591
manage minor
baby problems, and the specialised unit magnet for nursing and medical staff. The Cambridge workers, however, have demonacts as a
be done: from late 1974 the unit adopted a policy of rigorous selection which had the effect of reducing admissions from 25% of hospital births to 12.2% and 10.7% in 1975 and 1976. Malpresentations, instrumental deliveries, and caesarean sections were no longer automatic indications for admission, nor, among other problems were weight 2100-2500 g, lightness-for-dates, or jaundice with bilirubin less than 18 mg/dl (300 mol/1). They found that a number of mildly asphyxiated babies, though requiring ventilation at birth, were pink and lusty by age 10 minutes, and these too were excluded. In general their results show no evidence that babies suffered from exclusion from the unit, although two babies below the 3rd centile but weighing over 2500 g had hypoglyca’mic convulsions, presumably through mismanagement on the maternity wards: standing instructions in these wards were then altered to prevent a recurrence. The success of such a venture relies above all on adequate provision and training of maternity-ward staff, at present hard to achieve because of an acute nationwide nursing shortage. This is an important goal, since obstetric nursing involves care of babies as well as mothers. There is also a strong case for more pxdlatric training for junior obstetric staff, not just for the requirements of the Royal College examinations, but also as part of the complete training of an obstetrician. Here initiatives would be needed from senior obstetricians as well as paediatricians. Though ultimate responsibility for all babies lies with the paediatrician, immediate handling of some of the routine work and minor problems could be performed by junior obstetric staff, relieving the paediatric house-officers of some of the extra work that a restricted admission policy would entail. Although hard indications for s.c.B.u. admission cannot be applied to every baby (admission is often negotiated in the small hours between midwife and pxdiatric house-officer), the guidelines adopted at Cambridge are quite comprehensive and, with the above provisos, seem safe. Dr ROBERTSON and his colleagues have shown the way: who will follow their lead?
strated that it
can
TEENAGERS AND TELEVISION VIOLENCE Dr William Belson’s
study of the association between
exposure to television violence and the occurrence of violence in adolescent boysI must be the most thorough and most complex investigation of its kind yet undertaken. 1500 London boys aged 12-17 and their 1 TV Violence and the Adolescent
Boy. By WILLIAM A. BELSON. Hants: Saxon House. 1978. Pp. 529. £12.50.
Farnborough,
were asked, in home interviews, about the boys’ personal background and television viewing habits, and each boy later attended the research centre for a 32-hour intensive interview designed to elicit information about his attitudes to, and involvement in, violence. The data collected were used to test twenty-two hypotheses on the effects of long-term exposure to television violence. And the results very strongly supported just one-that high exposure to television violence increases the degree to which boys engage in serious violence. The credibility of this hypothesis was strengthened by the finding that the reverse hypothesis-that boys who
mothers
engage in serious violence watch more violence on television than do less violent boys-was not supported by the evidence. The findings gave very little support indeed to the various hypotheses relating to conscious attitudes, such as preoccupation with acts of violence seen on television or callousness towards violence in real life. In other words, whereas television violence was associated with an increase in violent behaviour, it made little difference to the boys’ attitudes to violence. From this Belson deduces that the major mental process underlying the changes effected by television violence is disinhibition-the erosion of inhibitions against violent behaviour that have been built up by parents and other socialising agencies. He found no evidence of a desensit-
ising (conscious) mechanism. Belson finds his results convincing enough to recommend some major changes in television policy-principally, of course, that the amount of violence shown should be substantially reduced. If the television planners act on his recommendations, his analysis of the effects of 25 different types of programme should help them to eliminate the most harmful types of violence from the screen. Violence in westerns and realistic fiction and programmes in which the "good guy" committed acts of violence appeared to have a strong influence, but violence in sports programmes, cartoons, and science fiction had little effect. These guidelines would be modified as necessary in the light of further research. Belson recommends that a monitoring system should be used to keep track of the amount and kind of violence shown on television, and that the results should be published. Belson’s work is impressive; nevertheless it is open to several criticisms, not the least of which relates to his definition of "serious" violence. This is important, for the results show, surprisingly, little association between television violence and all grades of violent behaviour. To obtain an index of violence, Belson asked the boys to describe violent acts they had committed in the past 6 months, and these acts were rated on a six-point scale by a panel of adult judges. But in some instances the judges gave widely differing assessments, which casts doubt on the reliability of the scale. In the interviews, which took place in 1972-73, the boys were asked to recall programmes they had seen in 1958-71. The risk of unreliability inherent in any study based on recall must be substantially increased by the young ages of even the older boys at the beginning of that period. At a meeting of the Open Section of the Royal Society of Medicine last month, at which Dr Belson described his findings, a representative of the Independent Broadcasting Authority declared himself unconvinced by what Mr Milton Shulman, of the Evening Standard, called
592 the "obvious facts". Television violence, he said, was researchable, whereas other possible causes of teenage violence were more difficult to study. Certainly research in other areas is needed. The effects of other media should be studied; and so should the influence of television programmes which do not contain violence but which might engender dissatisfaction or envy. An inquiry in girls, similar to Belson’s study in boys, would be particularly interesting, since delinquency in girls has trebled in the 1970s. Social factors, too, could be investigated in more detail: for example, why did grammarschool boys in Belson’s inquiry tend to be less violent than other boys exposed to similar amounts of television violence, and why was serious violence negatively associated with the occupational level of the boys’ fathers? Television policy-makers will want much stronger evfdence before they consider the case against televised violence proven. It is encouraging, however, that the B.B.C. has this week announced the publication of a new code of conduct which will advise television producers not to include scenes of extreme brutality or violence in early-evening news bulletins. AMIODARONE
benzofuran derivative with vasodilatintroduced seventeen years ago as an ing properties, antianginal drugl·2 at a time when coronary dilatation
AMIODARONE,
a
the case both in animals8.9and in many and more extensive clinical trials showed that its antiarrhythmic properties" were particularly useful in the treatment of tachyarrhythmias associated with the Wolff-ParkinsonWhite syndrome.12 It may succeed where other drugs fail. Laboratory investigations often serve merely to elucidate and explain empirical observations of therapeutic efficacy in man, and it is only lately that analysis of the various classes of action of antiarrhythmic drugs in animals" has been used to predict clinical effects. The antiarrhythmic efficacy of amiodarone may be attributed to two distinct properties-an acute effect, consequent upon its antiadrenergic action (class 213), and a delayed effect, due to prolongation of A.P.D. (class 3). Amiodarone also causes bradycardia, which doubtless contributes to its antianginal efficacy. An electrophysiological study in manl4 has confirmed that amiodarone prolongs Q-Tc and that the effect takes several weeks to
develop fully; action
amiodarone has, moreover, "a uniform
cardiac tissue". It is very soluble in distilled water (5%) and is stably distributed in plasma. In contact with saline, however, it tends to come out of solution. A complication of therapy is the appearance of corneal deposits. These have proved to be innocuous, however, and they disappear when dosage is reduced. on
was
thought to be a primary requirement in the therapy angina pectoris. It not only dilates coronary arteries acutely, but also has antiadrenergic properties of a noncompetitive nature3 and reduces sympathetic transmitter release presynaptically.4 Amiodarone is still widely used in several countries for the treatment of angina, and numerous clinical trials attest to its efficacy.5 One puzzling feature is that, although the acute haemodynamic effects of amiodarone are soon over,6 the optimal therapeutic effect is not seen for days or weeks. In hyperthyroidism atrial fibrillation is not uncommon, whereas in hypothyroidism cardiac dysrhythmias are rare. In an electrophysiological study of different thyroid states on intracellularly recorded cardiac action potentials, thyroidectomy caused a large and uniform prolongation of action-potential duration (A.P.D.).’ Prolongation ofA.P.D., provided it is uniform, should reduce the probability of arrhythmias by prolonging absolute refractory period. (This must be distinguished from a "prolonged Q-T", which may conceal great heterogeneity of A.P.D. in different regions of myocardium.) Although not an antithyroid drug, amiodarone was found to mimic the hypothyroid state by prolonging A.P.D. in both atria and ventricles,8 a discovery which suggested that the drug should be antiarrhythmic. This proved to be
was
of
1. Charlier, R., Baudine, A., Tondeur, R., Binon, F.
Arch. Int. Pharma-
codyn. 1962, 139, 255. Deltour, G., Binon, F., Tondeur, R., Goldenberg, C., Hénaux, F., DeRay, E. Charlier, R. ibid. p. 247. 3. Charlier, R. Br. J. Pharmac. 1970, 39, 668. 4. Bacq., Z. M., Blakeley, A. C. H., Summers, R. J. Biochem. Pharmac. 1976. 25, 1195. 5. Vastesaeger, M., Gillot, P., Rasson, G. Acta cardiol. 1967, 22, 483. 6. Charlier, R., Deltour, G., Baudine, A., Chaillet, F. ArzneimittelForsch. 1968, 18, 1408. 7. Freedberg, A. S., Papp, J. Gy., Vaughan Williams, E. M. J. Physiol. Lond. 1970, 207, 357. 8. Singh, B. N., Vaughan Williams, E. M. Br. J. Pharmac. 1970, 39, 657. 9. Charlier, R., Delaunois, G., Bauthier, J., Deltour, G. Cardiologia, 1969, 54,
2.
83.
IMMUNE-COMPLEX SPLITTING
ANTIGENS, antibodies, and immune complexes may coexist in the circulation at certain times in a disease. This is readily demonstrated in experimental serum sickness where initially free antigen predominates, then immune complexes coincide with the acute symptoms, and finally, as free antibody levels increase, the animal recovers. This sequence of events is seldom recognised in human disease because the antigen is usually not known. A major problem in such conditions is laboratory interpretation of the tests for either antigen or antibody since they may escape detection when they circulate in complexed form. For instance, the conventional double-antibody radioimmunoassay for human growth hormone becomes uninterpretable when the patient has antibodies to the hormone as well. Similar difficulties may arise in immune-complex diseases such as systemic lupus erythematosus (S.L.E.) where anti-D.N.A. antibodies area marker for the disease and to a certain extent correlate with disease activity. Here there is further controversy, for it has not been conclusively established that D.N.A. is the antigen within the circulating immune complexes. If it is the antigen, then the radioimmunoassay for D.N.A. binding should give falsely low levels when the antiD.N.A. antibody is in complexed form. Immune-complex splitting in vitro should answer the question. Harbeck et aLl initially reported a rise in D.N.A. binding after 10. Ferrero, C., Benabderhamane, M. Giorn It. Card. 1972, 2, 186. 11. Rosenbaum, M. B., Chiale, P. A., Halpern, M. S., Vau, G., Przybylski, J., Levi, R. J., Lazzari, J. O., Elizari, M. W. Am. J. Cardiol. 1976, 38, 934. 12. Rosenbaum, M. B., Chiale, P. A., Ryba, D., Elizari, M. W. ibid. 1974, 34, 215. 13. Vaughan Williams, E. M. Adv. Drug Res. 1974, 9, 69. 14. Rasmussen, V., Berning, J. Acta med. scand 1979, 205, 31 1
Harbeck, R. J., Bardana, E. J , Kohler, P. F., Carr, R. I. J clin. Invest
1973, 52, 789.
manage minor
baby problems, and the specialised unit magnet for nursing and medical staff. The Cambridge workers, however, have demonacts as a
be done: from late 1974 the unit adopted a policy of rigorous selection which had the effect of reducing admissions from 25% of hospital births to 12.2% and 10.7% in 1975 and 1976. Malpresentations, instrumental deliveries, and caesarean sections were no longer automatic indications for admission, nor, among other problems were weight 2100-2500 g, lightness-for-dates, or jaundice with bilirubin less than 18 mg/dl (300 mol/1). They found that a number of mildly asphyxiated babies, though requiring ventilation at birth, were pink and lusty by age 10 minutes, and these too were excluded. In general their results show no evidence that babies suffered from exclusion from the unit, although two babies below the 3rd centile but weighing over 2500 g had hypoglyca’mic convulsions, presumably through mismanagement on the maternity wards: standing instructions in these wards were then altered to prevent a recurrence. The success of such a venture relies above all on adequate provision and training of maternity-ward staff, at present hard to achieve because of an acute nationwide nursing shortage. This is an important goal, since obstetric nursing involves care of babies as well as mothers. There is also a strong case for more pxdlatric training for junior obstetric staff, not just for the requirements of the Royal College examinations, but also as part of the complete training of an obstetrician. Here initiatives would be needed from senior obstetricians as well as paediatricians. Though ultimate responsibility for all babies lies with the paediatrician, immediate handling of some of the routine work and minor problems could be performed by junior obstetric staff, relieving the paediatric house-officers of some of the extra work that a restricted admission policy would entail. Although hard indications for s.c.B.u. admission cannot be applied to every baby (admission is often negotiated in the small hours between midwife and pxdiatric house-officer), the guidelines adopted at Cambridge are quite comprehensive and, with the above provisos, seem safe. Dr ROBERTSON and his colleagues have shown the way: who will follow their lead?
strated that it
can
TEENAGERS AND TELEVISION VIOLENCE Dr William Belson’s
study of the association between
exposure to television violence and the occurrence of violence in adolescent boysI must be the most thorough and most complex investigation of its kind yet undertaken. 1500 London boys aged 12-17 and their 1 TV Violence and the Adolescent
Boy. By WILLIAM A. BELSON. Hants: Saxon House. 1978. Pp. 529. £12.50.
Farnborough,
were asked, in home interviews, about the boys’ personal background and television viewing habits, and each boy later attended the research centre for a 32-hour intensive interview designed to elicit information about his attitudes to, and involvement in, violence. The data collected were used to test twenty-two hypotheses on the effects of long-term exposure to television violence. And the results very strongly supported just one-that high exposure to television violence increases the degree to which boys engage in serious violence. The credibility of this hypothesis was strengthened by the finding that the reverse hypothesis-that boys who
mothers
engage in serious violence watch more violence on television than do less violent boys-was not supported by the evidence. The findings gave very little support indeed to the various hypotheses relating to conscious attitudes, such as preoccupation with acts of violence seen on television or callousness towards violence in real life. In other words, whereas television violence was associated with an increase in violent behaviour, it made little difference to the boys’ attitudes to violence. From this Belson deduces that the major mental process underlying the changes effected by television violence is disinhibition-the erosion of inhibitions against violent behaviour that have been built up by parents and other socialising agencies. He found no evidence of a desensit-
ising (conscious) mechanism. Belson finds his results convincing enough to recommend some major changes in television policy-principally, of course, that the amount of violence shown should be substantially reduced. If the television planners act on his recommendations, his analysis of the effects of 25 different types of programme should help them to eliminate the most harmful types of violence from the screen. Violence in westerns and realistic fiction and programmes in which the "good guy" committed acts of violence appeared to have a strong influence, but violence in sports programmes, cartoons, and science fiction had little effect. These guidelines would be modified as necessary in the light of further research. Belson recommends that a monitoring system should be used to keep track of the amount and kind of violence shown on television, and that the results should be published. Belson’s work is impressive; nevertheless it is open to several criticisms, not the least of which relates to his definition of "serious" violence. This is important, for the results show, surprisingly, little association between television violence and all grades of violent behaviour. To obtain an index of violence, Belson asked the boys to describe violent acts they had committed in the past 6 months, and these acts were rated on a six-point scale by a panel of adult judges. But in some instances the judges gave widely differing assessments, which casts doubt on the reliability of the scale. In the interviews, which took place in 1972-73, the boys were asked to recall programmes they had seen in 1958-71. The risk of unreliability inherent in any study based on recall must be substantially increased by the young ages of even the older boys at the beginning of that period. At a meeting of the Open Section of the Royal Society of Medicine last month, at which Dr Belson described his findings, a representative of the Independent Broadcasting Authority declared himself unconvinced by what Mr Milton Shulman, of the Evening Standard, called
592 the "obvious facts". Television violence, he said, was researchable, whereas other possible causes of teenage violence were more difficult to study. Certainly research in other areas is needed. The effects of other media should be studied; and so should the influence of television programmes which do not contain violence but which might engender dissatisfaction or envy. An inquiry in girls, similar to Belson’s study in boys, would be particularly interesting, since delinquency in girls has trebled in the 1970s. Social factors, too, could be investigated in more detail: for example, why did grammarschool boys in Belson’s inquiry tend to be less violent than other boys exposed to similar amounts of television violence, and why was serious violence negatively associated with the occupational level of the boys’ fathers? Television policy-makers will want much stronger evfdence before they consider the case against televised violence proven. It is encouraging, however, that the B.B.C. has this week announced the publication of a new code of conduct which will advise television producers not to include scenes of extreme brutality or violence in early-evening news bulletins. AMIODARONE
benzofuran derivative with vasodilatintroduced seventeen years ago as an ing properties, antianginal drugl·2 at a time when coronary dilatation
AMIODARONE,
a
the case both in animals8.9and in many and more extensive clinical trials showed that its antiarrhythmic properties" were particularly useful in the treatment of tachyarrhythmias associated with the Wolff-ParkinsonWhite syndrome.12 It may succeed where other drugs fail. Laboratory investigations often serve merely to elucidate and explain empirical observations of therapeutic efficacy in man, and it is only lately that analysis of the various classes of action of antiarrhythmic drugs in animals" has been used to predict clinical effects. The antiarrhythmic efficacy of amiodarone may be attributed to two distinct properties-an acute effect, consequent upon its antiadrenergic action (class 213), and a delayed effect, due to prolongation of A.P.D. (class 3). Amiodarone also causes bradycardia, which doubtless contributes to its antianginal efficacy. An electrophysiological study in manl4 has confirmed that amiodarone prolongs Q-Tc and that the effect takes several weeks to
develop fully; action
amiodarone has, moreover, "a uniform
cardiac tissue". It is very soluble in distilled water (5%) and is stably distributed in plasma. In contact with saline, however, it tends to come out of solution. A complication of therapy is the appearance of corneal deposits. These have proved to be innocuous, however, and they disappear when dosage is reduced. on
was
thought to be a primary requirement in the therapy angina pectoris. It not only dilates coronary arteries acutely, but also has antiadrenergic properties of a noncompetitive nature3 and reduces sympathetic transmitter release presynaptically.4 Amiodarone is still widely used in several countries for the treatment of angina, and numerous clinical trials attest to its efficacy.5 One puzzling feature is that, although the acute haemodynamic effects of amiodarone are soon over,6 the optimal therapeutic effect is not seen for days or weeks. In hyperthyroidism atrial fibrillation is not uncommon, whereas in hypothyroidism cardiac dysrhythmias are rare. In an electrophysiological study of different thyroid states on intracellularly recorded cardiac action potentials, thyroidectomy caused a large and uniform prolongation of action-potential duration (A.P.D.).’ Prolongation ofA.P.D., provided it is uniform, should reduce the probability of arrhythmias by prolonging absolute refractory period. (This must be distinguished from a "prolonged Q-T", which may conceal great heterogeneity of A.P.D. in different regions of myocardium.) Although not an antithyroid drug, amiodarone was found to mimic the hypothyroid state by prolonging A.P.D. in both atria and ventricles,8 a discovery which suggested that the drug should be antiarrhythmic. This proved to be
was
of
1. Charlier, R., Baudine, A., Tondeur, R., Binon, F.
Arch. Int. Pharma-
codyn. 1962, 139, 255. Deltour, G., Binon, F., Tondeur, R., Goldenberg, C., Hénaux, F., DeRay, E. Charlier, R. ibid. p. 247. 3. Charlier, R. Br. J. Pharmac. 1970, 39, 668. 4. Bacq., Z. M., Blakeley, A. C. H., Summers, R. J. Biochem. Pharmac. 1976. 25, 1195. 5. Vastesaeger, M., Gillot, P., Rasson, G. Acta cardiol. 1967, 22, 483. 6. Charlier, R., Deltour, G., Baudine, A., Chaillet, F. ArzneimittelForsch. 1968, 18, 1408. 7. Freedberg, A. S., Papp, J. Gy., Vaughan Williams, E. M. J. Physiol. Lond. 1970, 207, 357. 8. Singh, B. N., Vaughan Williams, E. M. Br. J. Pharmac. 1970, 39, 657. 9. Charlier, R., Delaunois, G., Bauthier, J., Deltour, G. Cardiologia, 1969, 54,
2.
83.
IMMUNE-COMPLEX SPLITTING
ANTIGENS, antibodies, and immune complexes may coexist in the circulation at certain times in a disease. This is readily demonstrated in experimental serum sickness where initially free antigen predominates, then immune complexes coincide with the acute symptoms, and finally, as free antibody levels increase, the animal recovers. This sequence of events is seldom recognised in human disease because the antigen is usually not known. A major problem in such conditions is laboratory interpretation of the tests for either antigen or antibody since they may escape detection when they circulate in complexed form. For instance, the conventional double-antibody radioimmunoassay for human growth hormone becomes uninterpretable when the patient has antibodies to the hormone as well. Similar difficulties may arise in immune-complex diseases such as systemic lupus erythematosus (S.L.E.) where anti-D.N.A. antibodies area marker for the disease and to a certain extent correlate with disease activity. Here there is further controversy, for it has not been conclusively established that D.N.A. is the antigen within the circulating immune complexes. If it is the antigen, then the radioimmunoassay for D.N.A. binding should give falsely low levels when the antiD.N.A. antibody is in complexed form. Immune-complex splitting in vitro should answer the question. Harbeck et aLl initially reported a rise in D.N.A. binding after 10. Ferrero, C., Benabderhamane, M. Giorn It. Card. 1972, 2, 186. 11. Rosenbaum, M. B., Chiale, P. A., Halpern, M. S., Vau, G., Przybylski, J., Levi, R. J., Lazzari, J. O., Elizari, M. W. Am. J. Cardiol. 1976, 38, 934. 12. Rosenbaum, M. B., Chiale, P. A., Ryba, D., Elizari, M. W. ibid. 1974, 34, 215. 13. Vaughan Williams, E. M. Adv. Drug Res. 1974, 9, 69. 14. Rasmussen, V., Berning, J. Acta med. scand 1979, 205, 31 1
Harbeck, R. J., Bardana, E. J , Kohler, P. F., Carr, R. I. J clin. Invest
1973, 52, 789.
