1343
ing swimming
to
asthmatic children, doctors and others
should bear in mind the potential hazard of bronchial irritation by chlorine. But the risks are probably small in relation to the benefits of sterilisation.
MINDS UNDER THE FLIGHTPATH NO-ONE ought to have to live under the narrow landing corridor to a major airport, but a lot of housing, much of it in the public sector, is so sited. Near London’s Heathrow classroom teaching can be interrupted, lipreading is a useful skill, and subsidies have to be provided for soundproofing buildings. A preliminary communication, published exactly ten years ago, suggested
that stress from exposure to aircraft was reflected in increased admissions to hospital for mental illness. Noise annoys,2 and the din of jet engines is no exception, but the notion that illness severe enough to warrant inpatient psychiatric care might ensue came as a surprise. The first attempt to confirm these findings was by Gattoni and Tarnopolsky ;3 a couple of chi-squared values get near the magic figure when the data are rearranged to suit the original hypothesis, but that is all. Now Tarnopolsky and his colleagues have published a further chapter in the Hounslow/Heathrow/Springfield Hospital saga4 as part of a Medical Research Council programme under the direction of Prof. Michael Shepherd. The latest inquiry is more thorough than the one by Abey-Wickrama et al.,’ and it is on a much larger scale than anything that has gone before. The three studies based on Springfield admissions differ greatly in the way residence, hospital catchment, and noise boundaries were handled. Another negative result would not have been surprising, but instead we get in the third inquiry4 a highly significant trend in the reverse direction-more noise, lower admission-rates. Tarnopolsky and his coworkers do not seem to know what to make of this finding. They warn against drawing conclusions from "exploratory research", yet this was not a pilot study but a careful investigation based on a population of about a million people and covering forty times as many admissions and twice the duration of the earlier studies. Dr Tarnopolsky has kindly provided us with a copy of a paper,5 given at a congress in Freiburg last year, which provides a further twist to the tale. Admissions to the Holloway Sanatorium at Virginia Water, a hospital about one-sixth the size of Springfield and serving a population under the baleful influence of the airport but much more rural in character, support the noise hypothesis for first admissions of single people and for all admissions except for the noisiest zone where the population at risk is small and we are advised to ignore the aberration. Even after a decade of research, therefore, it is not possible to say whether aircraft noise can seriously damage the psyche-indeed it is doubtful if anything 1.
Abey-Wickrama I, a’Brook MF, Gattoni FEG, Herridge CF. Mental hospital admissions and aircraft noise. Lancet 1969; ii: 1275-77.
2. Editorial. Noise, annoyance, and mental health. Lancet 1977; i: 1090. 3. Gattoni F, Tarnopolsky A. Aircraft noise and psychiatric morbidity. Psychol Med 1973; 3: 515-20. 4. Jenkins LM, Tarnopolsky A, Hand DJ, Barker SM. Comparison of three studies of aircraft noise and psychiatric hospital admissions conducted in the same area. Psychol Med 1979; 9: 681-93. 5. Hand DJ, Tarnopolsky A, Barker SM, Jenkins LM. Relationships between psychiatric hospital admissions and aircraft noise: a new study. In: Proceedings of Third International Congress on Noise as a Public Health Problem. (In press.)
useful can be learned from further retrospective studies based on one airport and relating to the early 1970s (even the largest study covers no admissions after Dec. 31, 1972). Intuitively, it would seem unlikely that two populations, one living right under the jets and one further off, would be the same in every respect other than exposure to aircraft noise, but this is difficult to check on at a distance of seven years or more. The problem of social matching is made even harder by the fact that demographic risk factors for psychiatric illness come in unusual packages (an unemployed graduate living on his own, for example). Furthermore, admission or community care for a mental problem is nowadays as likely to be determined on social as on medical grounds; nor can the question of immigrant communities around Heathrow be neglected. more
COLONIC COMPLICATIONS OF ACUTE PANCREATITIS "AcuTE pancreatitis is the most terrible of all the calamities that occur in connection with the abdominal viscera," proclaimed Sir Berkeley Moynihan1 in 1925. This opinion has been supported by an ever-increasing list of complications both intra-abdominal and extra-
abdominal.22 The incidence of primary acute pancreatitis in the United Kingdom varies greatly from year to year,3 but overall the disease seems to be increasing, particularly when associated with alcohol or drugs. Unless this increase is due to very mild forms of pancreatitis, there is likely to be an increase in the complications seen. Abscess and pseudocyst are the commonest intra-abdominal complications; damage to the colon (obstruction, fistula, bleeding, or stricture) is rare, but often life-threatening. (The watery-diarrhoea syndrome with varied serum levels of intestinal polypeptides might also be added to the colonic complications.4 Abcarian and his colleagues5 have reviewed 65 published case reports of colonic complications of acute pancreatitis, together with 10 of their own cases managed in a three-year period in Cook County Hospital, Chicago. This represented 1% of the total number of patients admitted with acute pancreatitis (predominantly alcoholic) during that same period. It is surprising that such colonic complications are not more common since the transverse mesocolon is an intimate anterior relation of the pancreas. 2 of the 10 Chicago patients died, and this creditably low mortality rate was attributed to a high index of clinical suspicion coupled with early aggressive surgery, particularly for colonic bleeding and fistula. Several useful clinical lessons emerge from this paper. The older patients (over 50 years) with mild pancreatitis may have pseudo-obstruction of the colon which must not be mistaken for malignant obstruction or ischaemic colitis; they have a good prognosis. Pseudocysts, inflammatory masses and abscesses must be carefully monitored by repeated clinical examination, ultrasonography, and barium studies to 1. 2.
Moynihan B. Acute pancreatitis. Ann Surg 1925; 81: 132-42. Carey LC. Extra-abdominal manifestations of acute pancreatitis. Surgery 1979; 86: 337-42.
3. Bourke JB. Variation in annual incidence of primary acute pancreatitis in Nottingham 1969-74. Lancet 1975; ii: 967-69. 4. Burbige, EJ, Manning, RJ, Belber JP. Watery diarrhea syndrome with elevated levels of vasoactive intestinal polypeptide associated with pancreatitis and pancreatic pseudocyst. Am J Gastroenterol 1978; 70: 136-40. 5. Abcarian H, Eftaiha M, Kraft AR, Nyhus LM. Colonic complications of acute
pancreatitis. Arch Surg 1979: 114: 995-1001.
1344 detect fistula formation and bleeding, which are apt to be fatal without early surgery. Operation must include wide retroperitoneal drainage, excision of affected bowel, and avoidance of primary anastomosis. Parenteral hyperalimentation, a concept unknown to Sir Berkeley Moynihan when he made his dire pronouncement, is valuable in the prolonged and difficult postoperative
management. CHILDREN’S COMMITTEE, ON PERINATAL CARE
,
BETTER care before birth and at birth is justified not only on health grounds but also on financial ones. Small sums spent on, say, screening for Down’s syndrome in prospective mothers over 401 and for neural-tube defects in those at high risk,2 could save the community much larger sums. This was a view set out in the Children’s Committee discussion document, The Reduction of Perinatal Morbidity and Mortality.3 Earlier this month the Committee, set up by the last Government (and after the present Government’s axe-work one of the few remaining quangos), invited many obstetricians, general practitioners, midwives, social workers, and parents to the Royal College of Physicians to discuss this document. Opening the meeting the Minister of State for Health, Dr Gerard Vaughan, said that perinatal mortality rates in England and Wales were dropping faster and more consistently than for many years. All those present were glad to acknowledge this, but no-one thought it grounds for complacency: numbers of births are now increasing, and no actual or relative reductions in the financing of maternity services should be allowed. Many participants called for confidential inquiries into perinatal deaths in the regions, and also regional implementation of an improved standard maternity information system. This system would give information every year about maternity care and might replace the national cohort surveys of the past. What of antenatal care? At present, women at high risk are referred to special centres for labour and delivery, and perhaps this principle of grouping according to need should apply to antenatal clinics also. There was discussion of how antenatal clinics might be more widely spread, with doctors and midwives going to different centres more frequently; and of finding out, from those women who do not usually come for antenatal care, which aspects of management they dislike so much. A plea was made for reassessment of both clinical care and laboratory investigations in pregnancy so that those tests which were most useful should be more uniformly employed and the others stopped. The coming financial cutbacks aroused pessimism since those who will be most affected are the young, the unmarried and those in socioeconomic classes IV and V- among whom perinatal death and morbidity
already above average.44 If we are looking for major decreases in perinatal mortality and morbidity, we must attack the social factors. But in the shorter run we can improve matters by better medical care. "What," asked one participant at rates are
1. Hagard S, Carter PA. Preventing the birth of infants with Down’s syndrome: a cost benefit analysis. Br Med J 1976; i: 753-56. 2. Hagard S, Carter FA, Milne RG. Screening of spina bifida cystica: a cost benefit analysis. Br J Prev Soc Med 1976; 30: 40-53. 3. The Children’s Committee. The reduction of perinatal mortality and morbidity: a discussion document. Children’s Committee, Brook House, Terrington Place, London WC1. 4. Chamberlain G. Background to Perinatal Health. Lancet 1979; ii: 1061-63.
the meeting, "will happen to the suggestions that have been made at this conference?" Let us hope the essence of the suggestions will be quickly published and widely distributed-among those who manage health care, among those who dispense it, and among those who receive it. Further, it is the committee’s job in this important area of medicine, to make firm recommendations to the Secretaries of State. Under present Governmental philosophy the committee may have a short life, but it could still catalyse reactions for much good in perinatal health.
RUNNING REPAIRS MASS "fun-runs"
attract
much medical attention
days-perhaps because doctors feel vaguely responsible for the exercise fad and its consequences. In Sydney, Australia, the City-to-Surf Fun Run has been held for nine years, and participants can now look for-
these
ward
excellent medical services. This 14 km event 16 500 runners, and the Nov. 3 issue of the Medical Journal of Australia contains three articles which should interest anyone who officiates at such rallies. The hazards are environmental, physical, and medical. Since 1973 the effect of environmental factors has been considerably reduced by holding the run in midAugust (i.e., late winter in Australia), although prolonged physical activity may induce symptoms of heat exhaustion even when environmental conditions seem to be "safe". The first 400 m are the worst-a downhill rush in the Gadarene manner. Since 1971, when the run was held in September and 1-76%) of the runners collapsed with heat exhaustion, the casualty-rate has decreased. In 1979 only 0-1% of the participants required medical attention, with 2 runners (0-1%) needing further treatment in hospital. In the history of the race there have been only 2 cases of myocardial infarction and 1 death. Participants are urged to train for the run, and this is probably one factor in the good safety record; and another is the efficient organisation of medical teams. These teams include trained "spotters" who can identify and advise exhausted runners before they collapse, and medical and nursing specialists in intensive management of heat exhaustion. Post-run seminars were also held to make recommendations for future events. Detailed records of 56 runners treated for heat exhaustion in 1977-79 have been analysed retrospectively and show how the risky and messy management with ice-wet towels has been successfully replaced by intravenous rehydration alone or with ice packs over large vessels. The 1978 event also served as a vehicle for research whereby the biochemical and haematological profiles of collapsed runners were compared with those of preselected control runners. The casualties had lower serum bicarbonate and higher creatinine, urea nitrogen, and uric acid than did the controls, and the differences were still evident four weeks after the run despite the absence of reported clinical manifestations. It is suggested that these changes indicate more intense tissue damage in the casualties and a subsequent slow recovery. Apart from urging proper physical preparation, the Australian workers draw attention to the hazard of stress injuries in runners who wear unsuitable shoes. to
attracts over
ing swimming
to
asthmatic children, doctors and others
should bear in mind the potential hazard of bronchial irritation by chlorine. But the risks are probably small in relation to the benefits of sterilisation.
MINDS UNDER THE FLIGHTPATH NO-ONE ought to have to live under the narrow landing corridor to a major airport, but a lot of housing, much of it in the public sector, is so sited. Near London’s Heathrow classroom teaching can be interrupted, lipreading is a useful skill, and subsidies have to be provided for soundproofing buildings. A preliminary communication, published exactly ten years ago, suggested
that stress from exposure to aircraft was reflected in increased admissions to hospital for mental illness. Noise annoys,2 and the din of jet engines is no exception, but the notion that illness severe enough to warrant inpatient psychiatric care might ensue came as a surprise. The first attempt to confirm these findings was by Gattoni and Tarnopolsky ;3 a couple of chi-squared values get near the magic figure when the data are rearranged to suit the original hypothesis, but that is all. Now Tarnopolsky and his colleagues have published a further chapter in the Hounslow/Heathrow/Springfield Hospital saga4 as part of a Medical Research Council programme under the direction of Prof. Michael Shepherd. The latest inquiry is more thorough than the one by Abey-Wickrama et al.,’ and it is on a much larger scale than anything that has gone before. The three studies based on Springfield admissions differ greatly in the way residence, hospital catchment, and noise boundaries were handled. Another negative result would not have been surprising, but instead we get in the third inquiry4 a highly significant trend in the reverse direction-more noise, lower admission-rates. Tarnopolsky and his coworkers do not seem to know what to make of this finding. They warn against drawing conclusions from "exploratory research", yet this was not a pilot study but a careful investigation based on a population of about a million people and covering forty times as many admissions and twice the duration of the earlier studies. Dr Tarnopolsky has kindly provided us with a copy of a paper,5 given at a congress in Freiburg last year, which provides a further twist to the tale. Admissions to the Holloway Sanatorium at Virginia Water, a hospital about one-sixth the size of Springfield and serving a population under the baleful influence of the airport but much more rural in character, support the noise hypothesis for first admissions of single people and for all admissions except for the noisiest zone where the population at risk is small and we are advised to ignore the aberration. Even after a decade of research, therefore, it is not possible to say whether aircraft noise can seriously damage the psyche-indeed it is doubtful if anything 1.
Abey-Wickrama I, a’Brook MF, Gattoni FEG, Herridge CF. Mental hospital admissions and aircraft noise. Lancet 1969; ii: 1275-77.
2. Editorial. Noise, annoyance, and mental health. Lancet 1977; i: 1090. 3. Gattoni F, Tarnopolsky A. Aircraft noise and psychiatric morbidity. Psychol Med 1973; 3: 515-20. 4. Jenkins LM, Tarnopolsky A, Hand DJ, Barker SM. Comparison of three studies of aircraft noise and psychiatric hospital admissions conducted in the same area. Psychol Med 1979; 9: 681-93. 5. Hand DJ, Tarnopolsky A, Barker SM, Jenkins LM. Relationships between psychiatric hospital admissions and aircraft noise: a new study. In: Proceedings of Third International Congress on Noise as a Public Health Problem. (In press.)
useful can be learned from further retrospective studies based on one airport and relating to the early 1970s (even the largest study covers no admissions after Dec. 31, 1972). Intuitively, it would seem unlikely that two populations, one living right under the jets and one further off, would be the same in every respect other than exposure to aircraft noise, but this is difficult to check on at a distance of seven years or more. The problem of social matching is made even harder by the fact that demographic risk factors for psychiatric illness come in unusual packages (an unemployed graduate living on his own, for example). Furthermore, admission or community care for a mental problem is nowadays as likely to be determined on social as on medical grounds; nor can the question of immigrant communities around Heathrow be neglected. more
COLONIC COMPLICATIONS OF ACUTE PANCREATITIS "AcuTE pancreatitis is the most terrible of all the calamities that occur in connection with the abdominal viscera," proclaimed Sir Berkeley Moynihan1 in 1925. This opinion has been supported by an ever-increasing list of complications both intra-abdominal and extra-
abdominal.22 The incidence of primary acute pancreatitis in the United Kingdom varies greatly from year to year,3 but overall the disease seems to be increasing, particularly when associated with alcohol or drugs. Unless this increase is due to very mild forms of pancreatitis, there is likely to be an increase in the complications seen. Abscess and pseudocyst are the commonest intra-abdominal complications; damage to the colon (obstruction, fistula, bleeding, or stricture) is rare, but often life-threatening. (The watery-diarrhoea syndrome with varied serum levels of intestinal polypeptides might also be added to the colonic complications.4 Abcarian and his colleagues5 have reviewed 65 published case reports of colonic complications of acute pancreatitis, together with 10 of their own cases managed in a three-year period in Cook County Hospital, Chicago. This represented 1% of the total number of patients admitted with acute pancreatitis (predominantly alcoholic) during that same period. It is surprising that such colonic complications are not more common since the transverse mesocolon is an intimate anterior relation of the pancreas. 2 of the 10 Chicago patients died, and this creditably low mortality rate was attributed to a high index of clinical suspicion coupled with early aggressive surgery, particularly for colonic bleeding and fistula. Several useful clinical lessons emerge from this paper. The older patients (over 50 years) with mild pancreatitis may have pseudo-obstruction of the colon which must not be mistaken for malignant obstruction or ischaemic colitis; they have a good prognosis. Pseudocysts, inflammatory masses and abscesses must be carefully monitored by repeated clinical examination, ultrasonography, and barium studies to 1. 2.
Moynihan B. Acute pancreatitis. Ann Surg 1925; 81: 132-42. Carey LC. Extra-abdominal manifestations of acute pancreatitis. Surgery 1979; 86: 337-42.
3. Bourke JB. Variation in annual incidence of primary acute pancreatitis in Nottingham 1969-74. Lancet 1975; ii: 967-69. 4. Burbige, EJ, Manning, RJ, Belber JP. Watery diarrhea syndrome with elevated levels of vasoactive intestinal polypeptide associated with pancreatitis and pancreatic pseudocyst. Am J Gastroenterol 1978; 70: 136-40. 5. Abcarian H, Eftaiha M, Kraft AR, Nyhus LM. Colonic complications of acute
pancreatitis. Arch Surg 1979: 114: 995-1001.
1344 detect fistula formation and bleeding, which are apt to be fatal without early surgery. Operation must include wide retroperitoneal drainage, excision of affected bowel, and avoidance of primary anastomosis. Parenteral hyperalimentation, a concept unknown to Sir Berkeley Moynihan when he made his dire pronouncement, is valuable in the prolonged and difficult postoperative
management. CHILDREN’S COMMITTEE, ON PERINATAL CARE
,
BETTER care before birth and at birth is justified not only on health grounds but also on financial ones. Small sums spent on, say, screening for Down’s syndrome in prospective mothers over 401 and for neural-tube defects in those at high risk,2 could save the community much larger sums. This was a view set out in the Children’s Committee discussion document, The Reduction of Perinatal Morbidity and Mortality.3 Earlier this month the Committee, set up by the last Government (and after the present Government’s axe-work one of the few remaining quangos), invited many obstetricians, general practitioners, midwives, social workers, and parents to the Royal College of Physicians to discuss this document. Opening the meeting the Minister of State for Health, Dr Gerard Vaughan, said that perinatal mortality rates in England and Wales were dropping faster and more consistently than for many years. All those present were glad to acknowledge this, but no-one thought it grounds for complacency: numbers of births are now increasing, and no actual or relative reductions in the financing of maternity services should be allowed. Many participants called for confidential inquiries into perinatal deaths in the regions, and also regional implementation of an improved standard maternity information system. This system would give information every year about maternity care and might replace the national cohort surveys of the past. What of antenatal care? At present, women at high risk are referred to special centres for labour and delivery, and perhaps this principle of grouping according to need should apply to antenatal clinics also. There was discussion of how antenatal clinics might be more widely spread, with doctors and midwives going to different centres more frequently; and of finding out, from those women who do not usually come for antenatal care, which aspects of management they dislike so much. A plea was made for reassessment of both clinical care and laboratory investigations in pregnancy so that those tests which were most useful should be more uniformly employed and the others stopped. The coming financial cutbacks aroused pessimism since those who will be most affected are the young, the unmarried and those in socioeconomic classes IV and V- among whom perinatal death and morbidity
already above average.44 If we are looking for major decreases in perinatal mortality and morbidity, we must attack the social factors. But in the shorter run we can improve matters by better medical care. "What," asked one participant at rates are
1. Hagard S, Carter PA. Preventing the birth of infants with Down’s syndrome: a cost benefit analysis. Br Med J 1976; i: 753-56. 2. Hagard S, Carter FA, Milne RG. Screening of spina bifida cystica: a cost benefit analysis. Br J Prev Soc Med 1976; 30: 40-53. 3. The Children’s Committee. The reduction of perinatal mortality and morbidity: a discussion document. Children’s Committee, Brook House, Terrington Place, London WC1. 4. Chamberlain G. Background to Perinatal Health. Lancet 1979; ii: 1061-63.
the meeting, "will happen to the suggestions that have been made at this conference?" Let us hope the essence of the suggestions will be quickly published and widely distributed-among those who manage health care, among those who dispense it, and among those who receive it. Further, it is the committee’s job in this important area of medicine, to make firm recommendations to the Secretaries of State. Under present Governmental philosophy the committee may have a short life, but it could still catalyse reactions for much good in perinatal health.
RUNNING REPAIRS MASS "fun-runs"
attract
much medical attention
days-perhaps because doctors feel vaguely responsible for the exercise fad and its consequences. In Sydney, Australia, the City-to-Surf Fun Run has been held for nine years, and participants can now look for-
these
ward
excellent medical services. This 14 km event 16 500 runners, and the Nov. 3 issue of the Medical Journal of Australia contains three articles which should interest anyone who officiates at such rallies. The hazards are environmental, physical, and medical. Since 1973 the effect of environmental factors has been considerably reduced by holding the run in midAugust (i.e., late winter in Australia), although prolonged physical activity may induce symptoms of heat exhaustion even when environmental conditions seem to be "safe". The first 400 m are the worst-a downhill rush in the Gadarene manner. Since 1971, when the run was held in September and 1-76%) of the runners collapsed with heat exhaustion, the casualty-rate has decreased. In 1979 only 0-1% of the participants required medical attention, with 2 runners (0-1%) needing further treatment in hospital. In the history of the race there have been only 2 cases of myocardial infarction and 1 death. Participants are urged to train for the run, and this is probably one factor in the good safety record; and another is the efficient organisation of medical teams. These teams include trained "spotters" who can identify and advise exhausted runners before they collapse, and medical and nursing specialists in intensive management of heat exhaustion. Post-run seminars were also held to make recommendations for future events. Detailed records of 56 runners treated for heat exhaustion in 1977-79 have been analysed retrospectively and show how the risky and messy management with ice-wet towels has been successfully replaced by intravenous rehydration alone or with ice packs over large vessels. The 1978 event also served as a vehicle for research whereby the biochemical and haematological profiles of collapsed runners were compared with those of preselected control runners. The casualties had lower serum bicarbonate and higher creatinine, urea nitrogen, and uric acid than did the controls, and the differences were still evident four weeks after the run despite the absence of reported clinical manifestations. It is suggested that these changes indicate more intense tissue damage in the casualties and a subsequent slow recovery. Apart from urging proper physical preparation, the Australian workers draw attention to the hazard of stress injuries in runners who wear unsuitable shoes. to
attracts over
