Showing papers in "BMJ in 1986"

Confidence intervals rather than P values: estimation rather than hypothesis testing.

Abstract: Overemphasis on hypothesis testing--and the use of P values to dichotomise significant or non-significant results--has detracted from more useful approaches to interpreting study results, such as estimation and confidence intervals. In medical studies investigators are usually interested in determining the size of difference of a measured outcome between groups, rather than a simple indication of whether or not it is statistically significant. Confidence intervals present a range of values, on the basis of the sample data, in which the population value for such a difference may lie. Some methods of calculating confidence intervals for means and differences between means are given, with similar information for proportions. The paper also gives suggestions for graphical display. Confidence intervals, if appropriate to the type of study, should be used for major findings in both the main text of a paper and its abstract.

Prevalence of polycystic ovaries in women with anovulation and idiopathic hirsutism

Abstract: Polycystic ovaries were defined with ultrasound imaging in a series of 173 women who presented to a gynaecological endocrine clinic with anovulation or hirsutism. Polycystic ovaries were found in 26% of women with amenorrhoea, 87% with oligomenorrhoea, and 92% with idiopathic hirsutism--that is, hirsutism but with regular menstrual cycles. Fewer than half the anovulatory patients with polycystic ovaries were hirsute, but in 93% of cases there was at least one endocrine abnormality to support the diagnosis of polycystic ovaries--that is, raised serum concentrations of luteinising hormone, raised luteinising hormone: follicle stimulating hormone ratio, or raised serum concentrations of testosterone or androstenedione. This study shows that polycystic ovaries, as defined by pelvic ultrasound, are very common in anovulatory women (57% of cases) and are not necessarily associated with hirsutism or a raised serum luteinising hormone concentration. Most women with hirsutism and regular menses have polycystic ovaries so that the term "idiopathic" hirsutism no longer seems appropriate.

The hospital anxiety and depression scale.

Abstract: There is a need to assess the contribution of mood disorder, especially anxiety and depression, in order to understand the experience of suffering in the setting of medical practice. Most physicians are aware of this aspect of the illness of their patients but many feel incompetent to provide the patient with reliable information. The Hospital Anxiety And Depression Scale, or HADS, was designed to provide a simple yet reliable tool for use in medical practice. The term 'hospital' in its title suggests that it is only valid in such a setting but many studies conducted throughout the world have confirmed that it is valid when used in community settings and primary care medical practice. It should be emphasised that self-assessment scales are only valid for screening purposes; definitive diagnosis must rest on the process of clinical examination.

Ultrasound scanning in the detection of hepatic fibrosis and steatosis.

Abstract: Hepatic steatosis and fibrosis produce abnormal echo patterns on ultrasound scanning, but the potential of ultrasound scanning for diagnosing these conditions in routine clinical practice is uncertain. A prospective comparative study of 85 patients with histologically assessed liver conditions was performed, and specificity was assessed in 76 patients with functional bowel disease who were presumed to have normal livers. Histological examination showed steatosis ranging from mild to severe in 48 patients and fibrosis ranging from increased fibrous tissue to established cirrhosis in 35 patients. Ultrasound scanning accurately identified steatosis, recognising 45 cases (sensitivity 94%) with a specificity of 84%. Fibrosis was less reliably detected (sensitivity 57% and specificity 88%). Of the 50 patients with alcoholic liver disease, 47 (94%) yielded abnormal results on scanning. In the 76 patients with functional bowel disease there was only one false positive result, giving a specificity of 99% in this group. As hepatic steatosis is the earliest change in alcoholic liver disease and seems to be of prognostic importance for the development of cirrhosis, ultrasound scanning provides an effective screening procedure, particularly in the occult alcoholic, who often presents with non-specific gastrointestinal complaints.

Randomised trial of treatment of hypertension in elderly patients in primary care.

Abstract: A randomised trial of the treatment of hypertension in 884 patients aged 60 to 79 years at the onset showed a reduction of 18/11 mm Hg in blood pressure over a mean follow up period of 4.4 years. The principal antihypertensive agents were atenolol and bendrofluazide. There was a reduction in the rate of fatal stroke in the treatment group to 30% of that in the control group (95% confidence interval 11-84%, p less than 0.025). The rate of all strokes (fatal and non-fatal) in the treatment group was 58% of that in the control group (95% confidence interval 35-96%, p less than 0.03). The incidence of myocardial infarction and total mortality was unaffected by treatment. Questionnaires completed by the patients and their relatives failed to identify any differences in symptoms that were likely to be due to treatment.

High levels of energy expenditure in obese women.

Abstract: Total free living energy expenditure was compared in lean and obese women by the new doubly labelled water method and partitioned into basal metabolism and thermogenesis plus activity by whole body calorimetry. Average energy expenditure was significantly higher in the obese group (10.22 versus 7.99 MJ/day (2445 versus 1911 kcal/day); p less than 0.001) resulting from an increase in the energy cost of both basal metabolism and physical activity. Self recorded energy intakes were accurate in the lean subjects but underestimated expenditure by 3.5 MJ/day (837 kcal/day) in the obese group. Basal metabolic rate and energy expenditure on thermogenesis plus activity were identical in the two groups when corrected for differences in fat free mass and total body mass. In the obese women in this series there was no evidence that their obesity was caused by a metabolic or behavioural defect resulting in reduced energy expenditure.

Impact of maternal postnatal depression on cognitive development of young children.

Abstract: Ninety four women and their first born children took part in a longitudinal study of maternal mental health during pregnancy and after delivery. The children's cognitive functioning was assessed at age 4 using the McCarthy scales, without knowledge of the mothers' psychiatric history or current health. As expected girls performed slightly better than boys and children from middle class and professional families did better than children from working class homes, as did children whose mothers had achieved at least one A level at school. Significant intellectual deficits were found in the children whose mothers had suffered with depression, but only when this depression occurred in the first year of the child's life. Marital conflict and a history of paternal psychiatric problems were independently linked with lower cognitive test scores; together with a working class home background these were the only factors that contributed to the deleterious effect of maternal postnatal depression.

Six minute walking test for assessing exercise capacity in chronic heart failure.

Abstract: Twenty six patients, mean age 58 years (range 36-68), with stable chronic heart failure, New York Heart Association class II-III, and 10 normal subjects of a similar age range were studied. Exercise capacity was assessed by determining oxygen consumption reached during a maximal treadmill exercise test and by measuring the distance each patient walked in six minutes. There were significant differences in the distance walked in six minutes between normal subjects, patients with heart failure, class II, and those with class III heart failure (683 m, 558 m, and 402 m, respectively (p less than 0.003)). The relation between maximal oxygen consumption and the distance walked in six minutes was curvilinear; thus the distance walked varied considerably in those with a low maximal oxygen consumption but varied little in patients and normal subjects with a high maximal oxygen consumption. All subjects preferred performing the six minute walking test to the treadmill exercise test, considering it to be more closely related to their daily physical activity. The six minute test is a simple objective guide to disability in patients with chronic heart failure and could be of particular value in assessing patients with severe heart failure but less useful in assessing patients with mild heart failure.

Levels and sources of stress in medical students.

Abstract: Levels of stress, as measured by the general health questionnaire, were assessed in 318 medical students in their fourth year at three British universities. Mean scores were higher than those in other groups within the general population, and the estimated prevalence of emotional disturbance was 31.2%, a proportion similar to that reported in medical students in the United States. There were no differences in prevalence or in mean scores of stress between the sexes. Twelve (4%) students reported high intake of alcohol, and almost half of the students had increased their intake in the past two years. The four categories most commonly cited in answers to an open ended question on recent stressful events were talking to psychiatric patients, effects on personal life, presenting cases, and dealing with death and suffering. Relationships with consultants raised the strongest negative feelings, with 102 (34%) students finding these particularly stressful. Stress among medical students should be acknowledged and attempts made to alleviate it.

Recommendations on blood pressure measurement.

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Risk factors for uterine fibroids: reduced risk associated with oral contraceptives.

Abstract: Risk factors for pathologically confirmed uterine leiomyomas (fibroids) were investigated using data from the Oxford Family Planning Association study, a long term follow up study of women using various methods of contraception. For each of 535 women who had had a fibroid an individual control was selected who matched the patient on age, date of entry into the cohort, and family planning clinic at recruitment and who was alive (and still being followed up) at the date the patient underwent surgery for fibroids. Case-control analysis showed that reproductive experiences were closely linked to development of fibroids. Risk of fibroids decreased consistently with increasing number of term pregnancies; women with five term pregnancies had only a quarter of the risk of women who had had none. Risk also decreased consistently with increasing duration of oral contraceptive use; the risk of fibroids was reduced by some 31% in women who had used oral contraceptives for 10 years. Risk was strongly related to weight: women who weighed under 55 kg had a particularly low risk, and overall the risk rose roughly 21% for each 10 kg increase. Cigarette smoking was associated with a decreased risk of fibroids; smokers of 20 cigarettes a day had a risk roughly two thirds that of non-smokers. These risk factors have all previously been identified as risk factors for endometrial cancer; this strongly suggests that the underlying risk factor is "unopposed" oestrogen.

Beneficial effects of angiotensin converting enzyme inhibition on renal function in patients with diabetic nephropathy.

Abstract: The effects of angiotensin converting enzyme inhibition with captopril were investigated in patients with diabetic nephropathy and hypertension. After nine days9 treatment with captopril glomerular filtration rate was unchanged in 13 patients, whereas renal plasma flow had increased from 265 to 302 ml/min/1.73 m2 body surface area (p less than 0.05) and the filtration fraction had decreased from 14.3 to 12.8% (p less than 0.025). During two years9 treatment with captopril in 14 patients the mean arterial blood pressure had fallen by 5 mm Hg (p less than 0.005) and the deterioration in glomerular filtration rate had decreased from 10.3 to 2.4 ml/min/year (p less than 0.005). There was no correlation between the fall in blood pressure and the reduction in the deterioration of glomerular filtration rate. These findings suggest that the effects of angiotensin converting enzyme inhibition on renal haemodynamics protect renal function. Inhibitors of angiotensin converting enzyme should be considered for lowering blood pressure in patients with diabetic nephropathy.

Consultation skills of young doctors: I--Benefits of feedback training in interviewing as students persist

Abstract: Thirty six young doctors who as medical students had been randomly allocated to either video feedback training or conventional teaching in interviewing skills during a psychiatry clerkship were reassessed five years later. Each doctor interviewed one patient with a psychiatric illness and two with a physical illness. Each interview was rated independently. Both groups had improved since the fourth year clerkship, but those given feedback training had maintained their superiority in the skills associated with accurate diagnosis. This superiority was as evident in their interviews with physically ill patients as it was with psychiatric patients. Both groups, however, still used "closed" questions and were more reluctant to cover psychosocial problems in physically ill patients. Those trained conventionally were clinically inadequate in both these aspects and in clarifying their patients' statements. Given these lasting benefits, all medical students should have feedback training in interviewing skills.

Campylobacter pyloridis and associated gastritis: investigator blind, placebo controlled trial of bismuth salicylate and erythromycin ethylsuccinate.

Abstract: An investigator blind trial was performed comparing bismuth salicylate, erythromycin ethylsuccinate, and placebo in the treatment of Campylobacter pyloridis associated gastritis in patients without peptic ulceration. Fifty patients fulfilled the study criteria. There was a strong correlation between the presence of C pyloridis and histologically confirmed gastritis. Clearance of organisms led to improvement of the gastritis. C pyloridis was cleared from 15 patients; of these, 13 had gastritis initially, which resolved in 12. Conversely, gastritis resolved in only four of 32 patients not cleared of organisms (p less than 0.0001). There was significantly greater improvement in endoscopic appearances in the patients cleared of C pyloridis compared with those whose infection persisted (p less than 0.001). In the three treatment groups organisms were cleared from 14 of 18 patients receiving the locally active bismuth salicylate, only one of 15 patients receiving erythromycin ethylsuccinate, and none of 17 patients taking placebo. These findings suggest that the ideal antimicrobial for the successful eradication of C pyloridis associated gastritis should be locally active, stable at low pH, and should penetrate gastric mucus. The resolution of gastritis and improvement in endoscopic appearances associated with clearance of C pyloridis support the view that these organisms may play a part in this condition.

Persistent HIV antigenaemia and decline of HIV core antibodies associated with transition to AIDS.

Abstract: Sequential serum samples from 13 homosexual men who seroconverted for antibodies to human immunodeficiency virus (HIV) were tested for HIV antigen. In one of these men, who developed the acquired immune deficiency syndrome (AIDS), HIV antigenaemia preceded the onset of AIDS by more than a year and persisted throughout the course of the disease. This antigenaemia was accompanied by the disappearance of IgG antibody reactivity to the major HIV core protein p24. In none of the 12 others, who all remained without serious disease, were serum concentrations of HIV antigen detected, except on one occasion in one man. All their serum samples showed strong IgG antibody reactivity to p24. Nine children who were infected with HIV in 1981 by plasma transfusion from a single donor were also followed up for HIV antigenaemia. HIV antigen was almost constantly present in the serum (26 of 28 samples) of five children who developed AIDS related complex or AIDS and less often in the serum (four of 10 samples) of four children who remained free of symptoms. The two children who developed AIDS showed a virtual absence of antibody reactivity to p24. These results indicate that increased HIV gene expression is a contributing factor to the development of AIDS and also provide evidence for a switch from latent to active HIV infection.

Morphine intoxication in renal failure: the role of morphine-6-glucuronide.

Abstract: Patients with impaired renal function may experience severe and prolonged respiratory depression when treated with morphine. This has been attributed to accumulation of the drug during renal failure. Three patients are described who had classical signs of intoxication with morphine in the absence of measurable quantities of morphine in the plasma. The observed clinical effect is attributed to accumulation of the pharmacologically active metabolite morphine-6-glucuronide, which is usually renally excreted. It is concluded that morphine does not accumulate in patients with renal failure but that accumulation of metabolites does occur. The previously reported observations of morphine accumulation during renal failure probably result from the use of radioimmunoassays that cannot distinguish between morphine and morphine-6-glucuronide. Thus the apparent morphine concentration measured with these assays in fact reflects the total quantity of morphine and morphine-6-glucuronide present.

Effect of near normoglycaemia for two years on progression of early diabetic retinopathy, nephropathy, and neuropathy: the Oslo study.

Abstract: Forty five insulin dependent diabetics were randomised to treatment with continuous subcutaneous insulin infusion (CSII), multiple insulin injections (five or six daily), or conventional twice daily insulin injections. Near normoglycaemia was obtained with CSII and multiple injections but not with conventional treatment (p less than 0.01). Hypoglycaemic coma was observed less frequently with CSII than with multiple injections and conventional treatment (p less than 0.001), but blood glucose concentrations below 2.5 mmol/l (45 mg/100 ml) were more common. After two years fewer retinal microaneurysms and haemorrhages had developed in the patients given CSII and multiple injections compared with those given conventional treatment, in whom the number had increased significantly (p less than 0.01). Motor nerve conduction velocity deteriorated in the patients given conventional treatment; in those given CSII it was unchanged during the first year but had improved after two years (p less than 0.01). Glomerular hyperfiltration was reduced with CSII, but no change occurred in urine albumin excretion rates. Long term near normoglycaemia may prevent the progression of early stages of late diabetic complications.

Onset of obesity in a 36 year birth cohort study.

Abstract: A large national cohort of children studied from birth to 36 years was used to test the predictive value of childhood obesity for obesity in adult life. Only 21% (39) of obese 36 year olds had been obese at age 11 years, and even when associated social factors were taken into account the correctly predicted percentage was much lower than the prediction rate achieved using body mass data from age 26 years. The comparatively poor predictive value of childhood obesity and the association of adult obesity with educational achievements and socioeconomic circumstances of family of origin emphasise the need for encouraging good nutritional and exercise habits rather than placing undue emphasis on the control of childhood obesity.

Effects of breast conservation on psychological morbidity associated with diagnosis and treatment of early breast cancer.

Abstract: Psychiatric morbidity was assessed in 101 women treated for early breast cancer (T0,1,2,N0,1,M0). Patients had expressed no strong preference for treatment, so were randomised to either mastectomy or breast conservation. The incidence of anxiety states or depressive illness, or both, among women who underwent mastectomy was high (33%) and comparable with that found in other studies. Slightly more of the patients who underwent a lumpectomy followed by radiotherapy had affective disorders, 38% having an anxiety state, depressive illness, or both. These findings question the view that mutilating treatment is predominantly responsible for the measurable psychiatric morbidity reported previously. Counselling services should be provided for all women treated for breast cancer, not just those who undergo mastectomy.

Fate in intermittent claudication: outcome and risk factors.

Abstract: The fate of 257 consecutive patients (100 women) aged 36-85 years (mean 65) first seen with intermittent claudication in 1977 was analysed after a mean of 6.5 (SD 0.5) years. When first seen none of the patients complained of rest pain or had ulcers or gangrenous lesions on the feet. At follow up 113 of the patients (44%) had died. Causes of death were no different from those in the general population. Mortality was twice that of the general population matched for age and sex. Mortality among the men was twice that among the women. In men under 60 mortality was four times that expected. The rate of clinical progression of the arteriosclerotic disease (that is, rest pain or gangrene) of the worst affected leg was 7.5% in the first year after referral. Thereafter the rate was 2.2% a year. An ankle systolic blood pressure below 70 mm Hg, a toe systolic blood pressure below 40 mm Hg, or an ankle/arm pressure index below 50% were individually significantly associated with progression of the arteriosclerotic disease. These findings show the importance of peripheral blood pressure measurements in the management of patients with intermittent claudication due to arteriosclerotic disease.

Effect of captopril on kidney function in insulin-dependent diabetic patients with nephropathy.

Abstract: The influence of angiotensin II on kidney function in diabetic nephropathy was assessed by studying the effect of 12 weeks' monotherapy with captopril (25-50 mg twice a day) in 16 hypertensive insulin dependent diabetic patients with persistent albuminuria. In an initial one week randomised single blind trial of captopril versus placebo, captopril (for nine patients) reduced arterial blood pressure from 148/94 (SD11/6) to 135/88 (8/7) mm Hg (p less than 0.05) and albuminuria from 1549 (range 352-2238) to 1170 (297-2198) micrograms/min (p less than 0.05), while glomerular filtration rate remained stable. No significant changes occurred in seven patients treated with placebo. During the 12 weeks of captopril treatment arterial blood pressure in all patients fell from 147/94 (11/6) to 135/86 (13/7) mm Hg (p less than 0.01), albuminuria fell from 1589 (range 168-2588) to 1075 (35-2647) micrograms/min (p less than 0.01), and glomerular filtration rate fell from 99 (SD19) to 93 (25) ml/min/1.73 m2 (p less than 0.01). The renin-angiotensin system showed suppressed plasma concentrations of angiotensin II and increased concentrations of angiotensin I and renin. The study showed that glomerular filtration rate is not dependent on angiotensin II, that captopril reduces albuminuria, probably by lowering glomerular hypertension, and that captopril represents a valuable new drug for treating hypertension in diabetics dependent on insulin with nephropathy.

Epidemic of AIDS related virus (HTLV-III/LAV) infection among intravenous drug abusers.

Abstract: Stored blood samples from 164 intravenous drug abusers who attended a Scottish general practice were tested for HTLV-III/LAV (human T cell lymphotropic virus type III/lymphadenopathy associated virus) infection. Of those tested, 83 (51%) were seropositive, which is well above the prevalence reported elsewhere in Britain and Europe and approaches that observed in New York City. The timing of taking samples of negative sera and continued drug use suggest that as many as 85% of this population might now be infected. The infection became epidemic in late 1983 and early 1984, thereafter becoming endemic. The practice of sharing needles and syringes correlated with seropositivity, which, combined with the almost exclusive intravenous use of heroin and other behavioural patterns, may explain the high prevalence of HTLV-III/LAV infection in the area. Rapid and aggressive intervention is needed to control the spread of infection.

Benign melanocytic naevi as a risk factor for malignant melanoma.

Abstract: Examination of 180 patients with cutaneous malignant melanoma and 197 control patients in a case-control study showed that the risk of melanoma is strongly related to numbers of benign melanocytic naevi (moles). Some unusual features of naevi--a diameter exceeding 7 mm, colour variation, and irregular lateral outline--also showed a strong association with the risk of melanoma, but the relation of numbers of naevi to risk was present even in the group of patients whose naevi had none of these unusual features. Biopsy of clinically atypical naevi from several of the patients at highest risk generally did not show dysplastic histology. Thus a group of people at high risk of melanoma may be identified by using simple clinical assessment of naevi.

Carcinoma in situ of contralateral testis in patients with testicular germ cell cancer: study of 27 cases in 500 patients.

Abstract: Carcinoma in situ in the contralateral testis was diagnosed in 27 of 500 patients (5.4%) with unilateral testicular germ cell cancer. Eight of the 27 patients received intensive chemotherapy for spread of their initial testicular cancer. Follow up biopsy studies did not detect changes of carcinoma in situ in any of these patients, and none developed a contralateral testicular tumour (observation time 12-88 months). Of the remaining 19 patients with carcinoma in situ, seven developed contralateral testicular cancer. The estimated risk of developing invasive growth was 40% within three years and 50% within five years. None of the 473 patients without carcinoma in situ detected by screening biopsy developed contralateral testicular cancer (observation time 12-96 months). No serious complications arose from the biopsy procedures. All patients with unilateral testicular germ cell cancer should be offered biopsy of the contralateral testis.

Patterns of fractures in accidental and non-accidental injury in children: a comparative study

Abstract: The incidence and pattern of fractures in children who had been abused were compared with those of fractures sustained by children of similar ages in whom abuse had been excluded. From 1976 to 1982 there were 35 children with fractures resulting from child abuse, and all were aged under 5. Of the 826 children in the control group, seen from January to June 1981, 85% were aged over 5. Abused children were much more likely to have multiple fractures (p less than 0.001) and bruising of the head and neck (p less than 0.001). Fractures of the ribs were common in children who had been abused, and their presence, in the absence of major chest trauma, strongly suggested that abuse was occurring. Injuries to the long bones were invariably spiral or oblique fractures or subperiosteal new bone formation--both "gripping or twisting" injuries. Spiral fracture of the humeral shaft was significantly more common (p less than 0.001) in the group of abused children. Classic metaphyseal chip fractures were uncommon. One child in eight aged under 18 months who sustains a fracture may be a victim of child abuse.

Determinants and importance of stress hyperglycaemia in non-diabetic patients with myocardial infarction.

Abstract: Determinants of plasma glucose concentrations were studied in patients on admission to hospital with confirmed acute myocardial infarction but without previous glucose intolerance as evidenced by raised concentrations of glycosylated haemoglobin (HbAlc). Mortality in hospital increased significantly with increasing plasma concentrations of glucose in patients with both normal (p less than 0.0001, n = 311) and borderline (p less than 0.02, n = 70) concentrations of HbAlc. There was a weak relation between plasma glucose concentrations and infarct size as estimated by peak aspartate transaminase activity in both HbAlc groups (rs = 0.26, n = 101 and rs = 0.41, n = 35 respectively). A correlation was found between adrenaline and plasma glucose concentrations (r = 0.47, n = 27) and cortisol and plasma glucose concentrations (r = 0.75, n = 19), but the relation of plasma noradrenaline and plasma glucose suggested a threshold effect. Concentrations of adrenaline, but not those of noradrenaline or cortisol, correlated with infarct size as measured both by peak aspartate transaminase activity and cumulative release of creatine kinase MB isoenzyme. Multiple regression analysis showed that concentrations of cortisol, adrenaline, and noradrenaline (but not the concentration of HbAlc, infarct size, or age) are the main determinants of plasma glucose concentration measured in non-diabetic patients when admitted to hospital after acute myocardial infarction.

Alleviation of jet lag by melatonin: preliminary results of controlled double blind trial.

Abstract: Jet lag is an ill defined phenomenon resulting from rapid flight across several time zones.' It is considered to be due to desynchronisation of circadian rhythms, such as the sleep-wake cycle, with local time and to lack of sleep. ' A means of rapidly resynchronising body rhythms to local time would benefit people who suffer badly from jet lag. Various remedies for alleviating jet lag have been proposed: manipulation of dietary intake and, more recently, appropriate exposure to'bright light have been used, though both are time consuming.2 3 We previously suggested that melatonin, a methoxyindole secreted by the pineal gland, might be simpler and more effective in treating jet lag.4 In view of its resynchronising properties in animals,5 its ability to transduce light-dark information, its hypnotic effects in man, and its low toxicity we examined whether it helped people adapt to new time zones.

Amodiaquine induced agranulocytosis and liver damage.

Abstract: Seven cases of agranulocytosis and two of liver damage that were probably due to amodiaquine treatment were studied. In five cases agranulocytosis was combined with liver damage, and in one case of primary liver damage moderate neutropenia was present. Three patients died. High total doses or prolonged duration of treatment, or both, appear to favour the occurrence of these reactions. The clustering of five of the seven cases of agranulocytosis within six months in one medical centre indicates that the risk to benefit ratio of amodiaquine for malaria prophylaxis should be re-evaluated.

Effects of social support during parturition on maternal and infant morbidity.

Abstract: Because continuous social support during labour is a component of care in many societies but inconsistent in our own, the clinical effect of support during labour on maternal and neonatal morbidity were studied. Social support was provided by female companions. Four hundred and sixty five healthy primigravidous women were enrolled using a randomised design. Compared with 249 women undergoing labour alone 168 women who had supportive female companions throughout labour had significantly fewer perinatal complications (p less than 0.001), including caesarean sections (7% v 17%, p less than 0.01) and oxytocin augmentation (2% v 13%, p less than 0.001), and fewer infants admitted to neonatal intensive care (p less than 0.10). Of the women who had an uncomplicated labour and delivery requiring no interventions, those with a companion had a significantly shorter duration of labour (7.7 hours v 15.5 hours, p less than 0.001). This study suggests that constant human support may be of great benefit to women during labour.

Computer aided diagnosis of acute abdominal pain: a multicentre study.

Abstract: A multicentre study of computer aided diagnosis for patients with acute abdominal pain was performed in eight centres with over 250 participating doctors and 16,737 patients. Performance in diagnosis and decision making was compared over two periods: a test period (when a small computer system was provided to aid diagnosis) and a baseline period (before the system was installed). The two periods were well matched for type of case and rate of accrual. The system proved reliable and was used in 75.1% of possible cases. User reaction was broadly favourable. During the test period improvements were noted in diagnosis, decision making, and patient outcome. Initial diagnostic accuracy rose from 45.6% to 65.3%. The negative laparotomy rate fell by almost half, as did the perforation rate among patients with appendicitis (from 23.7% to 11.5%). The bad management error rate fell from 0.9% to 0.2%, and the observed mortality fell by 22.0%. The savings made were estimated as amounting to 278 laparotomies and 8,516 bed nights during the trial period--equivalent throughout the National Health Service to annual savings in resources worth over 20m pounds and direct cost savings of over 5m pounds. Computer aided diagnosis is a useful system for improving diagnosis and encouraging better clinical practice.