446
functional consequences as revealed by pharmacological and sensorimotor testing. Brain Res 1980; 199: 307-33. 6. Björklung A, Gage FH, Dunnett SB, Slenevi U. Regenerative capacity of central neurons as revealed by intracerebral grafting experiments. In: Bignani A, et al, eds. Central nervous system plasticity and repair. New York: Raven, 1985: 57-62. 7. Lindvall O, Rehncrona S, Gustavii B, et al. Fetal dopamine-rich mesencephalic grafts in Parkinson’s disease. Lancet 1988; ii: 1483-84. 8. Lindvall O, Rehncrona S, Brundin P, et al. Human fetal dopamine neurons grafted into the striatum in two patients with severe Parkinson’s disease. A detailed account of methodology and a 6-month follow-up. Arch Neurol 1989; 46: 615-31. 9. Hitchcock ER, Clough C, Hughes R, Kenny B. Embryos and Parkinson’s disease. Lancet 1988; i: 1274. 10. Molina H. Neurotransplantation in Parkinson’s disease—the Cuban experience. Restor Neurol Neurosci 1989; 1: 17-21. 11. Madrazo I, Leon V, Torres C, et al. Transplantation of fetal substantia nigra and adrenal medulla to the caudate nucleus in two patients with Parkinson’s disease. N Engl J Med 1988; 318: 51. 12. Quinn N. The clinical application of cell grafting techniques in patients with Parkinson’s disease. Prog Brain Res (in press). 13. Backlung E-O, Granberg P-O, Hamberger B, et al. Transplantation of adrenal medullary tissue to striatum in parkinsonism. First clinical trials. J Neurosurg 1985; 62: 169-73. 14. Lindvall O, Backlund E-O, Farde L, et al. Transplantation in Parkinson’s disease: two cases of adrenal medullary grafts to the putamen. Ann Neurol 1987; 22: 457-68. 15. Madrazo I, Drucker-Colin R, Diaz V, Martinez-Mata J, Torres C, Bocerril JJ. Open microsurgical autograft of adrenal medulla to the right caudate nucleus in two patients with intractable Parkinson’s disease. N Engl J Med 1987; 316: 831-34. 16. Allen GS, Burns RS, Tulipan NB, Parker RA. Adrenal medullary transplantation to the caudate nucleus in Parkinison’s disease. Initial clinical results in 18 patients. Arch Neurol 1989; 46: 487-91. 17. Goetz CG, Olanow CW, Koller WC, et al. Multicentre study of autologous adrenal medullary transplantation to the corpus striatum in patients with advanced Parkinison’s disease. N Engl J Med 1989; 320: 337-41. 18. Hurtig H, Joyce J, Sladek JR, Trojanowski JQ. Post-mortem analysis of adrenal-medulla to caudate autograft in a patient with Parkinson’s disease. Ann Neurol 1989; 25: 607-14. 19. Jankovic J. Adrenal medullary autografts in patients with Parkinson’s disease. N Engl J Med 1989; 321: 326.
transplants:
WAR, STRESS, AND CORONARY DISEASE That "stress" is an important cause of heart disease is widely believed by lay people, although the medical profession tends to be more sceptical. The essential difficulty is that stress cannot be defined or measured, so it does not lend itself to quantitative research. Since the word "stress" lacks scientific respectability, alternative phrases have been used, and they may not be entirely synonymous. Thus the term "behavioural aspects" is taken by some to mean stress from within, which seems to be exemplified by the type A personality, whereas "psychosocial aspects" presumably means stress from without. There may be an association between these two types of stress and coronary disease. In cross-sectional American studies, the competitive, striving, deadline-keeping personality trait described as type A was associated with coronary disease 2 Longitudinal studies failed to confirm the relation, although the Framingham survey3 suggested that type A behaviour in men was associated with the later development of angina. The main drawback with type A behaviour as a marker of stress and a cause of coronary disease was that it could not be transported across the Atlantic-studies outside the USA gave unconvincing results. Although type A behaviour is more common among the professional classes, coronary disease is much more common among manual workers. In Whitehall civil
servants, there was
a progressive decrease in the fatality rate from ischaemic heart disease as the importance of jobs rose from the lowest to the highest grades.4 This gradation could be due to psychosocial factors, but who is to say whether the lowest or the highest grade of civil servants is most stressed? It is certainly true that among the lower grades men are shorter, more obese, smoke more, have a higher prevalence of diabetes and hypertension, and are less active in their spare time. Men in lower grades clearly differ in more than psychosocial terms from their more successful seniors. Living in a poor social environment and being unemployed are related to an increased mortality from coronary disease,s but is it likely that this is simply the result of the stress of poverty? Alfredsson et al suggested that the main stress for people in lowly occupations comes from a sense of having no control over eventsyet few people in more "important" jobs claim to have much control over what they perceive to be important. In case-control studies, stressful life-events were associated with acute myocardial infarction but such studies always relate to survivor populations and we know that studies with positive results are more likely to be reported than those with negative results. A different, and perhaps more direct, approach comes from Sibai and colleagues in Beirut,8 where events related to the civil war in the Lebanon have been taken as markers of stress. Using a case-control technique, these researchers claim to show that people affected by war stress have more coronary disease than those who are less affected. They studied 127 patients who for various reasons underwent coronary angiography at the American University of Beirut Medical Center. 72 had greater than 70% stenosis of one or more major coronary arteries; these patients were called cases. 15 patients with milder coronary lesions were excluded from the analysis. 40 patients had entirely normal coronary arteries and were called patient controls. Patient numbers were therefore very small for an epidemiological survey. Moreover, the fact that a third of the patients who underwent angiography were found to have normal coronary arteries suggests that the intensity of investigations may have reflected American practice, so the results may not be relevant to the average man in a Lebanese street. The second control group was selected randomly from visitors to the hospital and these individuals, together with the cases and the patient controls, were interviewed by questionnaire to assess their exposure to war stress. The prevalence of classic risk factors was also recorded. Major stress was defined, among other things, as death, injury, kidnapping, assault, or severe threats to a member of the immediate family, or damage to property including the effect of squatters. Minor stress was "hassles specific to the environment"; the hassle that could most easily be quantified was the number of times per week that the individual had to cross one of the green lines that separate the warring parties. When cases were compared with patient controls and visitor controls, the relation between arteriographically documented coronary disease and the classic risk factors such as hypercholesterolaemia, hypertension, and smoking did not stand out very clearly. This finding may have reflected the small number of patients, but such a lack of correlation has been found in earlier angiographic studies.9 However, 43% of cases reported more than two major stress events compared with 18% of patient controls and 24% of visitor controls; the difference between cases and controls was
statistically significant.
There
was
a
similar and
447
significant difference between the groups in their exposure to some of the minor stresses, and the patients seemed to have crossed green lines more frequently. Such a small study, with patients included in a way that must have been highly selective, is unlikely to provide convincing evidence for the effect of stress on coronary disease, but the Lebanese researchers do give a clear definition of stress. Whether war stress is the same as psychosocial factors or whether it is comparable to the stress of having a type A personality is uncertain. The possible relation between stress and coronary disease has been argued since the time of0sler/" who seems to have been the first to have considered stress to be the cause of coronary disease. Investigators, however, have found no way of coping with the fact that one man’s stress is another man’s stimulus. 1. Marmot MG. Look after your heart: stress and cardiovascular disease—a
studiable case? Health Trends 1987; 19: 21-24. F, Kornitzer M, Dramaix M. Evaluation of type A personality. Postgrad Med J 1986; 62: 781-83. 3. Kannel WB, Eaker ED. Psychosocial and other features of coronary heart disease: insights from the Framingham study. Am Heart J 1986; 5: 1066-73. 4. Marmot MG, Shipley MJ, Rose G. Inequalities in death-specific explanations of a general pattern? Lancet 1984; i: 1003-06. 5. Moser KA, Fox AJ, Jones DR. Unemployment and mortality in the OPCS Longitudinal Study. Lancet 1984; ii: 1324-29. 6. Alfredsson L, Karasek R, Theorell T. Myocardial infarction risk and psycho-social work environment-an analysis of male Swedish working force. Soc Sci Med 1982; 16: 463-67. 7. Bianchi G, Fergusson D, Walshe J. Psychiatric antecedents of myocardial infarction. Med J Aust 1978; i: 297-301. 8. Sibai AM, Armenian HK, Alam S. Wartime determinants of arteriographically confirmed coronary artery disease in Beirut. Am J Epidemiol 1989; 130: 623-31. 9. Holmes DR, Elveback LR, Frye RL, Kottke BA, Elleeson RD. Association of risk factor variable and coronary artery disease documented with angiography. Circulation 1981; 3: 293-95. 10. Osler W. The Lumleian lectures on angina pectoris. Lancet 1910; i: 697, 2. Kittel
839-44, 973.
(eating
local
shellfish, for example) while others, such
as
maternal exposure to X rays and maternal age, are not. The relative risks with 95% confidence intervals exceeding unity number 17, 12 of which refer, with considerable interdependence, to work at and occupational radiation in the Sellafield facility. It is this aspect that captured the headlines in the newspapers of Feb 16. We are indeed back with the handful of leukaemia cases. "... we know", say Gardner et al "that three of the five Seascale [a village close to Sellafield] cases had fathers whose accumulated preconceptual radiation dose was in the group with an estimated sixfold to eightfold relative risk of leukaemia and the father of the fourth was in the group just below the cut off value used". These five cases (and no others) lived 4 km or less from Sellafield. The total paternal radiation doses, from film badges, do not take into account internal contamination; they were, for the above four cases, 97, 102, 162, and 188 mSv over 6-13 years. Gardner et al, without further discussion, dismiss as a "hypothesis" (it was a stage on from that) the study on unbuilt nuclear power stations.4 Japanese A-bomb data conflict with their finding, the children of fathers exposed, to a single high dose, in 1945 do not seem to have been at risk of leukaemia.6 A radiobiological explanation for the latest Sellafield data, especially in the absence of data on internal contamination, remains elusive. If total doses of 100 mSv or so do really damage the paternal germ cell line to increase the chance of childhood leukaemia/lymphoma there would be enormous implications not just for occupational annual dose limits, already being cut from 50 to 15 mSv, but also for how we look at natural radiation and at leukaemogenesis in general. 1. 2. 3. 4.
Independent Advisory Group (chairman Sir Douglas Black). London: H M Stationery Office, 1984. Committee on Medical Aspects of Radiation in the Environment. Second and third reports. London: H M Stationery Office, 1988 and 1989. Smith PG, Douglas AJ, Mortality of workers at the Sellafield plant of British Nuclear Fuels. Br Med J 1986; 293: 845-54. Cook-Mozaffari P, Darby S, Doll R. Cancer near potential sites of nuclear
installations. Lancet 1989; ii: 1145-47. MJ, Snee MP, Hall AJ, Powell CA, Downes S, Terrell JD. Results of case-control study of leukaemia and lymphoma among young people near Sellafield nuclear plant in West Cumbria. Br Med J 1990; 300: 423-29. 6. Ishimura T, Ichimaru M, Mihami M. Leukaemia incidence among individuals exposed in vitro, children of atomic bomb survivors and their controls, Hiroshima and nagasaki, 1945-1979 (RERF Tech Rep 11-81). Hiroshima: Radiation Effects Research Foundation, 1981. 5. Gardner
CHILDHOOD LEUKAEMIA, RADIATION, AND THE PATERNAL GERM CELL A handful of leukaemias and lymphomas in young people living on the coastal strip west of the English Lake Disrict has generated much puzzlement. In the 5 zyears since an official inquiry1 showed that there was indeed an increase in risk near the Sellafield nuclear facility in West Cumbria the perplexity has, if anything, increased. Straightforward exposure to radiation became even less likely with the realisation that the risk was associated with nuclear facilities in Britain which have had cleaner environment records than Sellafield, the oldest.2 We also learned that workers at Sellafield, whose exposure would surely be greater than that of their families, were not at increased risk of haematological malignancy.3 Then it emerged that mortality from leukaemia was unusually high around phantom nuclear power stations-ones never built or built later. In last week’s BM_7 Prof M. J. Gardner and his colleagues return to the Black inquiry-rather to one of its proposals, for a case-control study based on the Sellafield plant.s In a very thorough investigation Gardner et al tabulate no fewer than 150 relative risks with their 95 % confidence intervals. These cover possible risk factors that could be relevant to leukaemia under the age of 25 ; some are relevant to Sellafield
MODERN VACCINES: CURRENT PRACTICE AND NEW APPROACHES "Thank you, doctor, for sparing my child the miseries of measles, whooping cough, mumps, polio, and diphtheria". Such words are seldom heard; but gratitude is not the best index of good medicine. For all its lack of glamour, vaccination offers more for human life and health than any other medical activity, and the scope for further achievements is vast. With the guidance of Prof Richard Moxon The Lancet has commissioned seventeen articles from around the world on the fundamentals of immunisation, the new technologies, the areas of controversy in practice, and the best hopes for the future. Immunoprophylaxis is ready for a forward surge. On the next page Professor Moxon sets the scene.
functional consequences as revealed by pharmacological and sensorimotor testing. Brain Res 1980; 199: 307-33. 6. Björklung A, Gage FH, Dunnett SB, Slenevi U. Regenerative capacity of central neurons as revealed by intracerebral grafting experiments. In: Bignani A, et al, eds. Central nervous system plasticity and repair. New York: Raven, 1985: 57-62. 7. Lindvall O, Rehncrona S, Gustavii B, et al. Fetal dopamine-rich mesencephalic grafts in Parkinson’s disease. Lancet 1988; ii: 1483-84. 8. Lindvall O, Rehncrona S, Brundin P, et al. Human fetal dopamine neurons grafted into the striatum in two patients with severe Parkinson’s disease. A detailed account of methodology and a 6-month follow-up. Arch Neurol 1989; 46: 615-31. 9. Hitchcock ER, Clough C, Hughes R, Kenny B. Embryos and Parkinson’s disease. Lancet 1988; i: 1274. 10. Molina H. Neurotransplantation in Parkinson’s disease—the Cuban experience. Restor Neurol Neurosci 1989; 1: 17-21. 11. Madrazo I, Leon V, Torres C, et al. Transplantation of fetal substantia nigra and adrenal medulla to the caudate nucleus in two patients with Parkinson’s disease. N Engl J Med 1988; 318: 51. 12. Quinn N. The clinical application of cell grafting techniques in patients with Parkinson’s disease. Prog Brain Res (in press). 13. Backlung E-O, Granberg P-O, Hamberger B, et al. Transplantation of adrenal medullary tissue to striatum in parkinsonism. First clinical trials. J Neurosurg 1985; 62: 169-73. 14. Lindvall O, Backlund E-O, Farde L, et al. Transplantation in Parkinson’s disease: two cases of adrenal medullary grafts to the putamen. Ann Neurol 1987; 22: 457-68. 15. Madrazo I, Drucker-Colin R, Diaz V, Martinez-Mata J, Torres C, Bocerril JJ. Open microsurgical autograft of adrenal medulla to the right caudate nucleus in two patients with intractable Parkinson’s disease. N Engl J Med 1987; 316: 831-34. 16. Allen GS, Burns RS, Tulipan NB, Parker RA. Adrenal medullary transplantation to the caudate nucleus in Parkinison’s disease. Initial clinical results in 18 patients. Arch Neurol 1989; 46: 487-91. 17. Goetz CG, Olanow CW, Koller WC, et al. Multicentre study of autologous adrenal medullary transplantation to the corpus striatum in patients with advanced Parkinison’s disease. N Engl J Med 1989; 320: 337-41. 18. Hurtig H, Joyce J, Sladek JR, Trojanowski JQ. Post-mortem analysis of adrenal-medulla to caudate autograft in a patient with Parkinson’s disease. Ann Neurol 1989; 25: 607-14. 19. Jankovic J. Adrenal medullary autografts in patients with Parkinson’s disease. N Engl J Med 1989; 321: 326.
transplants:
WAR, STRESS, AND CORONARY DISEASE That "stress" is an important cause of heart disease is widely believed by lay people, although the medical profession tends to be more sceptical. The essential difficulty is that stress cannot be defined or measured, so it does not lend itself to quantitative research. Since the word "stress" lacks scientific respectability, alternative phrases have been used, and they may not be entirely synonymous. Thus the term "behavioural aspects" is taken by some to mean stress from within, which seems to be exemplified by the type A personality, whereas "psychosocial aspects" presumably means stress from without. There may be an association between these two types of stress and coronary disease. In cross-sectional American studies, the competitive, striving, deadline-keeping personality trait described as type A was associated with coronary disease 2 Longitudinal studies failed to confirm the relation, although the Framingham survey3 suggested that type A behaviour in men was associated with the later development of angina. The main drawback with type A behaviour as a marker of stress and a cause of coronary disease was that it could not be transported across the Atlantic-studies outside the USA gave unconvincing results. Although type A behaviour is more common among the professional classes, coronary disease is much more common among manual workers. In Whitehall civil
servants, there was
a progressive decrease in the fatality rate from ischaemic heart disease as the importance of jobs rose from the lowest to the highest grades.4 This gradation could be due to psychosocial factors, but who is to say whether the lowest or the highest grade of civil servants is most stressed? It is certainly true that among the lower grades men are shorter, more obese, smoke more, have a higher prevalence of diabetes and hypertension, and are less active in their spare time. Men in lower grades clearly differ in more than psychosocial terms from their more successful seniors. Living in a poor social environment and being unemployed are related to an increased mortality from coronary disease,s but is it likely that this is simply the result of the stress of poverty? Alfredsson et al suggested that the main stress for people in lowly occupations comes from a sense of having no control over eventsyet few people in more "important" jobs claim to have much control over what they perceive to be important. In case-control studies, stressful life-events were associated with acute myocardial infarction but such studies always relate to survivor populations and we know that studies with positive results are more likely to be reported than those with negative results. A different, and perhaps more direct, approach comes from Sibai and colleagues in Beirut,8 where events related to the civil war in the Lebanon have been taken as markers of stress. Using a case-control technique, these researchers claim to show that people affected by war stress have more coronary disease than those who are less affected. They studied 127 patients who for various reasons underwent coronary angiography at the American University of Beirut Medical Center. 72 had greater than 70% stenosis of one or more major coronary arteries; these patients were called cases. 15 patients with milder coronary lesions were excluded from the analysis. 40 patients had entirely normal coronary arteries and were called patient controls. Patient numbers were therefore very small for an epidemiological survey. Moreover, the fact that a third of the patients who underwent angiography were found to have normal coronary arteries suggests that the intensity of investigations may have reflected American practice, so the results may not be relevant to the average man in a Lebanese street. The second control group was selected randomly from visitors to the hospital and these individuals, together with the cases and the patient controls, were interviewed by questionnaire to assess their exposure to war stress. The prevalence of classic risk factors was also recorded. Major stress was defined, among other things, as death, injury, kidnapping, assault, or severe threats to a member of the immediate family, or damage to property including the effect of squatters. Minor stress was "hassles specific to the environment"; the hassle that could most easily be quantified was the number of times per week that the individual had to cross one of the green lines that separate the warring parties. When cases were compared with patient controls and visitor controls, the relation between arteriographically documented coronary disease and the classic risk factors such as hypercholesterolaemia, hypertension, and smoking did not stand out very clearly. This finding may have reflected the small number of patients, but such a lack of correlation has been found in earlier angiographic studies.9 However, 43% of cases reported more than two major stress events compared with 18% of patient controls and 24% of visitor controls; the difference between cases and controls was
statistically significant.
There
was
a
similar and
447
significant difference between the groups in their exposure to some of the minor stresses, and the patients seemed to have crossed green lines more frequently. Such a small study, with patients included in a way that must have been highly selective, is unlikely to provide convincing evidence for the effect of stress on coronary disease, but the Lebanese researchers do give a clear definition of stress. Whether war stress is the same as psychosocial factors or whether it is comparable to the stress of having a type A personality is uncertain. The possible relation between stress and coronary disease has been argued since the time of0sler/" who seems to have been the first to have considered stress to be the cause of coronary disease. Investigators, however, have found no way of coping with the fact that one man’s stress is another man’s stimulus. 1. Marmot MG. Look after your heart: stress and cardiovascular disease—a
studiable case? Health Trends 1987; 19: 21-24. F, Kornitzer M, Dramaix M. Evaluation of type A personality. Postgrad Med J 1986; 62: 781-83. 3. Kannel WB, Eaker ED. Psychosocial and other features of coronary heart disease: insights from the Framingham study. Am Heart J 1986; 5: 1066-73. 4. Marmot MG, Shipley MJ, Rose G. Inequalities in death-specific explanations of a general pattern? Lancet 1984; i: 1003-06. 5. Moser KA, Fox AJ, Jones DR. Unemployment and mortality in the OPCS Longitudinal Study. Lancet 1984; ii: 1324-29. 6. Alfredsson L, Karasek R, Theorell T. Myocardial infarction risk and psycho-social work environment-an analysis of male Swedish working force. Soc Sci Med 1982; 16: 463-67. 7. Bianchi G, Fergusson D, Walshe J. Psychiatric antecedents of myocardial infarction. Med J Aust 1978; i: 297-301. 8. Sibai AM, Armenian HK, Alam S. Wartime determinants of arteriographically confirmed coronary artery disease in Beirut. Am J Epidemiol 1989; 130: 623-31. 9. Holmes DR, Elveback LR, Frye RL, Kottke BA, Elleeson RD. Association of risk factor variable and coronary artery disease documented with angiography. Circulation 1981; 3: 293-95. 10. Osler W. The Lumleian lectures on angina pectoris. Lancet 1910; i: 697, 2. Kittel
839-44, 973.
(eating
local
shellfish, for example) while others, such
as
maternal exposure to X rays and maternal age, are not. The relative risks with 95% confidence intervals exceeding unity number 17, 12 of which refer, with considerable interdependence, to work at and occupational radiation in the Sellafield facility. It is this aspect that captured the headlines in the newspapers of Feb 16. We are indeed back with the handful of leukaemia cases. "... we know", say Gardner et al "that three of the five Seascale [a village close to Sellafield] cases had fathers whose accumulated preconceptual radiation dose was in the group with an estimated sixfold to eightfold relative risk of leukaemia and the father of the fourth was in the group just below the cut off value used". These five cases (and no others) lived 4 km or less from Sellafield. The total paternal radiation doses, from film badges, do not take into account internal contamination; they were, for the above four cases, 97, 102, 162, and 188 mSv over 6-13 years. Gardner et al, without further discussion, dismiss as a "hypothesis" (it was a stage on from that) the study on unbuilt nuclear power stations.4 Japanese A-bomb data conflict with their finding, the children of fathers exposed, to a single high dose, in 1945 do not seem to have been at risk of leukaemia.6 A radiobiological explanation for the latest Sellafield data, especially in the absence of data on internal contamination, remains elusive. If total doses of 100 mSv or so do really damage the paternal germ cell line to increase the chance of childhood leukaemia/lymphoma there would be enormous implications not just for occupational annual dose limits, already being cut from 50 to 15 mSv, but also for how we look at natural radiation and at leukaemogenesis in general. 1. 2. 3. 4.
Independent Advisory Group (chairman Sir Douglas Black). London: H M Stationery Office, 1984. Committee on Medical Aspects of Radiation in the Environment. Second and third reports. London: H M Stationery Office, 1988 and 1989. Smith PG, Douglas AJ, Mortality of workers at the Sellafield plant of British Nuclear Fuels. Br Med J 1986; 293: 845-54. Cook-Mozaffari P, Darby S, Doll R. Cancer near potential sites of nuclear
installations. Lancet 1989; ii: 1145-47. MJ, Snee MP, Hall AJ, Powell CA, Downes S, Terrell JD. Results of case-control study of leukaemia and lymphoma among young people near Sellafield nuclear plant in West Cumbria. Br Med J 1990; 300: 423-29. 6. Ishimura T, Ichimaru M, Mihami M. Leukaemia incidence among individuals exposed in vitro, children of atomic bomb survivors and their controls, Hiroshima and nagasaki, 1945-1979 (RERF Tech Rep 11-81). Hiroshima: Radiation Effects Research Foundation, 1981. 5. Gardner
CHILDHOOD LEUKAEMIA, RADIATION, AND THE PATERNAL GERM CELL A handful of leukaemias and lymphomas in young people living on the coastal strip west of the English Lake Disrict has generated much puzzlement. In the 5 zyears since an official inquiry1 showed that there was indeed an increase in risk near the Sellafield nuclear facility in West Cumbria the perplexity has, if anything, increased. Straightforward exposure to radiation became even less likely with the realisation that the risk was associated with nuclear facilities in Britain which have had cleaner environment records than Sellafield, the oldest.2 We also learned that workers at Sellafield, whose exposure would surely be greater than that of their families, were not at increased risk of haematological malignancy.3 Then it emerged that mortality from leukaemia was unusually high around phantom nuclear power stations-ones never built or built later. In last week’s BM_7 Prof M. J. Gardner and his colleagues return to the Black inquiry-rather to one of its proposals, for a case-control study based on the Sellafield plant.s In a very thorough investigation Gardner et al tabulate no fewer than 150 relative risks with their 95 % confidence intervals. These cover possible risk factors that could be relevant to leukaemia under the age of 25 ; some are relevant to Sellafield
MODERN VACCINES: CURRENT PRACTICE AND NEW APPROACHES "Thank you, doctor, for sparing my child the miseries of measles, whooping cough, mumps, polio, and diphtheria". Such words are seldom heard; but gratitude is not the best index of good medicine. For all its lack of glamour, vaccination offers more for human life and health than any other medical activity, and the scope for further achievements is vast. With the guidance of Prof Richard Moxon The Lancet has commissioned seventeen articles from around the world on the fundamentals of immunisation, the new technologies, the areas of controversy in practice, and the best hopes for the future. Immunoprophylaxis is ready for a forward surge. On the next page Professor Moxon sets the scene.
