Showing papers in "BMJ in 1981"

Strategy of prevention: lessons from cardiovascular disease.

Abstract: Prevention of coronary heart diseases seems to be possible as recent experiences in Australia and in the U.S. have shown. Increased risk of heart disease in women is presented by the use of hormonal contraceptives and in men by high cholesterol levels and by hypertension. Preventive strategy that concentrates on high-risk individuals has to consider the mass approach which however much it may offer to the community as a whole offers little to each participating individual; it is a measure which which applied to many will actually benefit few. There are 2 types of preventive measures; the first consists in the removal of an unnatural factor and the restoration of biological normality as the reduction of intake of saturated fats whould be in the case of heart disease; the second does not consist of removing a supposed cause of disease but in adding some other factors in the hope of conferring protection as a high intake of polyunsaturated fat and of long-term medication would be for heart disease. Preventive medicine can be helped by changes in behavior of society and such changes are often brought about not by medical measures but by social motivations and by the force of economics and convenience.

Non-smoking wives of heavy smokers have a higher risk of lung cancer: a study from Japan.

Abstract: In a study in 29 health centre districts in Japan 91 540 non-smoking wives aged 40 and above were followed up for 14 years (1966-79), and standardised mortality rates for lung cancer were assessed according to the smoking habits of their husbands. Wives of heavy smokers were found to have a higher risk of developing lung cancer and a dose-response relation was observed. The relation between the husband's smoking and the wife's risk of developing lung cancer showed a similar pattern when analysed by age and occupation of the husband. The risk was particularly great in agricultural families when the husbands were aged 40-59 at enrolment. The husbands' smoking habit did not affect their wives' risk of dying from other disease such as stomach cancer, cervical cancer, and ischaemic heart disease. The risk of developing emphysema and asthma seemed to be higher in non-smoking wives of heavy smokers but the effect was not statistically significant. The husband's drinking habit seemed to have no effect on any causes of death in their wives, including lung cancer. These results indicate the possible importance of passive or indirect smoking as one of the causal factors of lung cancer. They also appear to explain the long-standing riddle of why many women develop lung cancer although they themselves are non-smokers. These results also cast doubt on the practice of assessing the relative risk of developing lung cancer in smokers by comparing them with non-smokers.

Double-blind randomised controlled trial of folate treatment before conception to prevent recurrence of neural-tube defects.

Abstract: A randomized controlled double-blind trial was undertaken in south Wales to prevent the recurrence of neural-tube defects in women who had had one child with a neural-tube defect. Sixty women were allocated before conception to take 4 mg of folic acid a day before and during early pregnancy and 44 complied with these instructions. Fifty-one women were allocated to placebo treatment. There were no recurrences among the compliant mothers but two among the non-compliers and four among the women in the placebo group. Thus there were no recurrences among those who received supplementation and six among those who did not; this difference is significant (p = 0.04). It is concluded that folic acid supplementation might be a cheap, safe, and effective method of primary prevention of neural-tube defects but that this must be confirmed in a large, multicentre trial.

Epidemiology of head injury.

Abstract: To find the incidence of the various types of head injury that occur in the community separate yearly rates (per 10(5) population in Scotland) for deaths, admissions to hospital, and attendance at accident and emergency departments were estimated and compared (when possible) with rates in England and Wales and the United States. Hospital admissions provide the best data for comparing incidences in different geographical areas and rates of attendance at accident and emergency departments the most reliable guide to incidences in the community. Admission rates, however, vary with local facilities and policies, and these also determine the proportion of patients referred to regional neurosurgical units. Such epidemiological data must be sought both for planning health care for head injury and for monitoring the effectiveness of services.

British Regional Heart Study: cardiovascular risk factors in middle-aged men in 24 towns.

Abstract: The British Regional Heart Study seeks to define risk factors for cardiovascular disease, to examine their interrelationships, and to explain the geographic variations in cardiovascular disease in Britain. A clinical survey of men aged 40-59 in 24 British towns was carried out and preliminary data from the survey analysed. On a town basis cardiovascular mortality was associated with mean systolic blood pressure and the prevalence of heavy cigarette smoking and heavy alcohol consumption. No such association was seen for body mass index or mean serum total cholesterol or high-density-lipoprotein cholesterol concentration. Cigarette smoking and alcohol intake and, to a less degree, systolic blood pressure were related to the social class (percentage of manual workers) of a town, and these factors may determine to some extent the increased risk of cardiovascular disease in manual workers. Blood pressure in individual subjects was affected predominantly by age, body mass index, and alcohol intake. Body mass index appeared to affect blood pressure to a greater extent than alcohol intake and did so with a consistent and positive linear trend. Nevertheless, the differences between towns in mean blood pressure readings appeared to be more closely associated with variations in the prevalence of heavy drinking than with variations in body mass index. Alcohol intake and body mass index explained only a part of the striking differences between towns in mean blood pressure readings, and some important "town"factors remained unexplained.

Relation of angiographically defined coronary artery disease to plasma lipoprotein subfractions and apolipoproteins.

Abstract: The relation of coronary artery disease to plasma lipoproteins was examined in 104 men aged 35-65 years undergoing coronary angiography for suspected myocardial ischaemia. A score reflecting the number, degree, and length of stenoses in seven major coronary arteries was assigned to each angiogram. Lipid concentrations in lipoprotein subfractions were measured after preparative ultracentrifugation; plasma apolipoprotein concentrations were measured by electroimmunoassay. Men with high coronary scores tended to have lower plasma high-density lipoprotein (HDL) cholesterol concentrations and higher low-density lipoprotein (density 1.019-1.063 g/ml) cholesterol concentrations than subjects of similar age with low coronary scores (p approximately equal to 0.1). The strongest relation, however, was with the cholesterol concentration in the HDL2 subfraction (density 1.063-1.125 g/ml) of HDL, which averaged 44% lower in the severely affected patients (p less than 0.005). No associations were found between the coronary score and HDL3 cholesterol, the cholesterol content of lipoproteins of density less than 1.019 g/ml, plasma triglyceride, or the concentrations of apolipoproteins AI, AII, and E. The high coronary scores associated with low HDL2 concentrations reflected an increase in the number of both partial and complete stenoses distributed throughout the coronary tree. In contrast the sizes of the lesions and the proportion producing complete occlusion were unrelated to HDL2.

Strategy of prevention: lessons from cardiovascular disease.

Abstract: (hypercholesterolaemia, hypertension, smoking, obesity, lack of exercise, and diabetes mellitus) and ischaemic heart disease I concluded that, for each factor, the association is largely or wholly genetic in origin. Trends in the sexand age-specific mortality from ischaemic heart disease in US whites and non-whites during the period of falling rates, 1968-75, were also studied. They were compared with those for mortality from all causes-which are uncomplicated by errors of death certification. From the close parallels between the two sets of trends we can be reasonably confident that the recorded fall in mortality from ischaemic heart disease is largely genuine.' The special characteristics of the fall, especially in whites, imply that changes in the conventional \"risk factors\"-which on independent grounds appear to be non-causal-are most unlikely to have made any appreciable contribution. However, the trends are consistent with the hypothesis that the impact of one or more extrinsic precipitators of ischaemic heart disease has fallen.' (Mortality statistics for the Australian population2 show that a similar interpretation can be given to the fall in ischaemic heart disease recorded over the period from 1965-7 to 1977-8.) Agents that can act as precipitators include allergens and micro-organisms of all kinds, although viruses must be regarded as promising candidates for the precipitation of ischaemic heart disease because of the apparent exacerbating action3 4 of influenza viruses. (Precipitators start the active disease process by freeing \"forbidden clones\" of lymphocytes from the host's defence system; pathogenic forbidden clones proliferate and attack endothelial cells of coronary arteries. Exacerbators increase the severity of attack by already active forbidden clones.) If this interpretation is substantially correct then changes in diet, smoking, and exercise will have no appreciable influence on mortality from ischaemic heart disease unless they happen to change the prevalence, transmissibility, or effectiveness of the hypothetical precipitators. Confirmation and identification of these precipitating agents is much to be desired if we are to prevent ischaemic heart disease through planned control.

Withdrawal from long-term benzodiazepine treatment.

Abstract: Long-term, normal-dose benzodiazepine treatment was discontinued in 16 patients who were suspected of being dependent on their medication. The withdrawal was gradual, placebo-controlled, and double-blind. All the patients experienced some form of withdrawal reaction, which ranged from anxiety and dysphoria to moderate affective and perceptual changes. Symptom ratings rose as the drugs were discontinued, but usually subsided to prewithdrawal levels over the next two to four weeks. Other features of the withdrawal included disturbance of sleep and appetite and noticeable weight loss. Electroencephalography showed appreciable reduction in fast-wave activity as the drugs were withdrawn, and an improvement in psychological performance was recorded by the Digit Symbol Substitution Test. Because of the risk of dependence on benzodiazepines these agents should probably not be given as regular daily treatment for chronic anxiety.

A 20-year prospective study of cirrhosis.

Abstract: A total of 512 people from a defined population in west Birmingham served by a district general hospital were found to have cirrhosis in the period 1959-76. The annual incidence rose from 5.6 per 100 000 to a peak of 15.3 per 100 000 in 1974. This was due to an increase in the incidence of alcoholic cirrhosis, which in the last six years accounted for two-thirds of cases. The proportion of patients with decompensated cirrhosis when first seen (65%) did not alter during the 18 years. This was reflected in a death rate of 78% among the 468 patients traced up to the end of 1978. Liver failure, hepatoma, and gastrointestinal haemorrhage accounted for almost three-quarters of the deaths. The proportion of patients who survived for five years was 36% for alcoholic cirrhosis, 14% for cryptogenic cirrhosis, and 60% for chronic active hepatitis, and these figures too remained constant throughout the 18 years. Modern methods of treatment for decompensated cirrhosis did not improve prognosis and only abstention in patients with alcoholic cirrhosis had a beneficial effect on survival. Since alcoholic cirrhosis is now the most common form of the disease it is important to recognise those at risk and to encourage abstinence; also, more efforts are needed to identify the causes of cryptogenic cirrhosis. Whatever the cause, cirrhosis needs to be diagnosed before decompensation occurs, if treatment is to have any effect.

Bronchial hyperreactivity in response to inhalation of ultrasonically nebulised solutions of distilled water and saline.

Abstract: To assess non-specific bronchial reactivity the effect of inhaling ultrasonically nebulised solutions of distilled water and hypotonic (0.3%), isotonic (0.9%), and hypertonic (2.7%, 3.6%) saline was investigated in 10 asthmatic patients and nine normal subjects. Expired ventilation and the maximum percentage fall in forced expiratory volume in one second (FEV1) were recorded. The sensitivity to the inhaled solutions was determined by measuring the ventilation required to induce a fall in FEV1 of 20% from the prechallenge value. Hypotonic and hypertonic but not isotonic solutions caused a significant fall in FEV1 in the asthmatic subjects. Normal subjects showed no response to either distilled water or 3.6% saline, the only solutions with which they were challenged. The method used for this challenge is rapid, simple, and inexpensive and provides a new means of diagnosing non-immunologically mediated bronchial hyperreactivity.

How dangerous are falls in old people at home

Abstract: From a survey in six general practices information was obtained on 125 people aged 65 and over who fell in their own homes. Three fractured their femurs and 15 had other fractures; most of the rest suffered only trivial injuries. Twenty lay on the floor for more than one hour; none were known to have suffered hypothermia. One-quarter of these patients died within one year of the fall, five times as many as in an age- and sex-matched control group; while of those who lay on the floor for more than one hour, half died within six months of the fall. Factors associated with mortality from falls were impaired mobility, abnormal balance, and a disturbed pattern of gait. Falls at home in old age are often indicative of the presence of severe ill health.

Evidence for a circulating sodium transport inhibitor in essential hypertension.

Abstract: The active sodium transport of white cells and red cells obtained from patients with essential hypertension was impaired. Incubating white cells from normotensive subjects in serum obtained from patients with essential hypertension caused an impairment in sodium transport in the white cells of normotensive subjects similar to that found in the white cells of hypertensive patients. The impairment in sodium transport was due to a fall in the ouabain-sensitive component of the total sodium efflux rate constant. These results show that the serum of patients with essential hypertension contains a substance which influences sodium transport and that it has ouabain-like activity. They also suggest that it is this substance which causes the impairment in sodium transport in the leucocytes of patients with essential hypertension. These findings support the hypothesis that the rise in blood pressure in patients with essential hypertension is due to an increased concentration of a circulating sodium transport inhibitor which is continuously correcting a tendency for sodium retention by the kidney.

Incidence, trends, and risks of ectopic pregnancy in a population of women.

Abstract: In a 20-year longitudinal study on ectopic pregnancy in a defined population of women aged 15-39 years the rate of ectopic pregnancy per 1000 diagnosed conceptions increased from 5.8 during 1960-4 to 11.1 during 1975-9. The mean annual incidence of ectopic pregnancy per 1000 women increased from 0.6 to 1.2 during the same period. The numbers of ectopic pregnancies per 1000 diagnosed conceptions increased with increasing age of the women and were 4.1, in the teenage group 6.9, in women aged 20-29 years, and 12.9 in women aged 30-39. Among 20- to 29-year-old sexually active women at risk of pregnancy who had never had acute salpingitis the rates of ectopic pregnancy per 100 woman-years were the same in those who did not use contraceptives as in those using non-medicated or copper-medicated intrauterine contraceptive devices (IUCDs; 0.3/100 woman years). The risk of an ectopic pregnancy increased sevenfold after acute salpingitis. These findings confirm the increased risk of ectopic pregnancy after salpingitis and suggest that the increase in the incidence of ectopic pregnancy in Lund from 1960 to 1979 was partly accounted for by the use of IUCDs.

Another smoking hazard: raised serum IgE concentration and increased risk of occupational allergy.

Abstract: Individual smoking histories of a general population sample and of two groups of workers exposed to occupational allergens were related to serum IgE concentrations and results of radioallergosorbent and prick tests in the workers The geometric mean IgE concentration was higher in smokers than in non-smokers The distribution of serum IgE values in the two groups showed an apparent difference, with a bimodal appearance in the smokers Evidence of sensitisation against occupational allergens was more common in workers who smoked The adjuvant effect of smoking on IgE antibody production might be due to damage to airways mucosa and supports the mucosal theory of atopy

Reduced dopamine-beta-hydroxylase activity in Alzheimer's disease.

Abstract: The activity of the noradrenergic marker enzyme dopamine-beta-hydroxylase was measured in brains removed postmortem from control patients and patients with Alzheimer's disease. Enzyme activity was decreased in the frontal and temporal cortices and hippocampus in patients with Alzheimer's disease, but was within the normal range in patients with depression, multiinfarct dementia, and terminal coma.The decrease in enzyme activity in Alzheimer's disease may reflect an abnormality of cortical noradrenergic fibres in some patients with the disease.

Natural history of autoimmune thyroiditis.

Abstract: One hundred and sixty-three asymptomatic people with thyroid antibodies or raised serum thyrotrophin (TSH) concentrations, or both, and 209 age-matched and sex-matched controls without either marker of thyroid disorder were followed up for four years to determine the natural history of autoimmune thyroiditis. Mildly raised TSH concentrations alone and the presence of thyroid antibodies alone did not significantly increase the risk of developing overt hypothyroidism during the four years compared with the controls. Overt hypothyroidism developed at the rate of 5% a year in women who initially had both raised TSH concentrations and thyroid antibodies. Prophylactic treatment with thyroxine may be justified in women found to have both markers of impending thyroid failure. The cost effectiveness of screening the adult population remains to be evaluated.

Autoimmune haemolysis: an 18-year study of 865 cases referred to a regional transfusion centre.

Abstract: Clinical and serological records of 865 patients with confirmed autoimmune haemolysis (AIH)--a much larger series than any previously reported--were critically reviewed nd analysed. A proposed new classification for AIH based on serological findings differs from traditional classifications in that a new category of "mixed" AIH has been defined in which both "warm" and "cold" autoantibodies are present, and both are capable of causing haemolysis. Patients in this mixed group tend to have severe disease that may run a chronic intermittent course. The presentation of cold agglutinin disease is much more variable than has been seen in previous studies, haemolysis due to low titre autoantibodies being common. The AIH associated with pregnancy, usually considered as being of bad prognosis, is often mild and self limiting in the absence of other associated disorders.

Improvement in glucose tolerance due to Momordica charantia (karela).

Abstract: The effect of karela (Momordica charantia), a fruit indigenous to South America and Asia, on glucose and insulin concentrations was studied in nine non-insulin-dependent diabetics and six non-diabetic laboratory rats. A water-soluble extract of the fruits significantly reduced blood glucose concentrations during a 50 g oral glucose tolerance test in the diabetics and after force-feeding in the rats. Fried karela fruits consumed as a daily supplement to the diet produced a small but significant improvement in glucose tolerance. Improvement in glucose tolerance was not associated with an increase in serum insulin responses. These results show that karela improves glucose tolerance in diabetes. Doctors supervising Asian diabetics should be aware of the fruit's hypoglycaemic properties.

Prescribing for the elderly.

Abstract: Generally, prescribing in Britain today is in a mess : the annual expenditure of the NHS on drugs is ?500m; expenditure on drugs not taken, "non-compliance," is 3C20m.1 Prescription rates are as follows : 55% of the whole male population receive at least one prescription a year2; 65% of the whole female population receive at least one prescription a year2; 33% of all women aged 45-59 receive psychotrophic drugs2; 37% of all women aged 75 and over receive psychotrophic drugs2; 75% of the whole population aged 75 and over receive drugs of some kind2; two-thirds receive one to three drugs, and one third four to six drugs simultaneously3; 25% of all adults are taking medicines first prescribed more than one year previously4; 75% of prescriptions are repeat prescriptions4; 50% of patient's bottles seen in a geriatric outpatient clinic have no dosage directions (personal observation) ; 80% of patients admitted to geriatric wards are receiving drugs3; for most of these patients, and for patients seen in geriatric outpatient clinics, it is impossible to be certain what the drugs are; and 10% of admissions to geriatric wards are due to iatrogenic disease caused by drugs.3 The need for a prescription for every ill felt by both doctors and patients is not new. Readers of George Eliot's Middlemarch will recall the struggles of young Dr Lydgate and the unpopu? larity that he brought on himself, with both his colleagues and his patients, by trying to resist the demand for useless bottles of physic. In this respect doctors are more culpable than patients. Studies5 have shown that, whereas 80-90% of doctors expect patients to want prescriptions, only 30-50% of patients actually do; the remainder would prefer an examination, advice, and reassurance, but are frequently given a prescription instead. In the past placebos, or the bona-fide medicines of the day, were often unpleasant, but they seldom had the powerful physiological actions of today's drugs, nor were they so freely available. Today the elderly are the main victims of modern drugs and the system by which they are administered. The reasons for this are: (1) multiple pathology of the elderly, (2) polypharmacy, (3) increased sensitivity of the elderly to drugs and side effects, (4) doctors' lack of training in geriatric pre? scribing, (5) unsuitable drug packaging and instructions, (6) poor supervision of elderly patients, and (7) dual prescribing systems in hospitals and in general practice, which prevent doctors from being fully responsible for their own prescribing.

Longitudinal study of obesity in the National Survey of Health and Development.

Abstract: In a nationally representative cohort of 5362 children born in one week in March 1946 weights and heights were recorded at 6, 7, 11, 14, 20, and 26 years. Overweight was defined as a weight that exceeded the standard weight for height, age, and sex by more than 20% (relative weight greater than 120%). The prevalence of overweight was 1.7% and 2.9% in boys and girls respectively at 6 years; 2.0% and 3.8% at 7 years; 6.4% and 9.6% at 11 years; 6.5% and 9.6% at 14 years; 5.4% and 6.5% at 20 years; and 12.3% and 11.2% at 26 years. The risk of being overweight in adulthood was related to the degree of overweight in childhood and was about four in 10 for overweight 7-year-olds. Analysis of the data in the reverse direction showed that 7% and 13% respectively of 26-year-old overweight men and women had been overweight at the age of 7. These results suggest that there is no optimal age during childhood for the prediction of overweight in adult life and that excessive weight gain may begin at any time. Overweight children are more likely to remain overweight than their contemporaries of normal weight are to become overweight.

Pertussis immunisation and serious acute neurological illness in children

Abstract: OBJECTIVE--To determine long term outcome in children who had a severe acute neurological illness in early childhood associated with pertussis immunisation. DESIGN--Follow up study of cases and matched controls. SETTING--Assessment of children at home and at school throughout Britain. SUBJECTS--Children recruited into the national childhood encephalopathy study in 1976-9 were followed up, with one of their two original matched controls, in 1986-9. MAIN OUTCOME MEASURES--Performance in educational attainment tests; behaviour problems reported by teachers and parents; continuing convulsions; evidence of other neurological or physical dysfunction. RESULTS--Over 80% of cases and controls were traced. Case children were significantly more likely than controls to have died or to have some form of educational, behavioural, neurological, or physical dysfunction a decade after their illness. The prevalence of one or more of these adverse outcomes in case children who had been immunised with diphtheria, tetanus, and pertussis vaccine within seven days before onset of their original illness was similar to that in case children who had not been immunised recently. The relative risk for recent diphtheria, tetanus, and pertussis immunisation in children who had died or had any dysfunction in comparison with controls was 5.5 (95% confidence interval 1.6 to 23.7). However, the number of cases associated with vaccine (12) was extremely small and statistically vulnerable, and other possible agents or predisposing factors could not be excluded. CONCLUSIONS--Diphtheria, tetanus, and pertussis vaccine may on rare occasions be associated with the development of severe acute neurological illnesses that can have serious sequelae. Some cases may occur by chance or have other causes. The role of pertussis vaccine as a prime or concomitant factor in the aetiology of these illnesses cannot be determined in any individual case. The balance of possible risk against known benefits from pertussis immunisation supports continued use of the vaccine.

Remedial therapy after stroke: a randomised controlled trial.

Abstract: Of 1094 patients with a confirmed stroke admitted to Northwick Park, a district general hospital, 364 (33%) died while in hospital, 215 (20%) were fully recovered when discharged, and 329 (30%) were too frail or too ill from diseases other than stroke to be considered for active rehabilitation. Only 121 (11%) were suitable for intensive treatment. They and 12 patients referred direct to outpatients were allocated at random to one of three different courses of rehabilitation. Intensive was compared with conventional rehabilitation and with a third regimen which included no routine rehabilitation, but under which patients were encouraged to continue with exercises taught while in hospital and were regularly seen at home by a health visitor. Progress at three months and 12 months was measured by an index of activities of daily living. Improvement was greatest in those receiving intensive treatment, intermediate in those receiving conventional treatment, and least in those receiving no routine treatment. Decreasing intensity of treatment was associated with a significant increase in the proportions of patients who deteriorated and in the extent to which they deteriorated. Probably only a few stroke patients, mostly men, are suitable for intensive outpatient rehabilitation, but for those patients the treatment is effective and realistic.

Corticosteroid resistance in chronic asthma

Abstract: Fifty-eight patients with chronic asthma in whom airflow obstruction was relieved by bronchodilator aerosols but not by oral corticosteroids were compared with 58 other chronic asthmatics who responded equally well to both treatments. The two groups were matched for age and sex. The only significant clinical differences between the two groups were that in the "corticosteroid-resistant" patients there was a more frequent family history of asthma and a longer duration of symptoms. Resistant patients also had a relatively lower peak expiratory flow rate in the morning than later in the day and a greater degree of bronchial reactivity to methacholine. Such features, however, may not be specific criteria of corticosteroid resistance since they were also observed in untreated asthmatics who subsequently responded well to corticosteroids. The failure of prednisolone to inhibit a monocyte-mediated bronchial reaction may explain why some chronic asthmatics do not respond to corticosteroids. Patients with corticosteroid-resistant asthma should be recognised at an early stage so that regular treatment with oral corticosteroids may be withdrawn. Failure to do this results in needless exposure to the risk of developing serious side effects.

The function of criticism.

Abstract: In the broadest sense criticism is evaluation?in the words of the Oxford English Dictionary it is the passing of judgments on the qualities of something Criticism need not, though it often is, be adverse criticism or fault finding, as the fact that it is perfectly ordinary to speak of adverse criticism indicates When I speak of the function of criticism I use the term function to mean not just the purpose of criticism but the way in which it fulfils its purpose: function is an active word stem? ming from the Latin verb fungor (I perform), and a function is "the special kind of activity proper to anything"; or "the mode of action by which it fulfils its purpose," again according to the OED Thus in considering the function of criticism I must consider not only its purpose or purposes but also the mode of action whereby it fulfils such purpose or purposes I must con? sider, that is, how it works Matthew Arnold is his classic discussion was writing about literary criticism: but he offers as his "definition" of criticism, "a disinterested endeavour to learn and propagate the best that is known and thought in the world"1 I think it is fairly clear that this can serve neither as a definition of criticism, for it does not describe what criticism is, nor as an account of the function of criticism, for it gives no indication of how criticism works With slight modifications, however, it seems to serve admirably as a unitary account of the purpose of criticism or at least of criticism at its best Thus we may say, with some sacrifice of Arnoldian elegance, that the purpose of criticism is a disinterested endeavour to learn and or to propagate the best that is or may be known and thought in the world The modifications are necessary, I believe, if we are to include in a single account of the purpose of criticism four quite different objectives Learning the best that is known or thought, propagating the best that is known or thought, learning the best that may be known or thought, and propagating the best that may be known or thought Thus the parent who criticises his child may be seeking to propagate the best, but he or she is not seeking to learn the best; the reader who privately criticises what he is reading may well seek to learn what is best without being interested in propagating it And the critic of some established and accepted

Analgesic effects of branding in treatment of headaches

Abstract: The effect of branding--that is, the labelling and marketing--of a well-known proprietary analgesic used to treat headaches was studied in a sample of women given a branded or unbranded form with either an inert or an active formulation. The sample was also divided according to whether the subjects were regular users of the brand or users of other brands. The findings showed that branded tablets were overall significantly more effective than unbranded tablets in relieving headaches. Differential effects were observed: the effects of branding were more noticeable one hour after the tablets were taken compared with 30 minutes; in the women given the placebo; and in the users of the brand compared with the users of other brands. It is hypothesised that these effects are due to increased confidence in obtaining relief with a well-known brand, and that branding has an analgesic effect that interacts with the analgesic effects of placebos and active ingredients.

How dangerous are falls in old people at home

Abstract: evidence that they diminish the chance of developing afebrile epilepsy in later life. Prolonged convulsions impair cerebral function whether they are associated with fever or not, and I agree that the main indications for prophylaxis are the severity or frequency of fits. I rarely recommend prophylaxis after one short seizure, but I might consider it if the child has indications of a low epileptic threshold (such as abnormal neurological development or early age of onset), particularly if the family live far from emergency medical attention. At present, sodium valproate is my drug of choice if I consider prophylaxis to be appropriate; but it is not free from side effects, which include liver toxicity, thrombocytopenia, nausea, obesity, and alopecia, and probably some depression of cerebral function.

Prognosis in giant-cell arteritis.

Abstract: In a study to assess the natural history of giant-cell arteritis, 90 patients with proved disease were followed up from the time of diagnosis. Early mortality was low and most commonly due to vertebral arteritis, but cerebral infarction did not appear to be a late complication. High maintenance dose steroids and visual loss were associated significantly with a shortened life span (p=0.0003 and p=0.0024). One-third of the patients developed chronic relapsing disease, but serious late complications were not encountered. After the initial attack has been controlled steroid dosage should be reduced to the minimum needed to alleviate symptoms.

Amiodarone increases plasma digoxin concentrations.

Abstract: As treatment regimens become more complex the dangers of drug interaction increase. We observed that several patients receiving maintenance digoxin treatment abruptly developed clinical evidence of toxicity when amiodarone, a newly available antiarrhythmic agent, was administered in addition. We therefore studied several patients to determine the response of plasma digoxin concentrations to treatment with amiodarone.

Fracture of neck of the femur: changing incidence.

Abstract: From 1959 to 1977 the numbers of hospital admissions for fracture of the neck of the femur increased by a factor of 2.7. Detailed analysis of data from the Hospital In-Patient Enquiry for 1968-77 showed that the increase applied to both sexes and at all ages over 45. The true incidence rate increased in parallel with the admission rate, and only a small part of the increased number of admissions was explained by the increasing numbers of the elderly. The increasing incidence of fracture of the neck of the femur imposes great strain on hospital resources, particularly trauma and orthopaedic departments, and merits urgent investigation. An explanation for the increase might be that the experience of one demand-led condition characterises a greater need for health care among the elderly for other conditions.