronary artery disease. Twenty-six men had extensive disease (stenosis of two or three major coronary vessels), and 24 had either stenosis of one vessel or no stenosis. The 26 men with extensive disease had significantly higher mean blood viscosity than those with mild or no disease and 25 healthy controls (p less than 0.001). The increased viscosity was due partly to a higher packed cell volume and partly to a higher fibrinogen concentration; plasma viscosity was not significantly increased. These differences could not be explained by smoking history. These results suggest an association between increased blood viscosity and extensive coronary artery disease in men, which merits further investigation.

Relation of anthropometric and dynamometric variables to serious postoperative complications.

Abstract: Prediction of serious postoperative complications by using standard anthropometric and biochemical nutritional variables was attempted in 225 patients admitted for major abdominal surgery. In 102 of the patients hand-grip dynamometry was also measured, and this proved the most sensitive test, predicting complications in 48 of the 55 patients (87%) who developed them (p < 0.001). Arm muscle circumference and forearm muscle circumference below 85% of the standard value were also of predictive value (p < 0.02 and p < 0.01 respectively); weight for height and serum albumin concentrations were less satisfactory, while weight loss of more than 10% was not significantly related to complications. Dynamometry is a useful, rapid, and inexpensive screening test for detecting malnutrition that is likely to predispose to serious postoperative morbidity.

Effect of counselling on the psychiatric morbidity associated with mastectomy.

Abstract: A controlled trial was conducted to determine whether counselling by a specialist nurse prevented the psychiatric morbidity associated with mastectomy and breast cancer. Seventy-five patients were counselled by the nurse and monitored during follow-up, while 77 patients received only the care normally given by the surgical unit. Counselling failed to prevent morbidity, but the nurse's regular monitoring of the women's progress led her to recognise and refer 76% of those who needed psychiatric help. Only 15% of the control group whose condition warranted help were recognised and referred. Consequently, 12 to 18 months after mastectomy there was much less psychiatric morbidity in the counselled group (12%) than in the control group (39%). These findings highlight the high degree of psychiatric morbidity in patients who have undergone mastectomy and indicate the need to find ways of reducing this morbidity.

Measurement of human fetal blood flow.

Abstract: Real-time B-mode ultrasonography was combined with a pulsed Doppler ultrasound technique for transcutaneous measurement of human fetal blood flow in the aorta and intra-abdominal part of the umbilical vein. The target vessel was located and its diameter measured in the two-dimensional real-time image. The pulsed Doppler transducer was attached to the real-time transducer at a fixed angle. By processing the Doppler shift signals the instrument estimated the mean and maximum blood velocities and the integral under the velocity curves. This permitted calculation of the blood flow. The method was applied to 26 fetuses in normal late pregnancies. Mean blood flow in the descending part of the fetal aorta based on maximum velocity was 191 ml/kg/min. Mean flow in the intra-abdominal part of the umbilical vein was 110 ml/kg/min. This method of measurement is non-invasive and opens new perspectives in studying fetal haemodynamics.

Chemotherapy in pancreatic cancer: results of a controlled, prospective, randomised, multicentre trial.

Abstract: Forty patients with inoperable pancreatic cancer were included in a prospective, randomised, controlled trial of multiple chemotherapy. The survival of 19 untreated control patients was compared with that of 21 patients who received an initiation course of intravenous fluorouracil, cyclophosphamide, methotrexate, and vincristine given over five days followed by intravenous fluorouracil and mitomycin given over three or five days at six-week intervals thereafter. Median survival in treated patients was 44 weeks, which was significantly longer than the nine weeks seen in controls. In patients without metastases median survival was 48 weeks in the treated group and 12 weeks in controls. In patients with metastases it was 30 weeks in treated patients and seven weeks in controls. The treatment was well tolerated and seemed to confer a significant prolongation of survival, comparing favourably with previous reports of chemotherapy with or without radiotherapy. If the results are confirmed this regimen may be useful in district general hospital practice.

Maternal vitamin D intake and mineral metabolism in mothers and their newborn infants

Abstract: Pregnant women receiving daily supplements of 400 IU (10 microgram) of vitamin D2 from the 12th week of pregnancy had plasma calcium concentrations higher at 24 weeks but similar at delivery to those in control pregnant women who did not receive the supplements. Infants of the women receiving the supplements had higher calcium, lower phosphorus, and similar magnesium concentrations on the sixth day of life and a lower incidence of hypocalcaemia than infants of the control women. Plasma concentrations of 25-hydroxycholecalciferol, which showed a seasonal variation, were higher in mothers and infants in the treated group. Cord-blood calcium, magnesium, phosphorus, and 25-hydroxycholecalciferol concentrations correlated with maternal values at delivery. Breast-fed infants had higher calcium and magnesium and lower phosphorus and 25-hydroxycholecalciferol concentrations than artificially fed infants. A defect of dental enamel was found in a high proportion of infants (many of whom had suffered from hypocalcaemia) born to the control women. These results suggest that vitamin D supplementation during pregnancy would be beneficial for mothers, whose intake from diet and skin synthesis is appreciably less than 500 IU of vitamin D daily.

Study of symptoms in middle life with special reference to the menopause.

Abstract: In an attempt to clarify the nature of the "menopausal syndrome" a survey of symptoms was carried out by means of postal questionnaires in a population sample of 1120 women and 510 men. Special care was taken to avoid letting the participants know that the survey was mainly concerned with the menopause. Response rates were 72% for women and 68% for men. Analysis of patterns of symptoms by age and sex showed that peaks of prevalence of flushing and sweating were closely associated with the mean age of menopause, coinciding with it or occurring a little after it. Less impressive peaks of prevalence of a group of minor mental symptoms were associated with an age just preceding the mean age of menopause. Complaints about aching breasts, irritability, and low backache diminished after the menopause. No association with the menopause was found for various other symptoms. The results of this study support the view that the menopausal syndrome exists but do not, of course, provide any evidence concerning the effectiveness (or safety) of hormone treatment.

Relapses in Wegener's granulomatosis: the role of infection.

Abstract: Out of 20 relapses that occurred in patients with Wegener's granulomatosis, nine were provoked by bacterial or viral infection. Seven of these occurred during maintenance treatment in response to infection with common pathogens, and treatment of the infection alone was insufficient to produce remission. Circulating immune complexes were seen only in relapses due to infection and rarely in infections that occurred without relapse. A possible mechanism for infection-provoked relapses is that infection-derived complexes reactivate disease; alternatively, the acute-phase or cellular response to infection may enhance quiescent disease. Infection may exacerbate Wegener's granulomatosis and other autoallergic diseases, but whether it does so by a common mechanism is not known and further study is required.

Hypokalaemia and diuretics: an analysis of publications

Abstract: Published data have been used to define the characteristics of the fall in serum potassium concentration after taking diuretics and the efficacy of the various treatments given to prevent or correct it. The average fall is less after the usual doses of frusemide (about 0.3 mmol/l) than after the usual doses of thiazides (about 0.6 mmol/l) and is little influenced by the dose or duration of treatment. The fall with a given drug is the same in heart failure and hypertension, but the initial serum potassium concentration is higher in heart failure, so that the final value is lower in hypertension. In standard doses potassium supplements are less effective than potassium-retaining diuretics in correcting the hypokalaemia. The relation between the average serum potassium value and the frequency of low values (hypokalaemia) is such that very low values after taking diuretics are unusual in patients with hypertension or heart failure. Hypokalaemia would almost disappear as an important complication of diuretic treatment if it was defined as a value less than 3.0 mmol/l rather than as a value less than 3.5 mmol/l.

Hearing impairment and mental state in the elderly living at home.

Abstract: Altogether 153 (60%) out of a sample of 253 people aged 70 years and over living in their own homes were found to have impaired hearing when tested by pure-tone audiometry. This is almost twice the prevalence found in all other studies, in which deafness was assessed clinically or by self-reporting. The prevalence of deafness increased with age. Evidence of organic brain syndrome (dementia), as determined by questionnaire, was present in 39 (16%) out of 245 respondents, and of depression in 82 (35%). Dementia and depression were both age related. An apparent association between deafness and dementia was shown to be due to age alone. A significant relation between deafness and depression was independent of age and socioeconomic state. The use of audiometric techniques of assessment established that an association exists between deafness and depression that is not simply a function of differential reporting reflecting the emotional state of the respondent.

The neuropsychiatry of megaloblastic anaemia.

Abstract: The neuropsychiatric states of 50 patients with vitamin B12 deficiency and 34 patients with folate deficiency presenting with megaloblastosis in a general hospital were examined and compared. Abnormalities of the nervous system were found in two-thirds of both groups. Peripheral neuropathy was the most common condition associated with vitamin B12 deficiency and affective disorder with folate deficiency. The proportions of patients with organic mental change were similar in the two groups. Subacute combined degeneration of the cord was an uncommon complication and occurred only in the patients with vitamin B12 deficiency. There was no relation between haematological and neuropsychiatric abnormalities. The neuropsychiatry of megaloblastic anaemia seen in this study of patients presenting to haematologists or general physicians contrasts with that reported previously, before haematological techniques for separating the two deficiencies were introduced.

Alcohol and the emergency service patient.

Abstract: To determine the prevalence of alcohol use in casualty patients breath-alcohol analysis was performed on 702 patients attending the accident and emergency department of a large teaching hospital during the evening. Forty per cent of patients had consumed alcohol before attending and 32% had a blood alcohol concentration exceeding 17.4 mmol/l (80 mg/100 ml). Clinical assessment of intoxication resulted in a false-negative diagnosis in 10% of inebriated patients, indicating that an objective measurement of the blood alcohol concentration by a test, such as breath-alcohol analysis, may be of additional value. These findings confirm that a high proportion of emergency-service patients are affected by alcohol and suggest that alcoholism treatment facilities need to be integrated with accident and emergency services.

Exceptionally low blood glucose response to dried beans: comparison with other carbohydrate foods.

Abstract: Normal volunteers took 50-g carbohydrate portions of eight varieties of dried legumes and 24 common foods drawn from grains, cereals and pasta, breakfast cereals, biscuits, and tuberous vegetables. Both the mean peak rise in blood glucose concentrations and mean area under the glucose curve of the subjects who ate beans were at least 45% lower than those of subjects who ate the other foods. These results suggest a potentially valuable role for dried leguminous seeds in carbohydrate exchanges for individuals with impaired carbohydrate tolerance.

Venous lipodermatosclerosis: treatment by fibrinolytic enhancement and elastic compression.

Abstract: The value of fibrinolytic enhancement with an anabolic steroid (stanozolol) combined with elastic stockings in treating venous lipodermatosclerosis was assessed in a six-month double-blind cross-over trial. Thirty-four legs of 23 patients in whom other treatments had failed were studied. The patients were randomly divided into two groups who were treated with either stanozolol plus elastic stockings or placebo plus elastic stockings for three months, and then vice versa. Treatment with or without stanozolol caused the area of lipodermatosclerosis to decrease, but the rate of healing when patients took stanozolol was double that when they took the placebo, and this was assumed to be biologically important. Stanozolol also reduced the incidence of extravascular fibrin detected in skin biopsy specimens. The elastic stocking with placebo produced significant decreases in leg volume, ankle circumference, and skin thickness. Stanozolol is valuable in treating intractable lipodermatosclerosis, giving relief of pain and reducing induration, inflammation, tenderness, and pigmentation.

Management of acute stroke in the elderly: follow-up of a controlled trial.

Abstract: Follow-up of a controlled trial of the management of acute stroke in the elderly showed that the improvement in functional outcome at the time of discharge from hospital that had been achieved through establishing a stroke unit had disappeared by one year. Factors that might have contributed to this included overprotection by the families of patients who had been treated in the stroke unit, who were not permitted to carry out activities of daily living in which they were independent, and the early discharge from medical units of patients whose full rehabilitation potential had not been realised. Prolonging the benefits of short-term gains in functional outcome through the intervention of a stroke unit requires that all the links in the chain of stroke rehabilitation are maintained, including the proper orientation of patients9 families before discharge from hospital.

Prostacyclin in pregnancy.

Abstract: Antibody persistence in stored sera-On testing in 1978 the geometric mean titre of haemagglutination inhibition antibody in the 16 sera collected 46 days after vaccination and still available for retitration was 64 4, compared with 128-8 originally; five samples (31 °O) showed a fourfold fall in titre (table). This was probably due to loss of antibody during storage and not to the different methods of removing norn-specific inhibitors (acid-washed kaolin in 1968, manganous chloride and heparin in 1978). Antibody persistence after vaccination-All sera had detectable haemagglutination antibody 10 years after vaccination (table). Antibody titres had fallen fourfold in four (20 (O) subjects (three of the 12 not revaccinated and one of the eight revaccinated) and had increased fourfold in one of the revaccinated subjects. Neutralising antibody was present in all 12 subjects not revaccinated, at titres of 1 in 32 (three subjects), 1 in 8 (five), and 1 in 4 (four).

Morphine: controlled trial of different methods of administration for postoperative pain relief.

Abstract: Forty-five patients who had undergone major operations were given a slow intravenous injection of morphine sulphate (1 mg/ml saline) until their pain was relieved and were then randomly divided into three equal groups to receive different regimens of morphine sulphate over the next 72 hours. Patients in group A received 3.5 times the pain-relieving dose (28-63 mg, mean 36 mg) by continuous intravenous infusion; those in group B received the pain-relieving dose (90-160 mg, mean 110 mg) intramuscularly, four-hourly for the first 24 hours, six-hourly for the next 24 hours, and then eight and 20 hours later; and those in group C received the pain-relieving dose (80-280 mg, mean 140 mg) intramuscularly as required. Pain was assessed on a linear analogue scale and vital capacity and peak expiratory flow rate measured 12-hourly. The mean pain score was significantly lower and respiratory function significantly better in group A than in groups B and C. Only one patient (in group A) required extra morphine. Thus morphine administered by continuous intravenous infusion is superior to other regimens, giving better pain relief at a lower dosage.

Objective assessment of antianginal treatment: a double-blind comparison of propranolol, nifedipine, and their combination.

Abstract: In a double-blind clinical trial the antianginal effects of nifedipine (30 and 60 mg/day) and propranolol 240 and 480 mg/day) and a combination of both drugs were compared with those of placebo in 16 patients with severe exertional angina pectoris. Response to treatment was assessed by the objective criteria of 16-point precordial exercise mapping and 48-hour ambulatory electrocardiographic monitoring and subjectively by analysis of patients' daily diaries of episodes of angina and consumption of glyceryl trintrate. The incidence of pain and consumption of glyceryl trinitrate were significantly decreased by each drug compared with placebo, and the combination produced a further significant improvement. Objectively the total area and amount of ST depression on the precordial exercise map and the total number of episodes of ST depression detected on ambulatory monitoring confirmed the efficacy of each treatment regimen; the combination was significantly better than either drug alone (p <0.005). The objective methods permitted greater separation of treatment efficacy and showed reliably that the combination of propranolol and nifedipine was significantly better than either drug alone. Thus this combination is a safe and effective form of treatment for angina.