409
MEASURING BLOOD-PRESSURE THE auscultatory method for measuring blood-pressure has been in continuous use since its introduction in
1905,1 with only minor modifications in technique and instruments. Comparison with intra-arterial recordings’-" shows the method to be reasonably accurate and reliable, although large and unexplained discrepancies mav arise in individual patients.’" Attempts to improve the objectivity of the method by obscuring the mercury column12 or by shifting the zero in random fashion" have been very successful, but the need for a human observer has always limited the frequency with which observations can be made. Replacement of the observer bv automatic mechanical inflation/deflation devices and a microphone to register the Korotkoff sounds14 has not been very successful, since the apparatus is necessarily cumbersome and subject to artifact. Ultrasound detection of arterial-wall movement is another approach which has been carefully evaluated 15 but the apparatus is expensive and not portable. None of these instruments has much to offer the clinician with his inexpensive mercury manometer and stethoscope, but the whole picture has changed with the upsurge of popular interest in blood-pressure which has stemmed from increasing evidence that treatment of high blood-pressure may reduce the risk of cerebrovascular accidents and myocardial infarction,’6 There is now great interest in mass screening of blood-pressure17 and a natural outcome is the construction of instruments which will enable the doctor to take a blood-pressure rapidly and easily and may even be used by people with no training.18 19 A profusion of automatic and semi-automatic machines, many with attractive flashing lights to indicate systolic and diastolic pressure, are on offer in’the professional and lay Press. It has even been suggested that these instruments should be installed in chemists shops next to the weighing-machine, But whereas the auscultatory method of measuring blood-pressure has survived rigorous and repeated examination, there is very little information on the accuracy and reliability of these new instruments. Serious deficiencies have been found in some which have been examined critically20 and little attention has been paid to the careful recommendations for evaluation laid down by the American Heart Association.21 It is left to the integrity of individual manufacturers and the enthusiasm 1 Korotkoff, M. S. Bull. imp. milit. Med. Acad. 1905, 11, 365. 2. Ragan, C., Bordley, J. Bull. Johns Hopkins Hosp. 1941, 69, 504. 3. Hamilton, W. F., Woodbury, R. A., Harper, H. I. J. Am. med. Ass. 1936, 107, 853.
4. Steele, J. M. J. Mt Sinai Hosp. 1942, 8, 1042. 5. Roberts, L. M., Smiley, J. R., Manning, G. W. Circulation, 1953, 8, 232. 6 Berliner, K., Fujiy, H., Ho Lee, D., Yildiz, M., Garnler, B. Cardiologia, Basel, 1960, 37, 118. 7 Buhlmann, A. Direkte Blutkruckmessung Beimmenschen. Berlin, 1958. 8 Holland, W. W., Humerfelt, S. Br. med. J. 1964, ii, 1241. 9. Kotte, J. H., Iglauer, A., McGuire, E. Am. Heart J. 1944, 28, 476. 10 Raftery, E. B., Ward, A. Cardiovasc. Res. 1968, 2, 210. 11 Briet, S. N., O’Rourke, M. F. Aust. N.Z. J. Med 1972, 4, 485. 12 Rose, G. A., Holland, W. W., Crowley, E. A. Lancet, 1964, i, 296. 13 Wright, B. M., Dore, C. F. ibid. 1970, i, 337. 14 Hinman, A. T., Engel, B. T., Bickford, A. F. Am. Heart J. 1962, 63, 663. 15 Gundersen, J. Ahlgren, I. Acta anœsth. scand. 1973, 17, 203. 16 Veterans Administration. J. Am. med. Ass. 1970, 213, 1143.
17 Sackett, D. L. Lancet, 1974, ii, 1189. 18 TheHi/Lo Baumanometer Blood-Pressure Kit. For physician-directed Home Use. New Product Data Sheet. W. P. Baum Co Inc., New York. 19 Owners Manual, Sphygmometrograph Blood-Pressure Recorder. Sears, Roebuck. 21 Labarthe, D. R., Hawkins, C. M., Remington, R. D. Am. J. Cardiol. 1973,
32, 546,
22 Circulation, 1973, 48, suppl. 6.
of some investigators (see p. 398) to ensure that inaccurate and misleading instruments do not become freely available. Perhaps it is time for the Committee on Safety of Medicines to inspect and licence new medical instruments.
PROPIONIC-ACID DERIVATIVES A NUMBER of anti-inflammatory drugs have been devised in the hope of bypassing the side-effects of aspirin, phenylbutazone, and indomethacin. Notable among these are the propionic-acid derivatives: all have much less tendency to cause gastric side-effects than
aspirin,
none causes important occult bleeding (though hxmatemesis has been reported), and all have analgesic potency akin to that of aspirin. Some have rather less anti-inflammatory activity and none reduces joint size-a property regarded by some rheumatologists as the hallmark of an anti-inflammatory drug.’ Clinical experience suggests that, while they are well suited to most rheumatic conditions, including osteoarthritis and softtissue rheumatism, they are not as effective as the tradi- tional anti-inflammatory agents in highly inflammatory disorders such as gout, ankylosing spondylitis, and very active rheumatoid arthritis. Despite the lack of effect on joint size, their anti-inflammatory potential is reflected by improvement in morning stiffness (a cardinal symptom of inflammation which seems to have been overlooked by Celsus and Galen). These new compounds therefore have more in common with the anti-inflammatory drugs than with simple analgesics. Huskisson2 classifies drugs for rheumatic disease under four headingssimple analgesics (e.g., paracetamol), analgesics with minor anti-inflammatory properties (e.g., ibuprofen), analgesics with major anti-inflammatory properties, (e.g., indomethacin) and pure anti-inflammatory drugs
(corticosteroids). The propionic-acid derivatives fenoprofen,3 ibuprofen,4 ketoprofen,5 and naproxen6 all have fewer sideeffects than aspirin. According to Huskisson et al.7 naproxen and fenoprofen seem slightly more effective than ibuprofen and ketoprofen; and naproxen and ibuprofen are less likely than the other two to cause gastric side-effects. But in this work the differences between individual patients’ responses to one drug were great. Individual variation is of great practical importance. An anti-inflammatory agent should be given for just long enough to see whether it will work; one or two weeks is enough. It may be necessary to try all the drugs to find the best. For all but the most active cases of rheumatoid arthritis, and disorders such as gout in which inflammation is prominent, propionic-acid derivatives can now be regarded as first-line treatment. Boardman, P. C., Hart, F. D. Br. med. J. 1967, iv, 264. Huskisson, E. C. Reports on Rheumatic Diseases; p. 54. Arthritis and Rheumatism Council, London, 1974. 3. Huskisson, E. C., Wojtulewski, J. A., Berry, H., Scott, J., Hart, F. D. Br. med. J. 1974, i, 176. 4. Huskisson, E. C., Hart, F. D., Shenfield, G. M., Taylor, R. T. Practitioner, 1971, 207, 639. 5. Qutchi, D. W., Man, S., Bloch, M., Mason, R. M. Rheum. Rehab. 1973, 12,
1. 2.
62.
Hill, H. F., Hill, A. G. S., Mowat, A. G., Ansell, B. M., Mathews, J. A., Seifert, M. H., Gumpel, J. M., Christie, G. A. Ann. rheum. Dis. 1974, 32, 12. 7. Huskisson, E. C., Woolf, D. L., Balme, H. W., Scott, J., Franklyn, S. Br. med. J. 1976, i, 1048. 6.
MEASURING BLOOD-PRESSURE THE auscultatory method for measuring blood-pressure has been in continuous use since its introduction in
1905,1 with only minor modifications in technique and instruments. Comparison with intra-arterial recordings’-" shows the method to be reasonably accurate and reliable, although large and unexplained discrepancies mav arise in individual patients.’" Attempts to improve the objectivity of the method by obscuring the mercury column12 or by shifting the zero in random fashion" have been very successful, but the need for a human observer has always limited the frequency with which observations can be made. Replacement of the observer bv automatic mechanical inflation/deflation devices and a microphone to register the Korotkoff sounds14 has not been very successful, since the apparatus is necessarily cumbersome and subject to artifact. Ultrasound detection of arterial-wall movement is another approach which has been carefully evaluated 15 but the apparatus is expensive and not portable. None of these instruments has much to offer the clinician with his inexpensive mercury manometer and stethoscope, but the whole picture has changed with the upsurge of popular interest in blood-pressure which has stemmed from increasing evidence that treatment of high blood-pressure may reduce the risk of cerebrovascular accidents and myocardial infarction,’6 There is now great interest in mass screening of blood-pressure17 and a natural outcome is the construction of instruments which will enable the doctor to take a blood-pressure rapidly and easily and may even be used by people with no training.18 19 A profusion of automatic and semi-automatic machines, many with attractive flashing lights to indicate systolic and diastolic pressure, are on offer in’the professional and lay Press. It has even been suggested that these instruments should be installed in chemists shops next to the weighing-machine, But whereas the auscultatory method of measuring blood-pressure has survived rigorous and repeated examination, there is very little information on the accuracy and reliability of these new instruments. Serious deficiencies have been found in some which have been examined critically20 and little attention has been paid to the careful recommendations for evaluation laid down by the American Heart Association.21 It is left to the integrity of individual manufacturers and the enthusiasm 1 Korotkoff, M. S. Bull. imp. milit. Med. Acad. 1905, 11, 365. 2. Ragan, C., Bordley, J. Bull. Johns Hopkins Hosp. 1941, 69, 504. 3. Hamilton, W. F., Woodbury, R. A., Harper, H. I. J. Am. med. Ass. 1936, 107, 853.
4. Steele, J. M. J. Mt Sinai Hosp. 1942, 8, 1042. 5. Roberts, L. M., Smiley, J. R., Manning, G. W. Circulation, 1953, 8, 232. 6 Berliner, K., Fujiy, H., Ho Lee, D., Yildiz, M., Garnler, B. Cardiologia, Basel, 1960, 37, 118. 7 Buhlmann, A. Direkte Blutkruckmessung Beimmenschen. Berlin, 1958. 8 Holland, W. W., Humerfelt, S. Br. med. J. 1964, ii, 1241. 9. Kotte, J. H., Iglauer, A., McGuire, E. Am. Heart J. 1944, 28, 476. 10 Raftery, E. B., Ward, A. Cardiovasc. Res. 1968, 2, 210. 11 Briet, S. N., O’Rourke, M. F. Aust. N.Z. J. Med 1972, 4, 485. 12 Rose, G. A., Holland, W. W., Crowley, E. A. Lancet, 1964, i, 296. 13 Wright, B. M., Dore, C. F. ibid. 1970, i, 337. 14 Hinman, A. T., Engel, B. T., Bickford, A. F. Am. Heart J. 1962, 63, 663. 15 Gundersen, J. Ahlgren, I. Acta anœsth. scand. 1973, 17, 203. 16 Veterans Administration. J. Am. med. Ass. 1970, 213, 1143.
17 Sackett, D. L. Lancet, 1974, ii, 1189. 18 TheHi/Lo Baumanometer Blood-Pressure Kit. For physician-directed Home Use. New Product Data Sheet. W. P. Baum Co Inc., New York. 19 Owners Manual, Sphygmometrograph Blood-Pressure Recorder. Sears, Roebuck. 21 Labarthe, D. R., Hawkins, C. M., Remington, R. D. Am. J. Cardiol. 1973,
32, 546,
22 Circulation, 1973, 48, suppl. 6.
of some investigators (see p. 398) to ensure that inaccurate and misleading instruments do not become freely available. Perhaps it is time for the Committee on Safety of Medicines to inspect and licence new medical instruments.
PROPIONIC-ACID DERIVATIVES A NUMBER of anti-inflammatory drugs have been devised in the hope of bypassing the side-effects of aspirin, phenylbutazone, and indomethacin. Notable among these are the propionic-acid derivatives: all have much less tendency to cause gastric side-effects than
aspirin,
none causes important occult bleeding (though hxmatemesis has been reported), and all have analgesic potency akin to that of aspirin. Some have rather less anti-inflammatory activity and none reduces joint size-a property regarded by some rheumatologists as the hallmark of an anti-inflammatory drug.’ Clinical experience suggests that, while they are well suited to most rheumatic conditions, including osteoarthritis and softtissue rheumatism, they are not as effective as the tradi- tional anti-inflammatory agents in highly inflammatory disorders such as gout, ankylosing spondylitis, and very active rheumatoid arthritis. Despite the lack of effect on joint size, their anti-inflammatory potential is reflected by improvement in morning stiffness (a cardinal symptom of inflammation which seems to have been overlooked by Celsus and Galen). These new compounds therefore have more in common with the anti-inflammatory drugs than with simple analgesics. Huskisson2 classifies drugs for rheumatic disease under four headingssimple analgesics (e.g., paracetamol), analgesics with minor anti-inflammatory properties (e.g., ibuprofen), analgesics with major anti-inflammatory properties, (e.g., indomethacin) and pure anti-inflammatory drugs
(corticosteroids). The propionic-acid derivatives fenoprofen,3 ibuprofen,4 ketoprofen,5 and naproxen6 all have fewer sideeffects than aspirin. According to Huskisson et al.7 naproxen and fenoprofen seem slightly more effective than ibuprofen and ketoprofen; and naproxen and ibuprofen are less likely than the other two to cause gastric side-effects. But in this work the differences between individual patients’ responses to one drug were great. Individual variation is of great practical importance. An anti-inflammatory agent should be given for just long enough to see whether it will work; one or two weeks is enough. It may be necessary to try all the drugs to find the best. For all but the most active cases of rheumatoid arthritis, and disorders such as gout in which inflammation is prominent, propionic-acid derivatives can now be regarded as first-line treatment. Boardman, P. C., Hart, F. D. Br. med. J. 1967, iv, 264. Huskisson, E. C. Reports on Rheumatic Diseases; p. 54. Arthritis and Rheumatism Council, London, 1974. 3. Huskisson, E. C., Wojtulewski, J. A., Berry, H., Scott, J., Hart, F. D. Br. med. J. 1974, i, 176. 4. Huskisson, E. C., Hart, F. D., Shenfield, G. M., Taylor, R. T. Practitioner, 1971, 207, 639. 5. Qutchi, D. W., Man, S., Bloch, M., Mason, R. M. Rheum. Rehab. 1973, 12,
1. 2.
62.
Hill, H. F., Hill, A. G. S., Mowat, A. G., Ansell, B. M., Mathews, J. A., Seifert, M. H., Gumpel, J. M., Christie, G. A. Ann. rheum. Dis. 1974, 32, 12. 7. Huskisson, E. C., Woolf, D. L., Balme, H. W., Scott, J., Franklyn, S. Br. med. J. 1976, i, 1048. 6.
