W. W. Holland

Geographical variation in mortality from conditions amenable to medical intervention in England and Wales

There is a need for indicators of the outcome of health-care services against which the use of resources can be evaluated. From a previously published series of outcome indicators, which included diseases for which mortality is largely avoidable given appropriate medical intervention, causes were selected which were regarded as most amenable to medical intervention (excluding conditions whose control depends mainly on prevention) and for which there were sufficient numbers of deaths to allow an analysis of the variation in mortality rates among the 98 area health authorities of England and Wales. Considerable variation between AHAs was found in mortality from most of these diseases, and this variation remained even after adjustment for social factors. This substantial variation should be examined further in relation to health-service inputs and other factors. A finding of large variations in the quality of health-care delivery in different parts of the country would have important implications for resource allocation.

Influence of family factors on the incidence of lower respiratory illness during the first year of life.

In a study of a cohort of over 2000 children born between 1963 and 1965, the incidence of bronchitis and pneumonia during their first year of life was found to be associated with several family factors. The most important determinant of respiratory illness in these infants was an attack of bronchitis or pneumonia in a sibling. The age of these siblings, and their number, also contributed to this incidence. Parental respiratory symptoms, including persistent cough and phlegm, and asthma or wheezing, as well as parental smoking habits, had lesser but nevertheless important effects. Parental smoking, however, stands out from all other factors as the one most amenable to change in seeking to prevent bronchitis and pneumonia in infants.

Factors Influencing the Onset of Chronic Respiratory Disease

To investigate the effect of different environmental and personal factors on ventilatory function 10,971 children resident and going to school in four areas of Kent were examined. Details of past respiratory illnesses were obtained by a questionary completed by the parents; the examination included measurement of height, weight, and peak expiratory flow. Area of residence, social class, family size, and a past history of pneumonia, bronchitis, or asthma were found to be associated with differing levels of peak expiratory flow. These four factors acted independently, and the effects were additive. It is suggested that environment in the early years of life can produce adverse changes which may exist throughout life and contribute to the development of chronic respiratory disease.

Evaluation of the Hypertensive Patient with Emphasis on Detecting Curable Causes

Being only palliative, the medical treatment of hypertension must be continued throughout the lifetime of the patient. To avoid unnecessary or ill-conceived treatment, to judge prognosis and to establish a baseline from which the efficacy of treatment can be judged, each hypertensive patient deserves a thorough evaluation before therapy is instituted, unless the urgency of the situation demands immediate treatment. In that case, evaluation can and should be postponed until the life-threatening hypertension has been controlled. The objectives of the evaluation of the hypertensive patient are fourfold: (1) to evaluate the patients general health. It may be inadvisable to treat hypertension when the patient has a disease that is a greater threat to his survival than the elevated blood pressure. Coexisting disease, such as diabetes, gout or hepatic dysfunction, may also influence the choice of drugs used to treat hypertension. (2) To discover curable causes of hypertension, such as pheochromocytoma, Cushings syndrome, renal vascular disease, primary aldosteronism and coarctation of the aorta. Whereas patients with these conditions probably constitute less than ten per cent of the hypertensive population, many can be cured by appropriate operations and thereby be spared a lifetime of medical treatment that is frequently unpleasant, sometimes ineffective (especially in regard to pheochromocytoma) and always expensive. (3) To evaluate the effect, if any, of the hypertension on target organseye, brain, heart and kidneys. The presence or absence of complications has an important bearing on prognosis and should influence the choice of drugs employed. (4) To be certain that the patient has persistent

Measurement of Blood-pressure: Comparison of Intra-arterial and Cuff Values

In recent years numerous reports have appeared?for example, Pickering (1955)?of discrepancies between arterial blood pressure measured by an intra-arterial method and by the usual cuff and sphygmomanometer. Part of this discrepancy has been attributed to the effect of arm circumference on arterial pressure measured with a cuff. Corrections based on measurements made by Ragan and Bordley (1941) have been published by Pickering, Roberts and Sowry (1954). While several workers report good agreement between systolic blood-pressure determined by the intra-arterial and that by the cuff method, there is disagreement over which of the two phases (phase 4, muffling, or phase 5, disappearance) represents the true diastolic pressure.

Chronic respiratory diseases.

If this is true of diet and smoking it is even more true of the social environment: housing, the nature or work, education, social relationships. The research agenda for public health now should not only ask how best to achieve change in unhealthy behaviours but how to identify the social and economic causes of ill health, whether they act by affecting behaviours or by other means related to the environment; whether they act in adulthood or whether they act early in life. 16s18 Roses insight on blood pressure and cholesterol applies also to social differences in ill health. People at the lower end of the social distribution, the poor, the homeless and the unemployed, have worse health than those better off. But although these individuals are at high risk and require attention, they are

Value of new laboratory tests in diagnosis and treatment.

Abstract Requests for laboratory investigations have quadrupled during the past decade. The increasing load of laboratory work is consuming a large amount of resources, and staffing the laboratory service will become even more difficult if the expansion continues at the present rate. There is a need for research studies of factors which lead to requests for such tests and of action taken on test results. Trials on the effect of investigations in improving the outcome for patients must also be carried out. However, perhaps the most crucial factor in dealing with this increased demand in the immediate future is to apply the suggested yardsticks rigorously before introducing any new test into routine clinical practice.

Influence of family factors on asthma and wheezing during the first five years of life.

Family factors associated with the incidence of asthma and wheezing during childhood have been studied in a cohort of over 2000 children who, together with their families, were followed-up for five years. Episodes of wheezing not regarded by the parents as asthma had a different pattern of association with family factors to that found for asthma. The outcome of the two conditions in terms of ventilatory function at the age of five years was also different, in that children with a history of asthma had a lower peak expiratory flow rate than did children with a history of non-asthmatic wheezing.

A survey of the nutritional status of schoolchildren. Relation between nutrient intake and socio-economic factors.

This study was designed to examine the dietary intake of schoolchildren, to investigate its relation ship to health and socio-economic factors, and to explore the extent and nature of poor nutrition. The techniques employed were based on those used by the Ministry of Health (1968) in their study of pre-schoolchildren. The reliability and problems of these have been discussed previously (Topp, Cook, and Elliott, 1972).

Influence of some social and environmental factors on the nutrient intake and nutritional status of schoolchildren.

Only children had significantly higher intakes of many nutrients and nutrients/1000 kcal than other children. A higher proportion of only children was found to be obese. There were no significant differences according to birthrank in intakes by children. There were more obese children among the fatherless than those with fathers, in particular among those whose mothers were widowed. However, this was not accounted for by the present dietary findings, since fatherless children had lower intakes of carbohydrate and added sugar. There were no differences in nutrient intake or intake/1000 kcal by mothers country of origin or her level of education, or by disposable income.