BRITISH MEDICAL JOURNAL
7 JULY 1979
controlled diabetes at the time of Ramadan. The most likely reason is the generally low expectation in standard of control in many of these patients, who experience wide fluctuations of blood sugar during the rest of the year, who are rarely assiduous in urine testing, and who perhaps expect a degree of malaise in Ramadan anyway. Further studies are under way to examine this. In general, we feel it appropriate that Muslims who have diabetes mellitus should be advised not to fast during Ramadan, unless their diabetes is controlled on diet alone. Those patients who elect to fast and who require insulin should understand that the insulin should be omitted in the morning and a suitable dose given in the evening. Ketosis-prone insulin-requiring patients should be particularly advised to avoid fasting. Patients on oral hypoglycaemic agents may need to reduce the dose of their tablets, should seek personal medical advice, and should pay particular attention to their diabetic control during Ramadan. S G BARBER SEBASTIAN FAIRWEATHER A D WRIGHT M G FITZGERALD J M MALINS The General Hospital, Birmingham B4 6NH
Analgesia in terminal malignant disease
SIR,-The letter by Dr P S B Russell (9 June, p 1561) draws attention to the difficulty of controlling symptoms in cases of advanced malignancy when oral medication is no longer possible. There are three very important reasons why injections should be avoided whenever possible. The first and most important one from the patient's point of view is that injections are painful-the more so when patients are cachectic and bed-bound so that the buttocks cannot be used. Moreover, in many such patients lymphoedema restricts the areas available. The other two reasons have been highlighted by Verel: he has shown that by intramuscular injection it is difficult to obtain adequate analgesia without the plasma level of the analgesic reaching the level at which side effects occur, and also that the plasma level of the analgesic falls quickly so that only a short period of analgesia is obtained. The attention of one of us (JK) was drawn to the advantages of oxycodone pectinate (Proladone) suppositories by the case of a nurse who had self-administered 12 such suppositories in an attempt at suicide but had merely slept quietly and with no serious respiratory depression for 24 hours, making an uneventful recovery. We started using this on our patients with a pain problem with very satisfactory results-obtaining at least six and often eight hours' analgesia with no side effects. Proladone was temporarily withdrawn from the market but suppositories of oxycodone pectinate 30 mg are now available on NHS prescriptions. Encouraged by the clinical success of this method we explored the use of other medication by suppository. We now frequently use prochlorperazine, 25 mg 8-hourly, or chlorpromazine, 100 mg 8-hourly, for vomiting and aminophylline, 360 mg 8-12-hourly, for "wet lungs." Suppositories of indomethacin 100 mg are very useful in controlling the pain of bony metastases as well as the pain of osteoarthritis.
47
A suppository given at night often means that the patient wakes in the morning without pain. Recently we have been using diazepam by suppository. Although these suppositories are available on the Continent they are not yet commercially available in this country. But a helpful pharmacist will usually oblige-all that is required is to crush a 5 or 10 mg tablet, mix it thoroughly with warmed cocoa butter, and pour it into a mould. If kept in a cool place these have a shelf life of many months. In one case we found it possible to control all the symptoms of an advanced cerebral tumour by the use of a suppository of 10 mg diazepam 8-hourly with no other medication. The patient was rousable for toilet and feeding purposes but otherwise slept quietly. Suppositories of diazepam we are finding very helpful in the control of muscle spasm associated with some spinal cord lesions, as well as being a useful sedative in tense patients.
effects of these drugs. There was one statement in Professor Oswald's review that bothered me, however, and that was "as a psychiatrist I see only the rarest justification for their (benzodiazepines) daytime use, except to enable the doctor to feel he is not being inactive." It must be presumed from this that a doctor might prescribe this medication to make the doctor feel as if he is doing something for the patient. If this is the case, and I surely hope not, then please for safety's sake write for a placebo. It is understandable that many physicians are under pressure from their patients to produce results. However, unnecessary pharmacotherapy with sedatives or any other chemical is a dangerous game which involves the other health professionals as unwilling players.
KENNETH L THOMPSON Hampton General Hospital, Hampton, Virginia 23669, USA
F R GUSTERSON J KAY Colour coding of insulins A W KINGSBURY SIR,-Colour coding has been used on insulin St Barnabas' Home, Columbia Drive, pack and label for many years in the UK to Worthing, West Sussex BN13 2QF identify the strengths (mainly 40 and 80 Royal College of Physicians of London, Topics in units/ml) and the types of insulin preparations. Therapeutics, No 4, ed D W Vere. Tunbridge The familiar blue and green backgrounds for Wells, Pitman Medical Publishing Company, 1978. 40 U/ml and 80 U/ml strengths respectively have been useful checks; but the colourhas become extremely SIR,-We were interested to read the article coding device for type has it had to incorporate Not only complex. by Drs C Drinkwater and R G Twycross but it also, in (5 May, p 1201) and the letter from Dr P S B 18 different insulin preparations with different years, has had to contend Russell (9 June, p 1561) regarding pain relief recent more, in terminal malignant disease. We also use a degrees of purification. More and by brand have to be identified insulins come four-hourly narcotic (diamorphine) in chloroform water instead of Brompton name. the With replacement of the 40 and 80 mixture. by a single 100 U/ml strength in For those patients who cannot swallow or strengths and the likely extension of insulin where gastric absorption is impaired we find prospect the Medical Advisory Committee that sublingual phenazocine (Narphen) is a purification, and Scientific Committee of very satisfactory substitute: 5-20 mg provides and the Medical Diabetic Association had already British the This for to six hours. up analgesia strong with the insulin meetings held preparatory avoids injections and the relative lack of and other involved bodies. It sedation may allow active life to continue for manufacturers proposed to make these changes along longer than may be possible if the patient was simplified labelling in a has to carry an infusion pump (however with standardised As a consequence of operation. planned single miniaturised). For those who have a dry decision to bring its insulin pack and mouth or dislike the taste morphine Novo's label designs in the UK into line with its suppositories provide an alternative. we called a special meeting We believe that injections or infusions practices elsewhere, new the situation could most how decide to should be only a last resort and non-invasive be met. The recommendations published methods of administration should be tried safely Mr J Mellowes in his letters to the BMJ first. If drug-induced vomiting becomes a by 1488) and the Pharmaceutical problem our experience suggests that halo- (2 June,(26pMay) as an annotaJ7ournal peridol is superior to the phenothiazines and tion in the Lancetand(26appearing May) were the conin low doses (0 5 mg orally two or three times by that meeting. Individual a day) will suppress nausea and vomiting clusions arrived atcompanies are, of course, without the sedation which accompanies pharmaceutical within the limits imposed by free, entirely regular phenothiazine administration. statutory regulations, to decide on such use of colour, and so I M C CLARKE matters as pack design,The British Diabetic S M TEMPEST on for themselves. has always acted as a common Association Pain Relief Service, meeting ground for the many interests and Leeds General Infirmary, Leeds LS1 3EX bodies involved in the care of the diabetic and agreement has been on a voluntary basis. The pharmaceutical firms, Novo not least among them, have given much support to The why and how of hypnotic drugs the medical, scientific, and welfare functions SIR,-The review on hypnotic drugs by of the association, for which it is grateful. It is Professor Ian Oswald (5 May, p 1167) once greatly to be hoped that this fruitful coagain reminds us of the cumulative effects of operation will continue. Until some uniform format for insulin hypnotics, especially the benzodiazepines. As a pharmacist in the United States, I dis- packaging is agreed, insulin-taking diabetics pense thousands of doses of benzodiazepines and all those concerned with their treatment per month and I have often wondered just how are advised to check carefully the type and much thought physicians give to the adverse strength of insulin prescribed from the
BRITISH MEDICAL
48
printed name and number (for example, 40 or 80) on the pack and label, ignoring colour as an indication of either. It would be advisable to keep an empty pack or vial to check the identity of repeat prescriptions. HARRY KEEN Chairman, Medical
Advisory Committee PETER WATKINS Secretary, Medical
Advisory Committee
ARNOLD BLOOM Chairman, Medical and Scientific Section
reminding us of the direct association between fractures round the ankle and soft tissue swelling. I have found this association useful for many years and indeed it was standard teaching at St Thomas's 25 years ago. Carefuil radiography will show the base of the fifth metatarsal in ankle films, and this is the only likely bony involvement with rotation strains in the ankle. Incidentally, has anyone reviewed the damage suffered by patients we have failed to x-ray ? R W WILKINSON
CHRISTOPHER HARDWICK Royal Berkshire Hospital, Chairman, Executive Reading, Berks RG1 5AN Council
British Diabetic Association, London WIM OBD
Injuries to boys who scramble
Photocoagulation and diabetic retinopathy SIR,-I was fortunate enough to be invited to a Guy's lecture on photocoagulation and diabetic retinopathy and heard Professor H Keen-like Mr B L Hercules and Dr I I Gayed (23 June, p 1710)-refer to the urgency of the need for photocoagulation in proliferative eye disease. I understand that most such cases come from eye rather than diabetic departments and that roughly 3(O in eye departments will have the condition. This is a serious matter because, whereas appointments for diabetic clinics are more or less immediate, for the eye departments six or seven months is a standard waiting time unless urgency is recognised. This is about the time for all to be over and done with so far as saving the sight is concerned. A possible solution could spring from the patient with an eye complaint placing homatropine in the eye before attending a GP's surgery. The recognition of the condition is not difficult. G P WALSH Blackburn, Lancs
X-ray examination of acute ankle injuries
SIR,-Drs Gerald de Lacey and Shirley Bradbrooke suggest that if there is no swelling over the malleoli it is not necessary to x-ray a twisted ankle (16 June, p 1597). Even for excluding a major fracture their advice is not entirely foolproof, as their figures show. However, x-rays should be taken in such patients' ankles not merely to exclude fractures but also to exclude a torn lateral ligament of the ankle. It is the localisation of tenderness as well as the presence or absence of swelling which provides the solution to this problem. If there is neither swelling nor tenderness over the malleoli there will be no major fracture. And if there is tenderness over the lateral ligament, forced inversion pictures should be taken. While the absence of swelling and tenderness excludes serious pathology, their presence does not prove its presence. But exclusion of the possibility is then impossible without x-rays. WILLIAM RUTHERFORD
SIR,-I would like to thank Drs R H Jackson and A W Craft for their comments on this topic (16 June, p 1625) and for pointing out an apparent error in my computation. In the explanation of my figures I did not make clear that the figure of 24 races includes the initial five practice races, but these were not included in the rider races calculation and there was an average number of 19 races per event. I can only agree with the observation that children of this age are not suited physically or mentally to take part in such sports. In many cases I feel that the parents are encouraging the child not for his enjoyment but for the feelings of displaced pleasure that they experience. Injury to their children does not diminish their enthusiasm, and I must say I was expecting a much greater frequency of serious injury when we embarked on the study. The implication of Drs Jackson and Craft's letter is that a medical presence at such events not only condones them but positively encourages the competitions. Sadly, the experience in other areas is that events take place irrespective of the medical cover provided, since there are no safety rules by which they must be governed. This organisation attends many functions in the interest of offering help to the "sick, wounded, disabled, or suffering" and unfortunately our personal attitude to them is not a consideration; our first concern is for those in pain. We hope our continued presence at such events will help to reduce the suffering of those injured or unwell, and that in our small way we can influence the organisers to pursue their interest in the safest possible way. Scrambling is increasing in popularity nationally, and regulations on the conducting of meetings are urgently required. M PLACE St John Ambulance, Gateshead Borough Division, Gateshead, Tyne and Wear
MRC treatment trial for mild hypertension
SIR,-In a paper given on 13 June at the sixth scientific meeting of the International Society of Hypertension, the management committee of the Australian National Blood Pressure Study reported results which have led them to stop their randomised controlled trial for the treatment of mild hypertension. Some of your Accident and Emergency Department, Royal Victoria Hospital, readers may want to know how this will affect Belfast BT12 6BA the somewhat similar MRC trial in Britain. The entry criteria in the two trials differ in SIR,-Drs Gerald de Lacey and Shirley Brad- an important way. The Australian trial brooke (16 June, p 1597) merit our thanks for included men and women aged 30-69 with
JOURNAL
7
juLY
1979
screening pressures within the 95-109 mm Hg diastolic (V) range. Randomisation for active or placebo tablets was determined after blood pressure measurements had been recorded at a subsequent entry examination, when all with pressures of 95 mm Hg or over were eligible. At that stage 16",, had pressures of 110 or over, and these were included. The Medical Research Council's trial includes men and women aged 35-64 with diastolic (V) pressures found at screening to be within the 90-109 mm Hg range but only if their pressures are confirmed within that range at the entry examination. In the Australian study pharmacological treatment conferred benefit only in those whose pressures at the entry examination were 100 mm Hg or greater; in this group treatment significantly reduced the incidence of fatal terminating events (P
7 JULY 1979
controlled diabetes at the time of Ramadan. The most likely reason is the generally low expectation in standard of control in many of these patients, who experience wide fluctuations of blood sugar during the rest of the year, who are rarely assiduous in urine testing, and who perhaps expect a degree of malaise in Ramadan anyway. Further studies are under way to examine this. In general, we feel it appropriate that Muslims who have diabetes mellitus should be advised not to fast during Ramadan, unless their diabetes is controlled on diet alone. Those patients who elect to fast and who require insulin should understand that the insulin should be omitted in the morning and a suitable dose given in the evening. Ketosis-prone insulin-requiring patients should be particularly advised to avoid fasting. Patients on oral hypoglycaemic agents may need to reduce the dose of their tablets, should seek personal medical advice, and should pay particular attention to their diabetic control during Ramadan. S G BARBER SEBASTIAN FAIRWEATHER A D WRIGHT M G FITZGERALD J M MALINS The General Hospital, Birmingham B4 6NH
Analgesia in terminal malignant disease
SIR,-The letter by Dr P S B Russell (9 June, p 1561) draws attention to the difficulty of controlling symptoms in cases of advanced malignancy when oral medication is no longer possible. There are three very important reasons why injections should be avoided whenever possible. The first and most important one from the patient's point of view is that injections are painful-the more so when patients are cachectic and bed-bound so that the buttocks cannot be used. Moreover, in many such patients lymphoedema restricts the areas available. The other two reasons have been highlighted by Verel: he has shown that by intramuscular injection it is difficult to obtain adequate analgesia without the plasma level of the analgesic reaching the level at which side effects occur, and also that the plasma level of the analgesic falls quickly so that only a short period of analgesia is obtained. The attention of one of us (JK) was drawn to the advantages of oxycodone pectinate (Proladone) suppositories by the case of a nurse who had self-administered 12 such suppositories in an attempt at suicide but had merely slept quietly and with no serious respiratory depression for 24 hours, making an uneventful recovery. We started using this on our patients with a pain problem with very satisfactory results-obtaining at least six and often eight hours' analgesia with no side effects. Proladone was temporarily withdrawn from the market but suppositories of oxycodone pectinate 30 mg are now available on NHS prescriptions. Encouraged by the clinical success of this method we explored the use of other medication by suppository. We now frequently use prochlorperazine, 25 mg 8-hourly, or chlorpromazine, 100 mg 8-hourly, for vomiting and aminophylline, 360 mg 8-12-hourly, for "wet lungs." Suppositories of indomethacin 100 mg are very useful in controlling the pain of bony metastases as well as the pain of osteoarthritis.
47
A suppository given at night often means that the patient wakes in the morning without pain. Recently we have been using diazepam by suppository. Although these suppositories are available on the Continent they are not yet commercially available in this country. But a helpful pharmacist will usually oblige-all that is required is to crush a 5 or 10 mg tablet, mix it thoroughly with warmed cocoa butter, and pour it into a mould. If kept in a cool place these have a shelf life of many months. In one case we found it possible to control all the symptoms of an advanced cerebral tumour by the use of a suppository of 10 mg diazepam 8-hourly with no other medication. The patient was rousable for toilet and feeding purposes but otherwise slept quietly. Suppositories of diazepam we are finding very helpful in the control of muscle spasm associated with some spinal cord lesions, as well as being a useful sedative in tense patients.
effects of these drugs. There was one statement in Professor Oswald's review that bothered me, however, and that was "as a psychiatrist I see only the rarest justification for their (benzodiazepines) daytime use, except to enable the doctor to feel he is not being inactive." It must be presumed from this that a doctor might prescribe this medication to make the doctor feel as if he is doing something for the patient. If this is the case, and I surely hope not, then please for safety's sake write for a placebo. It is understandable that many physicians are under pressure from their patients to produce results. However, unnecessary pharmacotherapy with sedatives or any other chemical is a dangerous game which involves the other health professionals as unwilling players.
KENNETH L THOMPSON Hampton General Hospital, Hampton, Virginia 23669, USA
F R GUSTERSON J KAY Colour coding of insulins A W KINGSBURY SIR,-Colour coding has been used on insulin St Barnabas' Home, Columbia Drive, pack and label for many years in the UK to Worthing, West Sussex BN13 2QF identify the strengths (mainly 40 and 80 Royal College of Physicians of London, Topics in units/ml) and the types of insulin preparations. Therapeutics, No 4, ed D W Vere. Tunbridge The familiar blue and green backgrounds for Wells, Pitman Medical Publishing Company, 1978. 40 U/ml and 80 U/ml strengths respectively have been useful checks; but the colourhas become extremely SIR,-We were interested to read the article coding device for type has it had to incorporate Not only complex. by Drs C Drinkwater and R G Twycross but it also, in (5 May, p 1201) and the letter from Dr P S B 18 different insulin preparations with different years, has had to contend Russell (9 June, p 1561) regarding pain relief recent more, in terminal malignant disease. We also use a degrees of purification. More and by brand have to be identified insulins come four-hourly narcotic (diamorphine) in chloroform water instead of Brompton name. the With replacement of the 40 and 80 mixture. by a single 100 U/ml strength in For those patients who cannot swallow or strengths and the likely extension of insulin where gastric absorption is impaired we find prospect the Medical Advisory Committee that sublingual phenazocine (Narphen) is a purification, and Scientific Committee of very satisfactory substitute: 5-20 mg provides and the Medical Diabetic Association had already British the This for to six hours. up analgesia strong with the insulin meetings held preparatory avoids injections and the relative lack of and other involved bodies. It sedation may allow active life to continue for manufacturers proposed to make these changes along longer than may be possible if the patient was simplified labelling in a has to carry an infusion pump (however with standardised As a consequence of operation. planned single miniaturised). For those who have a dry decision to bring its insulin pack and mouth or dislike the taste morphine Novo's label designs in the UK into line with its suppositories provide an alternative. we called a special meeting We believe that injections or infusions practices elsewhere, new the situation could most how decide to should be only a last resort and non-invasive be met. The recommendations published methods of administration should be tried safely Mr J Mellowes in his letters to the BMJ first. If drug-induced vomiting becomes a by 1488) and the Pharmaceutical problem our experience suggests that halo- (2 June,(26pMay) as an annotaJ7ournal peridol is superior to the phenothiazines and tion in the Lancetand(26appearing May) were the conin low doses (0 5 mg orally two or three times by that meeting. Individual a day) will suppress nausea and vomiting clusions arrived atcompanies are, of course, without the sedation which accompanies pharmaceutical within the limits imposed by free, entirely regular phenothiazine administration. statutory regulations, to decide on such use of colour, and so I M C CLARKE matters as pack design,The British Diabetic S M TEMPEST on for themselves. has always acted as a common Association Pain Relief Service, meeting ground for the many interests and Leeds General Infirmary, Leeds LS1 3EX bodies involved in the care of the diabetic and agreement has been on a voluntary basis. The pharmaceutical firms, Novo not least among them, have given much support to The why and how of hypnotic drugs the medical, scientific, and welfare functions SIR,-The review on hypnotic drugs by of the association, for which it is grateful. It is Professor Ian Oswald (5 May, p 1167) once greatly to be hoped that this fruitful coagain reminds us of the cumulative effects of operation will continue. Until some uniform format for insulin hypnotics, especially the benzodiazepines. As a pharmacist in the United States, I dis- packaging is agreed, insulin-taking diabetics pense thousands of doses of benzodiazepines and all those concerned with their treatment per month and I have often wondered just how are advised to check carefully the type and much thought physicians give to the adverse strength of insulin prescribed from the
BRITISH MEDICAL
48
printed name and number (for example, 40 or 80) on the pack and label, ignoring colour as an indication of either. It would be advisable to keep an empty pack or vial to check the identity of repeat prescriptions. HARRY KEEN Chairman, Medical
Advisory Committee PETER WATKINS Secretary, Medical
Advisory Committee
ARNOLD BLOOM Chairman, Medical and Scientific Section
reminding us of the direct association between fractures round the ankle and soft tissue swelling. I have found this association useful for many years and indeed it was standard teaching at St Thomas's 25 years ago. Carefuil radiography will show the base of the fifth metatarsal in ankle films, and this is the only likely bony involvement with rotation strains in the ankle. Incidentally, has anyone reviewed the damage suffered by patients we have failed to x-ray ? R W WILKINSON
CHRISTOPHER HARDWICK Royal Berkshire Hospital, Chairman, Executive Reading, Berks RG1 5AN Council
British Diabetic Association, London WIM OBD
Injuries to boys who scramble
Photocoagulation and diabetic retinopathy SIR,-I was fortunate enough to be invited to a Guy's lecture on photocoagulation and diabetic retinopathy and heard Professor H Keen-like Mr B L Hercules and Dr I I Gayed (23 June, p 1710)-refer to the urgency of the need for photocoagulation in proliferative eye disease. I understand that most such cases come from eye rather than diabetic departments and that roughly 3(O in eye departments will have the condition. This is a serious matter because, whereas appointments for diabetic clinics are more or less immediate, for the eye departments six or seven months is a standard waiting time unless urgency is recognised. This is about the time for all to be over and done with so far as saving the sight is concerned. A possible solution could spring from the patient with an eye complaint placing homatropine in the eye before attending a GP's surgery. The recognition of the condition is not difficult. G P WALSH Blackburn, Lancs
X-ray examination of acute ankle injuries
SIR,-Drs Gerald de Lacey and Shirley Bradbrooke suggest that if there is no swelling over the malleoli it is not necessary to x-ray a twisted ankle (16 June, p 1597). Even for excluding a major fracture their advice is not entirely foolproof, as their figures show. However, x-rays should be taken in such patients' ankles not merely to exclude fractures but also to exclude a torn lateral ligament of the ankle. It is the localisation of tenderness as well as the presence or absence of swelling which provides the solution to this problem. If there is neither swelling nor tenderness over the malleoli there will be no major fracture. And if there is tenderness over the lateral ligament, forced inversion pictures should be taken. While the absence of swelling and tenderness excludes serious pathology, their presence does not prove its presence. But exclusion of the possibility is then impossible without x-rays. WILLIAM RUTHERFORD
SIR,-I would like to thank Drs R H Jackson and A W Craft for their comments on this topic (16 June, p 1625) and for pointing out an apparent error in my computation. In the explanation of my figures I did not make clear that the figure of 24 races includes the initial five practice races, but these were not included in the rider races calculation and there was an average number of 19 races per event. I can only agree with the observation that children of this age are not suited physically or mentally to take part in such sports. In many cases I feel that the parents are encouraging the child not for his enjoyment but for the feelings of displaced pleasure that they experience. Injury to their children does not diminish their enthusiasm, and I must say I was expecting a much greater frequency of serious injury when we embarked on the study. The implication of Drs Jackson and Craft's letter is that a medical presence at such events not only condones them but positively encourages the competitions. Sadly, the experience in other areas is that events take place irrespective of the medical cover provided, since there are no safety rules by which they must be governed. This organisation attends many functions in the interest of offering help to the "sick, wounded, disabled, or suffering" and unfortunately our personal attitude to them is not a consideration; our first concern is for those in pain. We hope our continued presence at such events will help to reduce the suffering of those injured or unwell, and that in our small way we can influence the organisers to pursue their interest in the safest possible way. Scrambling is increasing in popularity nationally, and regulations on the conducting of meetings are urgently required. M PLACE St John Ambulance, Gateshead Borough Division, Gateshead, Tyne and Wear
MRC treatment trial for mild hypertension
SIR,-In a paper given on 13 June at the sixth scientific meeting of the International Society of Hypertension, the management committee of the Australian National Blood Pressure Study reported results which have led them to stop their randomised controlled trial for the treatment of mild hypertension. Some of your Accident and Emergency Department, Royal Victoria Hospital, readers may want to know how this will affect Belfast BT12 6BA the somewhat similar MRC trial in Britain. The entry criteria in the two trials differ in SIR,-Drs Gerald de Lacey and Shirley Brad- an important way. The Australian trial brooke (16 June, p 1597) merit our thanks for included men and women aged 30-69 with
JOURNAL
7
juLY
1979
screening pressures within the 95-109 mm Hg diastolic (V) range. Randomisation for active or placebo tablets was determined after blood pressure measurements had been recorded at a subsequent entry examination, when all with pressures of 95 mm Hg or over were eligible. At that stage 16",, had pressures of 110 or over, and these were included. The Medical Research Council's trial includes men and women aged 35-64 with diastolic (V) pressures found at screening to be within the 90-109 mm Hg range but only if their pressures are confirmed within that range at the entry examination. In the Australian study pharmacological treatment conferred benefit only in those whose pressures at the entry examination were 100 mm Hg or greater; in this group treatment significantly reduced the incidence of fatal terminating events (P
