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The BMJ aims to help doctors everywhere practise better medicine and to influence the debate on health. To achieve these aims we publish original scientific studies, review and educational articles, and papers commenting on the clinical, scientific, social, political, and economic factors affecting health.

British Medical Journal (Clinical research ed.)

[The nature of disease]

The oesophageal transit of six commonly used tablets and capsules containing barium sulphate was evaluated radiologically using fluoroscopy in 121 healthy volunteers. To determine the influence of the subject's position and the amount of water taken each subject swallowed three preparations while recumbent and standing and with 25 ml or 100 ml of water. Failure of swallowing (defined as oesophageal transit taking more than 90 seconds) occurred in 22% of 726 swallowings, but globus was complained of in only 33% of these. Sixty per cent of the volunteers had difficulty in taking one or more of the preparations. Many preparations adhered to the oesophageal membrane and started to disintegrate in the lower part of oesophagus. It is recommended that subjects should remain standing for at least 90 seconds after taking capsules or tablets and that all preparations should be taken with at least 100 ml of water. Small tablets are swallowed most easily. Liquid forms of medication (suspensions) should be considered for bedridden patients and those who have difficulty in swallowing.

Esophageal transit of six commonly used tablets and capsules

The first five years of life

A 5-week-old previously healthy baby girl was found in her pram with a cat lying over her face. She was deeply cyanosed and gasping. Her father, a doctor, gave mouth-to-mouth resuscitation, and her colour and breathing became normal after about 30 seconds. A few hours later she had severe diarrhoea, fever, and poor peripheral circulation and was admitted to hospital. Examination showed no abnormalities apart from her blue-grey colour and tachypnoea. There was biochemical evidence of slight dehydration with severe metabolic acidosis (pH 7.18), which was corrected. Lumbar puncture showed no abnormality, urine and cerebrospinal fluid were sterile, and no pathogenic bacteria were found in the stools. The diarrhoea stopped after two days. An electroencephalogram taken a few days later was abnormal, with spikes and waves over the frontal and temporal regions. During the next few days she had several convulsions, which responded to phenobarbitone. Over the subsequent months her psychomotor development was clearly retarded and she again had convulsions consistent with infantile spasms. Electroencephalography showed hypsarrhythmia. She was treated with adrenocorticotrophic hormone but died at the age of 8 months from bronchopneumonia. Postmortem examination showed bronchopneumonia as the immediate cause of death. The brain was severely shrunken and showed massive bilateral symmetrical dissolution of the white matter of the cerebral hemispheres and multiple cystic trabeculated cavities of varying size. There was severe focal atrophy of the cerebral cortex. Histologically there was massive loss of brain substance with widespread gliosis. There was loss of Purkinje cells, and some of the surviving ones had poorly demarcated fluffy borders.

Can a cat smother and kill a baby?

Much of the mortaltiy and morbidity among children in developing countries is preventable. The three main causes of admissions to hospital are protein energy malnutrition, respiratory infections, and diarrhoea. These three account for 30-40% of all paediatric admissions. The next most common illnesses are anaemia, common infections of childhood such as measles and pertussis, parasitic diseases (especially malaria and intestinal helminths), tuberculosis, and burns and other accidents including poisoning. Together these nine conditions account for most of the paediatric problems in the developing world.

Child health.

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671

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The clinical years.

Research.

"Normal" temperature

Cost of treatment.

Calculating confidence intervals for non-parametric analyses

All change for research

Health and efficiency

Treatment of common minor ailments

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291

292

The t tests

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951

952

Health information systems

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53

If I had.

If I had . . .

If I had...

A 70-year-old depressed woman was admitted to the casualty department 30 minutes after attempting to commit suicide by ingesting 350 ml of household Dettol (Reckit and Colman), which contains chloroxylenol 48 g/l, terpineol, and ethyl alcohol (±7.0%). She was in a deep coma, areflexic, and unresponsive to painful stimuli, and her pupils were moderately constricted showing little response to light. Her systolic blood pressure was 30 mm Hg, and her pulse 60 beats/min; she was breathing spontaneously at 8 per minute. Her rectal temperature was 35°C and she had signs of peripheral venous dilatation and a raised jugular venous pressure. There were no signs of corrosion or chemical irritation of the skin or mucosae and her ECG showed pronounced ischaemic changes. An intravenous line was established, oxygen given via a face mask, and the stomach content carefully aspirated via a Ryles tube inserted through a nostril. The stomach content was milky and smelt strongly of Dettol. Careful gastric lavage was performed with small amounts of water, and afterwards 100 ml of liquid paraffin was left in the stomach. The patient was then transferred to the intensive care unit, where her vital functions were monitored continuously. Her blood pressure was controlled by dopamine infusion. About four hours after admission she developed a nodal tachycardia, which responded well to intravenous verapamil. After six to eight hours she started to regain consciousness and was fully conscious after 24 hours. She was then transferred to the general psychiatric ward and apart from severe watery diarrhoea during the first 48 hours recovered uneventfully.

Severe Dettol (chloroxylenol and terpineol) poisoning

Population control.

The connotations of the term "a disease" were investigated by studying the ways in which both medical and non-medical people used the word. A list of common diagnostic terms was read slowly to groups of non-medical academic staff of a university, secondary-school students, medical academics, and family practitioners, who then indicated whether they thought each word referred to disease.All groups rated illnesses due to infections as diseases, but the doctors, and particularly the general practitioners, were more generous in accepting as diseases the terms for non-infectious conditions. Apart from the nature of the cause, the most influential factor in determining whether or not an illness was considered to be a disease was the importance of the doctor in diagnosis and treatment.These findings provide further evidence that there is ambiguity about the meaning of the term disease. To the layman a disease seems to be a living agency that causes illness. Doctors have obviously accepted more heterogeneous defining characteristics but remain reluctant to adopt unequivocally nominalist ways of thought. The position is not unlike that in the physical sciences, in which there is a good precedent for distinguishing between the formal scientific and the everyday uses of terms such as "force" and "power."

The concept of disease

The authors used 18 children (6 boys, 12 girls) aged 2-13 years who were selected from the paediatric oncology unit and who were receiving cyclical cytotoxic chemotherapy, which was complicated by nausea and vomiting, for a variety of malignant diseases. Either intravenous metoclopramide (0.5 mg/kg body weight) or domperidone (up to 1 mg/kg body weight) was given in a random, cross-over design, on at least two occasions immediately before cytotoxic treatment. We did not consider it ethical to include a placebo group. Patients and parents were told that one of two drugs, both effective in controlling womiting, would be given. Parents or nurses not participating in giving the drugs recorded prodromal symptoms, such as insomnia, anxiety, and vomiting in the 12 hours before treatment, and episodes of nausea and vomiting for a period of 36 hours after treatment. The incidence of nausea and vomiting on the 20 occasions on which the 18 patients were treated with metoclopramide and domperidone is shown in the table. Prodromal symptoms were similar in both groups. Thirteen patients vomited less after domperidone, two vomited more, and three as often as after metoclopramide. Vomiting was significantly reduced after domperidone (P < 0.01, McNemar test, two-tailed probability). Domperidone had a considerable effect in the first four hours after cytotoxic treatment, but little protective effect after that, suggesting that its duration of action is about four hours. Thirteen patients had less nausea after domperidone, one had more, and four were as nauseated as after metoclopramide: a significant difference (P< 0.01, McNemar test, two-tailed probability). Patients were followed up at three-weekly intervals, and none experienced any acute symptom that could be implicated as an unwanted effect of either domperidone or metoclopramide. No patient during the study had an unusual fluctuation in blood count or clinical evidence of jaundice, and no patient died.

Domperidone or metoclopramide in preventing chemotherapeutically induced nausea and vomiting

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1798

Review Body Report.

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53

Review Body report.

t tests.

P values.

The i-patient.

Control of treatment.

Relative risk.

#### Summary points

Scoliosis is a three dimensional deformity of the spine defined as a lateral curvature of the spine in the coronal plane of more than 10°.1 It can be categorised into three major types—congenital, syndromic, and idiopathic. Congenital scoliosis refers to spinal deformity caused by abnormally formed vertebrae. Syndromic scoliosis is associated with a disorder of the neuromuscular, skeletal, or connective tissue systems; neurofibromatosis; or other important medical condition. Idiopathic scoliosis has no known cause and can be subdivided based on the age of onset—infantile idiopathic scoliosis includes patients aged 0-3 years, juvenile idiopathic scoliosis includes patients aged 4-10 years, and adolescent idiopathic scoliosis affects people aged >10 years.

Adolescent idiopathic scoliosis (AIS) is the most common spinal deformity seen by primary care physicians, paediatricians, and spinal surgeons.2 This review is focused on AIS and reviews the diagnosis, management, and controversies surrounding this condition based on the available literature.

#### Sources and selection criteria

We searched Medline and the Cochrane Library using MeSH terms “adolescent idiopathic scoliosis”, and “scoliosis bracing”. We included systematic reviews, randomised controlled trials, and good quality prospective observational studies mainly from the past 15 years but did not …

Adolescent idiopathic scoliosis

Three types of health education

Kapil Sahnan, Samuel O Adegbola, Phillip J Tozer, Josef Watfah, Robin KS Phillips

Perianal abscess

Man flu" is a term so ubiquitous that it has been included in the Oxford and Cambridge dictionaries. Oxford defines it as "a cold or similar minor ailment as experienced by a man who is regarded as exaggerating the severity of the symptoms." 1 Since about half of the world's population is male, deeming male viral respiratory symptoms as "exaggerated" without rigorous scientific evidence, could have important implications for men, including insufficient provision of care. Despite the universally high incidence and prevalence of viral respiratory illnesses, 2 no scientific review has examined whether the term "man flu" is appropriately defined or just an ingrained pejorative term with no scientific basis. Tired of being accused of overreacting , I searched the available evidence (box) to determine whether men really experience worse symptoms and whether this could have any evolutionary basis. Of mice and men Mice have long been accepted as good models of human physiology for medical research, 3 with records dating back to William Harvey in 17th century England. 4 Several studies show that female mice have higher immune responses than males. 5 6 This led to the hypothesis that sex dependent hormones have an important role in outcomes of influenza. Further studies suggest that oestradiol is implicated in this response in mice, 7 with one study concluding that the hormone reduces "responses associated with immunopathology" and enhances "responses associated with recruitment of innate immune cells…into the lungs." 8 However, another mouse study suggests that stress and corticosterone levels have a role, concluding that "the increase in infection-induced corticosterone levels demonstrated in females may have suppressed the behavioural symptoms of infection." 9 Lending further weight to the oestradiol theory, an in-vitro study sniffs at an underlying reason for man flu. Using human nasal epithelial cell cultures infected with seasonal influenza A, researchers showed that exposure to oestradiol or select oestrogen receptor modulators (SERMs) decreased influenza A titres in tissue from female, but not male, donors. Oestradiol also significantly downregulated cell metabolic processes. Adding oestrogen receptor antagonists reversed this antiviral effect. 10 Another study isolated mononuclear cells from 63 healthy people grouped according to age and sex and cultured the cells with rhinovirus. Cells cultured from premenopausal women had a stronger immune response to rhinovirus than those from men of the same age. This difference was not observed when post-menopausal women were compared with men of the same age, suggesting a hormonal link. 11 12 Patterns in humans Although animal and in-vitro studies are weak sources of evidence, human research also points to different responses to influenza in men and women. Even the World Health Organization stresses that "sex should be considered when evaluating influenza exposure and outcomes." 13 Epidemiological data from 2004-10 for seasonal influenza in Hong Kong showed that adult men had a higher risk of hospital admission, 14 and in a US observational study of influenza mortality from 1997 to 2007, men had higher rates of influenza associated deaths compared with women in the same age groups. This was true regardless of underlying heart disease, cancer, chronic respiratory system disease, and renal disease. 15 Studies of influenza vaccination suggest that women are more responsive to vaccination than men. 16 17 This is supported by the finding that women report more local and systemic reactions to influenza vaccine than men in questionnaires. 18 One study noted that men with higher testosterone levels had more down regulation of antibody response to vaccination, suggesting an immunosuppressive role for testosterone. 16 This is consistent with animal and in-vitro studies showing testosterone has an immunosuppressive effect 19 20 and a finding of higher levels of inflammatory cytokines in men with androgen deficiencies than in healthy controls. 21 The sex differences extend to other respiratory infections beyond influenza. In many acute respiratory diseases, males are more susceptible to complications and exhibit a higher mortality. 22 ksue@ualberta.ca For personal use only: See rights and reprints

The science behind "man flu"

Health and the State.

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934

Reading for Pleasure: Book of Kings

Parameters.

Research into the association between pet ownership and human health has produced intriguing, although frequently contradictory, results often raising uncertainty as to whether pet ownership is advisable on health grounds
Introduction
The question of whether someone should own a pet is never as simple as whether that pet has a measurably beneficial or detrimental effect on the owner's physical health. The emotional bond between owner and pet can be as intense as that in many human relationships and may confer similar psychological benefits. Death of a pet can cause grief similar to that in human bereavement, whereas threat of loss of a pet may be met with blunt refusal and non-compliance with advice on health.
We examine the current evidence for a link between pet ownership and human health and discuss the importance of understanding the role of pets in people's lives.

Is pet ownership associated with human health?
Research dating from the 1980s popularised the view that pet ownership could have positive benefits on human health. Benefits ranged from higher survival rates from myocardial infarction1; a significantly lower use of general practitioner services (prompting some researchers to speculate on considerable potential savings to health expenditure)2; a reduced risk of asthma and allergic rhinitis in children exposed to pet allergens during the first year of life3 4; a reduced risk of cardiovascular disease5; and better physical and psychological wellbeing in community dwelling older people.6 No studies have found significant social or economic differences between people who do or do not have pets that would adequately explain differences in health outcome, leading to the belief that pet ownership itself is the primary cause of the reported benefits.
Although the research did much to raise awareness of the importance that people attach to their pets, recent studies have failed to replicate the benefits. A review of the association between pets and allergic sensitisation found inconsistent results for cat ownership between studies of similar design, whereas dog ownership seemed to have no effect or even protected against specific sensitisation to dog allergens and allergic sensitisation in general.7 Other studies on the subject suggest that exposure to pets may be beneficial provided that exposure is sufficient, as lower levels may enhance sensitisation whereas higher levels may protect against sensitisation.8 Yet others suggest that the effects may heavily depend on age at exposure and type of pet.9
Similarly, recent research has failed to support earlier findings that pet ownership is associated with a reduced risk of cardiovascular disease,10 a reduced use of general practitioner services,11 or any psychological or physical benefits on health for community dwelling older people.12 Research has, however, pointed to significantly less absenteeism from school through sickness among children who live with pets.w1

Do we need a broader definition of health?
The main issue may not be whether pet ownership per se confers measurable physical benefits but the role that pets have in individual people's lives—namely, the contributions of the pet to quality of life or the costs to wellbeing through a pet's death. This issue embraces a broader definition of health that encompasses the dimensions of wellbeing (physical and mental) and a sense of social integration.
Three potential mechanisms have been proposed to explain the association between pet ownership and benefits to human health (fig 1).13 The first is that there is no real association between the two, rather that cofactors such as personality traits, age, and economic or health status impact on the decision to own a pet and thus produce an apparent link between pets and health. So far, however, evidence is lacking that any of these cofactors account for both health promoting attributes and propensity to own pets, suggesting that health benefits, when reported, may be attributable to some aspect of pet ownership.
View larger version:In a new windowDownload as PowerPoint SlideFig 1 
Three proposed mechanisms for association between pet ownership and health benefits for humans

A Munduruku boy carries his pet, a domesticated wild boar, for a daily cleansing swim in the Rio Canuma
Credit: GERD LUDWIG/PANOS

The second proposal is that pets may enhance social interactions with other people, thus providing an indirect effect on wellbeing. Social contact has been long recognised as beneficial in that it alleviates feelings of loneliness and social isolation. Pets undoubtedly act as “social catalysts,” leading to greater social contact between people.14 These factors may be particularly important for those at risk of social isolation, such as elderly people or people with physical disabilities, who lack many of the opportunities for social interactions of their more able bodied peers.15
The third proposal focuses on ways in which pet ownership may exert a direct effect on human health and wellbeing through the nature of the relationship. Close human relationships have a powerful influence on wellbeing by providing emotional support. They may reduce perceptions of stressful events thus protecting against anxiety related illness, may give confidence that successful coping strategies can be found to deal with stress, and may enhance recovery from serious illness such as stroke, myocardial infarction, and cancer. These aspects of a relationship are collectively referred to as social support. Social relationships, or the lack of, seem to constitute a major risk factor for health, rivalling the effects of well established risk factors such as cigarette smoking, blood pressure, blood lipid concentrations, obesity, and lack of physical activity.16

The value of companionship
Companionship—a commonly stated reason for pet ownership—is regarded as theoretically distinct from social support in that it does not offer extrinsic support but provides intrinsic satisfactions, such as shared pleasure in recreation, relaxation, and uncensored spontaneity, all of which add to quality of life. Thus companionship may be important in fostering positive mental health on a day to day basis, whereas social support may be of particular value in buffering threats to mental health and wellbeing from real or perceived stressors. Figure 2 illustrates the inter-relationship between functions served by pet ownership and human health outcomes.15
View larger version:In a new windowDownload as PowerPoint SlideFig 2 
Correlations between questionnaire items measuring social facilitation, affectionate relationship, social support, and recipients' self perceived health in study on non-task related benefits of a trained assistance dog to people with physical disabilities. Correlations, derived from carrying out Pearson's correlation, are significant at P<0.05

Although research has primarily focused on human relationships as providing support and companionship, it is a short step to extrapolating these to pets. Studies have shown that the support from pets may mirror some of the elements of human relationships known to contribute to health.17 Although support from pets should not be regarded as a replacement for help from people, the fact that pets are not human confers certain advantages; the relationships are less subject to provider burnout or to fluctuations, and they do not impose a strain or cause concern about continuing stability. Relationships with pets seem to be of value in the early stages of bereavementw2 and after treatment for breast cancer.w3

Most pets are valued family members
Credit: BARRY LEWIS/NETWORK PHOTOGRAPHERS

Why pet ownership should be taken seriously
The question of whether a person should acquire a pet or continue to own a pet requires careful consideration of the balance between benefits and potential problems. About half of households in the United Kingdom own pets.w4 Most are valued as family members. Conflict between health interests and pet ownership can cause non-compliance with advice on health. Some sources estimate that up to 70% of pet owners would disregard advice to get rid of a pet owing to allergies,w5 whereas reports abound of older people avoiding medical care through fear of being admitted to hospital or residential care as this often means giving up a pet.w6

Summary points
Over 90% of pet owners regard their pet as a valued family member
Reluctance to part with a pet may lead to non-compliance with health advice
Pets may be of particular value to older people and patients recovering from major illness
The death of a pet may cause great distress to owners, especially when the pet has associations with a deceased spouse or former lifestyle
Many people would welcome advice and support to enable them to reconcile or manage pet ownership and health problems whenever possible

The loss of a pet may be particularly distressing for owners if it was linked with a deceased spouse or if it offered companionship or social contact with people.18 For these reasons many people may appreciate help and advice on how to manage a pet in the event of a health problem in the family.
Animal welfare organisations cite allergies and the fear of zoonoses as common reasons for people giving up their pets. Yet in some cases this may not be necessary. Research from the University of West Virginia shows that simple, day to day hygiene and pet care can reduce allergic reactions by up to 95%.3 A recent review of pets in nursing homes provides a comprehensive list of potential health problems and steps that can be taken to avoid these.19
People do not own pets specifically to enhance their health, rather they value the relationship and the contribution their pet makes to their quality of life.20 Greater understanding among health professionals is needed to assure people that they do not need to choose between pet ownership and compliance with health advice.
Footnotes
References w1 to w6 are on bmj.com

Contributors and sources JMcN has special research interests in the influence of pet ownership on health and lifestyle. She was formerly based at the University of Warwick. Her current work is with Dogs for the Disabled, the Society for the Protection of Animals Abroad, and Cats Protection, UK. She is a member of the Society of Companion Animal Studies. AG gained his doctorate from the University of Warwick, researching the role of pets in the alleviation of loneliness. AR and SA are members of the Society of Companion Animal Studies. J-AD has a degree in psychology and is director of the Society of Companion Animal Studies. EO is chairwoman of the Society of Companion Animal Studies. References refer to primary sources located through MIMAS web of knowledge service/web of science records. JMcN wrote the article, with contributions from the other authors, and is guarantor.

Competing interests JMcN received a research award, 2000-2, from Masterfoods UK to investigate the role of pets in children's health. AG was employed as a research assistant at University of Warwick, 1999-2003, funded by Waltham Centre for Animal Nutrition.References↵Friedmann E, Katcher AH, Lynch JJ, Thomas S. Animal companions and one year survival of patients after discharge from a coronary care unit. Public Health Rep 1980; 95: 30712.OpenUrlMedlineWeb of Science↵Headey B. Health benefits and health cost savings due to pets: preliminary estimates from an Australian national survey. Soc Indic Res 1998: 111.↵Ownby DR, Johnson CC, Peterson EL. Exposure to dogs and cats in the first year of life and risk of allergic sensitization at 6 to 7 years of age. JAMA 2002; 288: 96372.OpenUrlFREE Full Text↵Nafsted P, Magnus P, Gaader PI, Jaakola JJK. Exposure to pets and atopy-related diseases in the first 4 years of life. Allergy 2001; 56: 30712.OpenUrlCrossRefMedlineWeb of Science↵Anderson WP, Reid CM, Jennings GL. Pet ownership and risk factors for cardiovascular disease. Med J Aust 1992; 157: 298301.OpenUrlMedlineWeb of Science↵Raina P, Waltner-Toews D, Bonnett B, Woodward C, Abernathy T. Influence of companion animals on the physical and psychological health of older people: an analysis of a one-year longitudinal study. J Am Geriatr Soc 1999; 47: 3239.OpenUrlMedlineWeb of Science↵Simpson A, Custovic A. Pets and the development of allergic sensitiziation. Curr Allergy Asthma Rep 2005; 5: 21220.OpenUrlMedlineWeb of Science↵Frew AJ. Advances in environmental and occupational diseases 2004. J Allergy Clin Immunol 2005; 115: 1197202.OpenUrlCrossRefMedlineWeb of Science↵Behrens T, Maziak W, Weiland SK, Rzehak P, Siebert E, Keil U. Symptoms of asthma and the home environment. The ISAAC I and III cross-sectional surveys in Munster, Germany. Int Arch Allergy Immunol 2005; 137: 5361.OpenUrlCrossRefMedlineWeb of Science↵Parslow RA, Jorm AF. Pet ownership and risk factors for cardiovascular disease: another look. Med J Aust 2003; 179: 4668.OpenUrlMedlineWeb of Science↵Parslow RA, Jorm AF. The impact of pet ownership on health and health service use: results from a community samples of Australians aged 40 to 44 years. Anthrozoos 2003; 16: 4356.OpenUrl↵Parslow RA, Jorm AF, Christensen H, Rodgers B, Jacomb P. Pet ownership and health in older adults: findings from a survey of 2551 community based Australians aged 60–64. Gerontology 2005; 51: 407.OpenUrlCrossRefMedlineWeb of Science↵Dono J, Ormerod EMcNicholas J, Murray A. The benefits of pets for older people: a review. In: Dono J, Ormerod E, eds. Older people and pets: a comprehensive guide. Oxford: Society for Companion Animal Studies Publications, 2005.↵McNicholas J, Collis GM. Dogs as catalysts for social interactions: robustness of the effect. Br J Psychol 2000; 91: 6170.↵Lane DR, McNicholas J, Collis GM. Dogs for the disabled: benefits to recipients and welfare of the dog. Appl Anim Behav Sci 1998; 59: 4960.OpenUrlCrossRef↵House JS, Landis KR, Umberson D. Social relationships and health. Science 1988; 241: 5404.OpenUrlFREE Full Text↵Wilson C, Turner DCollis GM, McNicholas J. A theoretical basis for health benefits of pet ownership: attachment versus psychological support. In: Wilson C, Turner D, eds. Companion animals and human health. Thousand Oaks, CA: Sage, 1998: 10522.↵Robinson IMcNicholas J, Collis GM. The end of a relationship: coping with pet loss. In: Robinson I, ed. The Waltham book of human-companion animal interactions. Oxford: Pergamon Press, 1995: 12743.↵Guay DR. Pet-assisted therapy in the nursing home setting: potential for zoonosis. Am J Infect Control 2001; 29: 17886.OpenUrlCrossRefMedlineWeb of Science↵Podbercek AL, Paul ES, Serpell JA, eds. Companion animals and us. Cambridge: Cambridge University Press, 2000.

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British Medical Journal (Clinical research ed.)

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