Chronic obstructive pulmonary disease in non-smokers

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Tobacco smoking is established as a major risk factor, but emerging evidence suggests that other risk factors are important, especially in developing countries. An estimated 25–45% of patients with COPD have never smoked; the burden of non-smoking COPD is therefore much higher than previously believed. About 3 billion people, half the worldwide population, are exposed to smoke from biomass fuel compared with 1·01 billion people who smoke tobacco, which suggests that exposure to biomass smoke might be the biggest risk factor for COPD globally. We review the evidence for the association of COPD with biomass fuel, occupational exposure to dusts and gases, history of pulmonary tuberculosis, chronic asthma, respiratory-tract infections during childhood, outdoor air pollution, and poor socioeconomic status.     

Combination Therapy Versus Monotherapy in Reducing Blood Pressure: Meta-analysis on 11,000 Participants from 42 Trials

Objective

To quantify the incremental effect of combining blood pressure-lowering drugs from any 2 classes of thiazides, beta-blockers, angiotensin-converting enzyme inhibitors, and calcium channel blockers over 1 drug alone and to compare the effects of combining drugs with doubling dose.

Methods

Meta-analysis of factorial trials in which participants were randomly allocated to 1 drug alone, another drug alone, both drugs together, or a placebo.

Results

We identified 42 trials (10,968 participants). With a thiazide used alone, the mean placebo-subtracted reduction in systolic blood pressure was 7.3 mm Hg and 14.6 mm Hg combined with a drug from another class. The corresponding reductions were 9.3 mm Hg and 18.9 mm Hg with a beta-blocker, 6.8 mm Hg and 13.9 mm Hg with an angiotensin-converting enzyme, and 8.4 mm Hg and 14.3 mm Hg with a calcium channel blocker. The expected blood pressure reduction from 2 drugs together, assuming an additive effect, closely predicted the observed blood pressure reductions. The ratios of the observed to expected incremental blood pressure reductions from combining each class of drug with any other over that from 1 drug were, respectively, for thiazides, beta-blockers, angiotensin-converting enzyme inhibitors, and calcium channel blockers: 1.04 (95% confidence interval [CI], 0.88-1.20), 1.00 (95% CI, 0.76-1.24), 1.16 (95% CI, 0.93-1.39), and 0.89 (95% CI, 0.69-1.09); the overall average was 1.01 (95% CI, 0.90-1.12). Comparison of our results with those of a published meta-analysis of different doses of the same drug showed that doubling the dose of 1 drug had approximately one fifth of the equivalent incremental effect (0.22 [95% CI, 0.19-0.25]).

Conclusion

Blood pressure reduction from combining drugs from these 4 classes can be predicted on the basis of additive effects. The extra blood pressure reduction from combining drugs from 2 different classes is approximately 5 times greater than doubling the dose of 1 drug.     

The Human Genome Project

In many Western jurisdictions, people with an intellectual disability are over-represented at various stages of the criminal justice system, including appearances before local courts, suspects undergoing police questioning, and in prisons. Whilst the over-representation has been established, little is known about concurrent factors which may contribute to the behaviour which brings them to the attention of the criminal justice system. Conversely, few data are available about people with an intellectual disability who have similar living environments, but who are not involved in criminal acts. This study examines a sample of 60 women, 30 of whom are ex-prisoners, and 30 of whom are presently living in similar unstable residential situations (refuge, welfare organisation accommodation, etc), but who do not have a history of prior imprisonment. No significant differences were found between the two groups in terms of prevalence of intellectual disability; 25% of the total group had an IQ score of 69 or lower, which would place them in the category of intellectual disability. In the ex-prisoner group, this figure was 29.7%, whereas in the non-prisoner group, it was 20%. A further 11.7% were in the borderline category of IQ score 70–79. Low verbal IQ scores correlated with alcohol or benzodiazepine abuse, smoking, self-harm and suicide, poor mental and physical health, low levels of education, and unstable accommodation. For both ex-prisoners and non-prisoners, high intelligence appeared to be a mediating factor, lessening the impact of other factors related to deprived and difficult living circumstances. The low levels of verbal ability revealed indicate the need for tailoring rehabilitation programmes for verbally impaired participants.     

The development of the physicians' peace movements

A brief historical account is given of the development of medical ethics, and of the gradual assumption of medical responsibilities in relation to victims of war. The idea that the medical profession as a whole should be concerned with health problems throughout the world, other than those of their own nationals, is quite recent. Collaboration in this area began with the International Health Organization of the League of Nations, and was greatly strengthened by the setting up of the World Health Organization by the United Nations in 1948. However, the idea that the medical profession has a duty to try to prevent war, rather than to mitigate its sufferings, is almost new and arose largely from the realization that war involving nuclear weapons poses the greatest immediate health hazard to humankind. The growth of physicians’ organizations during the past 30, but especially the past 5 or 6 years, is described, and the significance of their federation to form International Physicians for the Prevention of Nuclear War is discussed. The special role which physicians’ organizations can play in the solution of what is essentially a political problem—namely the scaling down and elimination of nuclear weapons—is briefly reviewed.