BMJ 7090

With head and heart and hand
Portraits of 20th century British doctors by Nick Sinclair

BMJ No 7090 Volume 314 Saturday 3 May 1997

This Week in BMJ | Editor's Choice | Press releases | Advertisement details

Editorials
1291 Contour control, survival, and quality of life Hugh Tunstall-Pedoe

1292 The future of Britain's high security hospitals Elaine Murphy

1294 New challenge for palliative care Nick Bosanquet

1295 Domestic violence and pregnancy Gillian C Mezey, Susan Bewley

1296 Patently confused David Taylor

News
1297 Cuban refugees self mutilate * Japan recognises brain death * Heart transplant pioneer cleared * Warning over hay fever drug * US backs CF testing * European research collaboration needed * GP reveals patients' secrets in pub * HIV transmitted by bone graft * Reports from the European Forum on Quality Improvement in Health Care * Philippines sell off mental hospital * Radiation risk from mobile phone towers

Papers
1303 Is hyperglycaemia an independent predictor of poor outcome after acute stroke? Results of a long term follow up study Christopher J Weir, Gordon D Murray, Alexander G Dyker, Kennedy R Lees

1307 Randomised comparison between adrenaline injection alone and adrenaline injection plus heat probe treatment for actively bleeding ulcers Sydney S C Chung, James Y W Lau, Joseph J Y Sung, Angus C W Chan, C W Lai, Enders K W Ng, Francis K L Chan, M Y Yung, Arthur K C Li

1311 Body weight: implications for the prevention of coronary heart disease, stroke, and diabetes mellitus in a cohort study of middle aged men A Gerald Shaper, S Goya Wannamethee, Mary Walker

1317 Prospective study of Helicobacter pylori seropositivity and cardiovascular diseases in a general elderly population Timo E Strandberg, Reijo S Tilvis, Matti Vuoristo, Magnus Lindroos, Timo U Kosunen

1318 Helicobacter pylori infection and coagulation in healthy people Fabrizio Parente, Giovanni Maconi, Venerina Imbesi, Ornella Sangaletti, Marina Poggio, Edoardo Rossi, Piergiorgio Duca, Gabriele Bianchi Porro

General practice
1320 Comparison of physiotherapy, manipulation, and corticosteroid injection for treating shoulder complaints in general practice: randomised, single blind study Jan C Winters, Jan S Sobel, Klaas H Groenier, Hans J Arendzen, Betty Meyboom-de Jong

1325 The social origins of infantile colic: questionnaire study covering 76,747 infants N S Crowcroft, D P Strachan

Clinical review
1329 Fortnightly review: Polymyalgia rheumatica and temporal arteritis: diagnosis and management A J Swannell

1333 ABC of clinical haematology: Haematological emergencies Rebecca Frewin, Andrew Henson, Drew Provan

Education and debate
1337 What will a primary care led NHS mean for GP workload? The problem of the lack of an evidence base Lone Lund Pedersen, Brenda Leese

1341 Socioeconomic determinants of health: Community marginalisation and the diffusion of disease and disorder in the United States Rodrick Wallace, Deborah Wallace

Letters
1346 Introducing the postoperative care team M J Boscoe; M Rosen; R C G Russell; W Notcutt

1347 Why people stay healthy F Eskin

1347 Exploitative collaborative research must be discouraged B A Gbolade

1347 Persistent fever in pulmonary tuberculosis J Crofton; P D O Davies

1348 Public scare has not deterred Finnish teenagers from using oral contraceptives E Kosunen and others

1348 Sight tests to detect glaucoma P G Griffiths; M Cole

1349 Systemic lupus erythematosus complicated by antiphospholipid antibody syndrome R Llewelyn; E M McDermott and others;
P Cockwell and others

1350 The tobacco industry and scientific publications A J Hedley; P Whidden

1351 More intensive care unit beds are needed P A Cupples and others

1351 Submucosal haemorrhage - or ruptured nodule in a multinodular goitre? B G Issa and M F Scanlon; R Walsh

1351 Journals and the internet M Palat; B Allan and others; J G Shaw

1352 Regulations on registration of a fetus papyraceus need to be revised R F Heys

1353 Risk of lung cancer needs to be studied in younger patients who keep pet birds P Holst

1353 CS gas is not a chemical means of restraining a person P J Gray

1353 Talk works - if the patient is willing t> A F Blakey

Obituaries
1354 J Birch, C J Cobbe, R J C Cobbold, R B Dobson, A A Duncan, A K Dutt, R Emery

Views & reviews

Soundings
1355 Night of the gatekeeper George Dunea

Personal views
Don't shoot me - I'm only the pharmacist David Kernick

Medicine and the media
1356 Bone marrow transplant raises issues of privacy Sally Davies

Medicine and books
1357 Breaking Bad News G Walker, J Bradburn, J Maher
Martin Tattersall

Neurological Investigations R A C Hughes
Julien Bogousslavsky

Minerva
1358

S2 Career Focus Classified supplement
Getting on in (and off on) medical politics Carl Gray

Editor's choice

Are you normal?

Are you normal? In terms of health you hope you are. In terms of talent, looks, and intelligence you might hope to be above normal. In Garrison Keillor's home town, Lake Wobegone, all children are above average. What is normal? It's one of the trickiest things in medicine to define, not least because medicine usually concerns itself with the abnormal: disease. Questions about normality flow through this journal.

The Bible of evidence based medicine - Clinical Epidemiology: a Basic Science for Clinical Medicine by Dave Sackett, Brian Haynes, Gordon Guyatt, and Peter Tugwell - offers six definitions of normal. All carry problems. One of the commonest definitions, the one usually used with diagnostic tests, is that you are normal if your results lie within two standard deviations of the mean. By definition, this means that for any given test 5% of people in a population are abnormal. Undergo enough tests and you are bound to be abnormal, even if there's nothing wrong with you. If you have 20 tests you have only a one in three chance of being normal. This is marvellous news for quacks who offer multiple screening tests.

Another way to define normal is that it carries the lowest risk of mortality or morbidity. One snag with this definition is that a whole population may be "abnormal" - as, for instance, with the distribution of cholesterol concentrations in Western populations. On p 1311, a group from the Royal Free Hospital in London tries to define normal weight in middle aged men. Readers will see at once that definitions of normality are likely to be different in Beijing and Buffalo, New York. The Royal Free researchers have collected data in 24 British towns and defined normal as that body mass index (kg/m²) carrying the lowest risk of a combined end point of cardiovascular death, heart attack, and diabetes. The best index is about 22, at the lower end of the range that is usually recommended purely on the basis mortality - 20-27.

Is infantile colic normal? Parents of colicky babies don't think so, but some doctors do. Researchers from London looked at almost 80 000 babies and found that colic is associated not with diet but with various social measures (p 1325). It's one of those "diseases" of the upper classes, being seen more commonly, they show, in older primigravid mothers who have a non-manual occupation and who stayed in full time education longest.

Is going into politics normal? Most people probably think not, but Carl Gray in Career Focus (classified advertisement supplement or www.bmj.com) urges doctors, particularly young ones, into medical politics to avoid "medarchy" - "rule by (mostly) middle aged white men. Travel through "the utter boredom that otherwise decent people inflict upon their fellow humans in committee rooms" to provide the profession with the leadership it needs.