Frequent Offenders Research Articles

Environmental control.

Environmental control measures help eliminate triggers that initiate the allergic reaction and reduce the conditions that sustain it. The most frequent offenders are the ubiquitous dust mites, which are ideally suited to living in the home environment. Control measures consist of minimizing their reservoirs in the patient's bedding, carpets, and upholstered furniture; decreasing humidity; and using acaricides. Cats are the source of another important indoor allergen that becomes and stays airborne as small particles. Removal of the animal (or washing it weekly) and the use of high-efficiency particulate air filters for air ducts and vacuum cleaners are useful in reducing dust mite and cat allergens. Dogs and rodents also produce allergens offensive to the sensitized patient and should be removed or relegated outdoors. Cockroaches have become an increasingly prevalent source of allergens responsible for asthma and rhinitis. Their removal is the focus of research, because current control measures are usually inadequate. Molds, which thrive in any moist environment, produce allergens. Closed windows prevent further influx of outdoor molds and pollens, whereas those harbored indoors, including those residing on plants, should be eliminated.

Metastases to Major Salivary Glands

Secondary neoplastic involvement of the major salivary glands, most often the parotid, can be from regional (supraclavicular) and distant (infraclavicular) primary neoplasms. Cutaneous squamous cell carcinomas and melanomas are the most frequent offenders, and their numbers dominate all statistics dealing with metastases to the salivary glands and their lymph nodes. Carcinomas of the lungs, breast, and kidneys are the most frequent infraclavicular neoplasms that metastasize to the major salivary glands, and they most often manifest a hematogenous dissemination. Supraclavicular primary disease metastasizes to the salivary glands and their lymph nodes via a more diverse manner: direct extension, lymphatic spread, or, less often, blood vascular transport.

Promotion by the British pharmaceutical industry, 1983-8: a critical analysis of self regulation.

Since 1958 the Association of the British Pharmaceutical Industry (ABPI) has attempted to regulate the promotion of prescription medicines through its code of practice. This regulation is described and analysed for the six years 1983-8 using the reports on 302 complaints considered by its code of practice committee and annual reports. The complaints came mainly from doctors (143, 48%) and competing companies (103, 33%). The committee found a total of 379 breaches of the code in 192 (63%) of the complaints. Additional breaches were detected by informational scrutiny of advertisements by the ABPI secretariat. Analysis showed that 270 (71%) of these breaches involved possible breaches of the Medicines Act. The rules that forbid misleading or unsubstantiated information and misleading claims or comparisons were broken most often. The committee found the most frequent offenders to be Organon (32 breaches), Smith Kline and French (23), Glaxo (21), A H Robins (18), Bayer (17), Merck Sharp and Dohme (17), and Lederle (16). Often the promotion of one product led to several breaches. The promotional wars over histamine H2 receptor antagonists accounted for 33 breaches. It is estimated that in 1983-8 about 100 breaches of the code were detected a year. In the 18 years 1972-88 the Medicines Act was breached probably over 1200 times. Health ministers, by not enforcing the regulations controlling promotion, have abrogated their responsibility to the ABPI, but the evidence suggests that the code has failed to deter promotional excesses. The ABPI's wish to secure compliance with the code seems weaker than its wish to pre-empt outside criticism and action: its self regulation seems to be a service to itself rather than to the public. It is suggested that the code of practice committee should become publicly accountable, that the majority of its members should represent the health professions and the public, and that effective sanctions are needed.

Drug-Induced Hypoglycemia: A Review of 1418 Cases

The present review catalogues 1418 reported cases of drug-induced hypoglycemia. The main findings are that sulfonylureas (especially chlorpropamide and glyburide), either alone or with a second hypoglycemic or potentiating agent, still account for 63% of all cases; that alcohol, propranolol, and salicylate, either singly or with another hypoglycemic drug, are the next most frequent offenders (19% of the total); and that one older drug (quinine) and three new ones (pentamidine, ritodrine, and disopyramide) have caused an additional 7% of all episodes of severe hypoglycemia. The clinical factors that set the stage for drug-induced hypoglycemia are still restricted food intake, age, hepatic disease, and renal disease, both individually and even more so in combination. Drug-induced hypoglycemia continues to be so common that virtually every unconscious patient should be considered hypoglycemic until immediate estimation of the blood sugar level rules it in or out. If ruled in, the clinician should promptly start 10% intravenous glucose and plan to maintain it uninterruptedly for 1 or more days, with added glucagon, hydrocortisone, and diazoxide administration if necessary, until sustained hyperglycemia guarantees that all drug effects have worn off.

DELINQUENCY BY ASSOCIATION?

This study examined whether at-risk youths would be more likely to commit major criminal offences following their continuous association with convicted delinquents in community-based intervention programme. One hundred and ten male subjects, aged 15-21 and matched for socio-demographic background, were studied. Four groups were formed: two which received the progamme--convicted youths (n=43), and at-risk youngsters (n=31)--and two which were placed on waiting lists--convicted (n=19) and at-risk (n=17) youths. Results showed that the at-risk group failed to differ from their comparison group regarding conviction rates at 16-months follow-up, namely, 9{middle dot}7 and 11{middle dot}8 per cent. respectively. The length of continuous association with convicted offenders (ie. 14 weeks or 28 weeks) did not increase the likelihood of major criminal involvement. These results are consistent with the hypothesis that, where pre-programme free association fails to influence at-risk youths to commit major offences, then mixed participation in a more structured controlled setting is just as unlikely to do so. There were also suggestions that recent-infrequent offenders who had received the programme were much more likely to be reconvicted during 16-months follow-up than both frequent and, especially, non-recent offenders. Subject to controlled confirmation, it is tentatively hypothesised that it is the recent-infrequent offenders who may have the highest risk of being adversely influenced by association with frequent offenders in community-based programmes.

The Need for a New Federalism in Criminal Justice

In this article, certain deficiencies of the criminal justice system are analyzed, drawing in part on Senator Specter's experience as Philadelphia District Attorney. It is argued that the traditional view of the role of state courts and criminal justice agencies is an unnecessary barrier to greater use of federal judicial and prosecutorial resources, unjustified either by principles of federalism or sound policy. How and why conditions in some urban state courts often frustrate prompt prosecution and sufficient sentencing of career criminals—a limited number of frequent offenders who commit a disproportionate amount of violent crime—are discussed and new laws and policies for increased federal prosecutions to supplement local prosecutions of felons using firearms, consistent with a “new federalism,” are suggested.

Management and Prevention of Infiltration and Extravasation Injury

Extravasation wounds are severe in hospital patients with few defenses against deep and painful necrosis. Hyperosmolar solutions, vasopressor agents, and chemotherapeutic drugs are the most frequent offenders. A knowledge of pitfalls in delivery systems may help to prevent such accidents.

Hypercalcemia and Malignant Disease

Virtually any malignancy may lead to hypercalcemia, but carcinoma of the breast, myeloma, and carcinoma of the lung are especially frequent offenders. A more difficult diagnostic problem is posed by the "silent" tumor which secretes a substance causing hypercalcemia. Foremost in this category are bronchogenic carcimona and hypernephroma.

Salmonella Infection in Ruptured Abdominal Aortic Aneurysm

NORMAL large elastic arteries are remarkably resistant to infection. 1,2 However, when congenital or acquired vascular abnormalities exist, this resistance may be compromised. For some unknown reason, enteric pathogens demonstrate a predilection for invasion of such abnormal vessels and members of the Salmonella group in particular are the most frequent offenders. Areas of arteriosclerotic change within large vessels are the usual site of bacterial invasion and aneurysmal rupture is the usual outcome. Prior to the advent of reconstructive vascular surgery, the ruptured abdominal aneurysm was largely a curiosity of academic interest. As vascular surgery was introduced it soon became apparent that infection was probably the gravest complication associated with reconstructive procedures. When infection exists prior to surgery, the chance of success is remote unless the infectious process can be eradicated. This report is prompted by a recent experience with a ruptured arteriosclerotic abdominal aortic aneurysm associated with salmonellosis. A review

Ambenonium in the Treatment of Urinary Retention and Constipation

TRINARY and fecal retention, either alone or ^-' together, poses a serious problem in the management of the patient. Unfortunately, these complications are appearing much more often than they were a few years ago. This is, for the most part, a result of the introduction and use of numerous highly potent drugs for the treatment of a variety of conditions from hypertension to Parkinson's disease. The ganglionic-blocking drugs widely used in the treatment of hypertension are frequent offenders, and all of them have a depressant action on the bowel and bladder that, in some patients, leads to serious loss of . . .

Poison Ivy, Poison Oak, and Poison Sumac

D ERMATITIS, caused by contact with approximately 460 plants and woods, has been reported in the medical literature. Of these plants, poison ivy, oak, and sumac are the most frequent offenders. Patients who have a dermatitis on exposed surfaces of the skin following possible exposure to shrubs or woods usually allude to one of these three plants as the specific cause of their skin eruption. Very few persons, however, are capable of recognizing these common plants and there is considerable confusion regarding the mode of contracting and treating these kinds of dermatitis. Many patients remark that they have poison ivy each year-brought on by merely walking near a plant. Others state that at one time they were quite sensitive to poison ivy but that they cured themselves and prevented repeated attacks by eating the leaves of the plant. Certainly there is a great deal of confusion regarding these skin conditions.

The bacteriostatic activity of pHisoHex on the vaginal flora

The results of this study indicate that pHisoHex will control the growth of certain bacteria. Its effectiveness was most consistent among gram-positive cocci and anaerobic bacteria, the more frequent offenders in puerperal infection. The coliform group which may also incite puerperal infections was less affected by the detergent. Actually when pHisoHex was self-administered positive cultures for these organisms increased. Hence, the hazard of coliform invasion of the vagina in self-administered therapy is a definite one. When frequent instillations were performed under aseptic precautions, marked reduction in coccal forms of bacteria was observed. In approximately 34 per cent of the patients who received this type of treatment, vaginal cultures became sterile.It is well recognized that potential pathogens such as aerobic and anaerobic streptococci are best maintained in a media at a constant pH which approaches that of blood. Therefore, the bacteriostatic effect of the detergent pHisoHex undoubtedly involves a reduction of the vaginal pH as well as the antibacterial action of the substance itself.

OCULAR ALLERGY

THE OPHTHALMOLOGIC aspects of allergy have occupied a prominent place in the development of knowledge of the subject from the beginning. A number of widely different ocular disorders, both external and internal, are of allergic origin. Dermatitis of the eyelids and conjunctival edema, vernal conjunctivitis, conjunctival folliculosis, subconjunctival hemorrhage, retinal hemorrhage and optic neuritis may be mentioned as ophthalmic conditions that are often due to allergy. Substances to which a person is specifically sensitized, such as plants and their pollens, cosmetics, nail polish, soaps, shampoos, drugs, hair dyes and emanations from fur, feathers and animals, are a few of the great variety of agents which may produce contact dermatitis. Lacquers, paints, paint solvents, refrigerants and other volatile substances used in industry are also frequent offenders. Aside from the local reaction which such agents may provoke, they may, by oft repeated inhalation, give rise to a variety of internal disorders, such

THIOGLYCOLLATE COLD WAVE PROCESS

A great variety of substances entering into the manufacture of cosmetics have caused allergic reactions in hypersensitive persons. The essential oils, perfumes and orris root are the most frequent offenders. Soaps containing these constituents and even pure high grade soaps may cause dermatitis. Jordan, Dolce and Osborne¹stated that eczematous dermatitis of the hands of housewives is one of the commonest and most refractory diseases for which dermatologists are consulted. They found 239 persons during a four year period in whom soap caused dermatitis on the hands, with and without involvement of other parts of the body. We have observed that in patch tests with medicated soap 15 per cent of the controls were allergic to a pure white soap. Vaughan²observed in routine patch tests with soap solutions that 5 to 10 per cent of persons tested reacted to one or another of the common brands, though

DERMATITIS DUE TO THE BLOSSOM OF GREVILLEA BANKSII

The occasional production of dermatitis venenata by contact with flowering plants has been commented on briefly by several writers. Weber,1in an extensive list of cutaneous irritants, mentioned the following plants as occasional sensitizers: daffodil (Narcissus pseudonarcissus), buttercup (Ranunculus asiaticus), tree of heaven (Ailanthus altissima), gas plant ( [Fraxinella] Dictamnus albus), olive spurge ([Mezereon] Daphne mezereum), catalpa (Catalpa sp.) and pasqueflower (Anemone patens). The list did not specify whether the blossoms or the leaves or both were irritating. Shelmire2discussed dermatitis from flowers and shrubs, remarking that florists and housewives, especially the latter, are naturally the most frequent sufferers from this. The most common skin sensitizers among the flowers and shrubs in his experience were the primose (Primula obconica), painted daisies ([Pyrethrum] Chrysanthemum sp.), feverfew (Chrysanthemum parthenium) and other members of the chrysanthemum family; less frequent offenders were the Shasta daisy, narcissus, tulip, iris, vinca, petunia, verbena, carnation, zinnia,

Nasal Sinusitis

In previous articles, I have described the technic for x-ray examination of the sinuses which I believe desirable and necessary for dependable diagnosis. I will not repeat that discussion here further than to say that films of the highest grade of technical excellence are necessary, and that views must be taken in all positions that might give any additional information. Under the most favorable circumstances, there are enough inherent potential sources of error in sinus diagnosis without adding the unnecessary ones of poor technic. Having obtained satisfactory films, it is still necessary to have some knowledge of the clinical aspects of the case if gross errors of interpretation are to be avoided. For instance, an antrum filled with polypoid tissue may look exactly the same on the film as it would if filled with pus. The knowledge that polypi were present in the nose, however, or that pus was draining from the antrum, would put an entirely different aspect on the situation. If the radiologist who interprets the films does not have this information, then the rhinologist who performs the physical examination must correlate his findings with the x-ray report, with a full understanding of the fundamental limitations of the x-ray and without criticism of his colleague. In this field of diagnosis co-operation is probably more important than in any other. For purposes of discussion, sinusitis may be classified as follows: Acute 1. Catarrhal Hay fever Cold in the head 2. Suppurative Cold in the head Contagious diseases Acute fulminating Chronic 1. Suppurative Recurring attacks More or less constant draining 2. Hyperplastic Allergic Edema of membrane Polypi Cysts Complicating suppuration Acute Sinusitis Acute catarrhal sinusitis is probably not often recognized, because there is little occasion to examine the sinuses roentgenologically in such cases. I believe any extended investigation of hay fever patients by x-ray would reveal a high percentage of opaque sinuses, particularly the maxillary, due to swelling and edema of the mucous membrane continuous with that in the nose. The same thing applies to the acute stage of a cold in the head. Interest in this type of sinusitis is, how-ever, largely academic, as it has little clinical significance. Acute suppurative sinusitis usually results either from the direct spread of infection from the nasal cavity in a head cold or as a complication of an infectious disease. Of these causes, influenza is undoubtedly the most common, but the acute contagious diseases of childhood are also frequent offenders.

Gastro-intestinal allergy—a review of 134 cases

1. From a review of 134 cases of gastro-intestinal allergy, we have presented the observations made in fifty cases in whom this diagnosis was of major significance. 2. The symptom-complex described by the common term “indigestion” conformed in general with that reported by other allergists. 3. Cabbage was the most frequently incriminated food. We were able to substantiate the findings of other allergists that milk, beans, eggs, chocolate and wheat were frequent offenders. We confirmed these suspicions by skin tests in 40 per cent of the cases. We feel that skin tests continue to be of importance in solving the diagnostic problem of these patients. 4. A high percentage of the cases had an associated gastro-intestinal diagnosis, either organic or functional in nature. 5. Ninety per cent of this group had associated allergic manifestations. 6. A family history of allergy was elicited in 84 per cent of the patients.

INJECTION OF ETHER INTO THE BILIARY TRACT AS TREATMENT FOR CHOLEDOCHOLITHIASIS

In recent years great strides have been made in the study of the chemistry and physiology of the biliary tract. This increase in knowledge, however, has not altered the position pathologic conditions of the biliary tract hold as formidable opponents of the surgeon's diagnostic and technical skill. In reviewing causes for some of the unsatisfactory surgical results, we find stones in the common duct to be one of the most frequent offenders. The simple case of a large stone high in the common duct, with a typical history of obstruction of the biliary tract, of course, offers no difficulty. However, the small stones low in the common duct frequently remain undiagnosed before and even during operation. Many observers have called attention to the symptomatic silence of this condition. Clute, 1 in reviewing seventy-nine cases of stones in the common duct, found that there was no history of jaundice in twenty-nine.