English in Medicine [1 ed.] 9789646874

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English in Medicine Authors: M. Rafatbakhsh,MA S. Sajjadi,PhD N. Shokrpour,PhD F. Seddigh,MA A. Amalsaleh,PhD G. Kamyab,PhD A. Mahboodi, PhD

Edited & Supervised by: N. Shokrpour,PhD

Publications of Shiraz University. of Medical Sciences .

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December 1952

Fig 3 Death and pollution levels in the fog ofDecember 1952. Part 1: Comprehension Exercises A. Using the information in the text, decide whether the following sentences are true or false . .. --1. Preventive medicine requires spending more money than curative

medicine. ----2. Personal factors are more important than place and time factors in illness. ----3 . Infant mortality is an important index of healthiness. ----4. Males are more susceptible to disease than females. ----5. In the U.S.A., the place factors are more influential than personal factors. ----6. Occupation affects health mentally and physically. ----7. 70% of the world's population are not given health services. •••• 8. The diseases of ageing population is prevalent throughout the ;orld. ----9. Scientists have identified most of the causes of lung cancer.

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----10. Epidemics of infectious diseases have been eradicated in most parts of the world.

B. Circle the letter next to the best answer. 1. In the epidemiological approach to medicine the final step would be finding out ----------- disease. A. a cure for B. the cause of C. the probable complications of D. the population suffering from 2. The last two sentences in paragraph 1 imply that -------------. A. "curative medicine" is more expensive than "preventive medicine" B. "preventive medicine" is not as effective as "curative medicine" C. the current view of"curative medicine" must be changed D. there would be no need for "curative medicine" if "preventive medicine" received more attention 3. In developed countries death rates are higher in -----------. A. adolescents B. young people C. old people D. children 4. The most usual index of healthiness in developing countries is the ---

A. budget spent on preventive medicine B. high level oflife standard C. mortality rates in late middle ages D. number of newborns surviving infantile period 5. One of the personal factors influencing whether or not people become ill-is -------A. sex B. social class C. ethnic group D. occupation

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6. Regarding disease, females are----------A. an inferior sex B. equally susceptible C. more liable D. more resistant 7. More death rates among the non-white is most likely attributable to their ----------. A. racial inferiority B. sex C. age D. environmental factors 8. In the comparison of mortality rates in different social classes two important factors are ----------. A. wealth and position B. age and health C. sex and race D. age and sex 9. The distribution of disease--------- in different countries A. varies B. is almost the same C. has risen D. is falling 10. Death and pollution levels in the fog of December 1952 in Britain is an example of ---------. A. high mortality due to chronic ftlnesses B. long-term variation in disease patterns C. non-standard safety measures in Britain D. non- infectious disease

Part II: Language Practice A. Choose the correct word form to fit into each sentence. I. infect A. The ward was full of children ---------- with TB.

B. After the operation the wound became------------. C. Flu is highly -----------. D. PeoP.le in the third world are more exposed to-----------.

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E. The policies and procedures of a hospital or other health facility to minimize the risk of nosocomial or community-acquired ------------spreading to patients or members of the staff is referred to as ----------control. 2. occur A. Infectious diseases--------- most frequently in poor countries.

B. The researchers are investigating the---------- of AIDS in different races. 3. infirm

A. The ----------- are people who are ill for long periods. B. Deafness and failing eyesight are among the------------ of old age.

C. State-run residential facilities for those who become elderly or------to remain independent are few. 4. characteristic A. A chronic, habitual, maladaptive, and socially unacceptable pattern of behavior and emotional response is known as------------- disorder.

B. What---------- distinguish these ·races from each other?

C. What is AIDS--------------- by? D. The creamy richness is---------- of the cheese from this region. 5. impair A. A recurring knee injury may have ------------ his chances of winning

the tournament. B. Lack of oxygen at birth can result in mental----------. C. How many people suffer from ---------- vision or hearing in our country?

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B. Using the words given, fill in the following blanks. a. positive c. merely e. criticized g. preamble i. idealistic

b. nevertheless d. strengths f. definition h. static j. include

Health is more difficult to define than is disease. Perhaps the bestknown ----1----- of health comes from the -----2----- to the constitution of the World Health Organization: "Health is a state of complete physical, mental, and social well-being and not ----3---- the absence of disease or infirmity." This definition has the ----4---- of recognizing that any meaningful concept of health must ----5---- all the dimensions of human life and that such a definition must be ----6---(i.e., "not merely the absence of disease or infirmity"). ----7----, the definition has been -·-8--- for two weaknesses. It is too ---9----- in its expectations for complete well-being, and it is too ----10---- in viewing h_ealth as a state rather than as a dynamic process that requires constant effort and activity to maintain.

1.------

6.------

2.-----7.------

3.------

4.------

5.------

8.------

9.------

10.--:---

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Unit2

,ackground of Section One: Reading Comprehension

Medicine in an Unjust World

Four and a Half Billion Patients in the Practice 1. The doctors of today have 4.6 billion people in their care. The practice has doubled in the past 30 years, and will double again even faster, unless there is some colossal famine or disaster. Of the nearly two billion more people to be cared for by the end of the century, about 1. 5 billion will be citizens of the developing world. The poorest 30 per cent of the practice are the low income countries whose per capita gross national product (GNP) amounts to $300 or less. They are mostly in Asia and Africa and include India, Bangladesh, Pakistan, Zaire, and Tanzania. Next come the middle income countries with a little less than half the world's population and a per capita GNP of between $300 and $3000. They include China, Nigeria, and most of Latin America. The richest countries, with a per capita GNP of over $3000, form about a quarter of the world's population. They include the industrial countries belonging to the OECD (USA, Japan, Scandinavia, and most of the countries of Europe), the centrally planned economies, such as the USSR, and the capital surplus oil exporters of the Middle East. 2. Places in the GNP league are changing. The newly developing countries such as Taiwan, South Korea, and Singapore, for example, are rapidly lifting themselves out of poverty. Some, such as the United Kingdom, whose place has fallen to 24th in the league are rapidly becoming the post-industrial "new poor".

3. The injustice of the world is such that three-quarters of the world's patients live on only a fifth of its income. About 800 million people are desperately poor, and, as Fig. 1 shows, 11).0St ofthern are likely to remain so. A recent World Bank report con.,cJuded that, even if optirl)istic rates of economic growth are achieved in the developing world, there will still be 600 million people trapped in absolut~povert~ in the year 2000. This the Bank defines as a condition of life so

(24) characterized by malnutrition, illiteracy, disease, high infant mortality, and low life expectancy as to be beneath any reasonable definition of human decency. Somehow these 600 million patients have to be cared for . 12 0 0 0 - - - - - - - - - - - - - - - - - - ,

J !,.. 8000

10000

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l eooo j

t

4000

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Low income countries

::> 2

1960

1965

1970

1975

1980

1985

1990

Fig 1 Projected trends in per capita GNP (Reported from.fig 4, World Development Report, 1979) Half the Practice are Villagers 4. Picture the village of Tubuan in the Philippines whose 550 people live in 94 houses hidden in a coconut grove and surrounded by paddy fields . At present, more·than a billion people live in villages like this, and if you include China it is almost two billion, or nearly half the people in the world. But the picture is changing. The cities of the developing countries are now growing even faster than their total population, with the result that the biggest of them are likely to exceed 30 million people by the end of this century. Providing these gigantic urban slums with health care promises to be hardly less difficult than caring for the villagers.

5. At present, in most developing countries three-quarters of the people still live in villages. Yet, despite this, three-quarters of the health expenditure is usually in towns. In the Indian state of Maharashtra, for example, although $1. 60 per person per year is spent on health, ·only 2 cents are spent on the villagers, and 80 per cent of the total sum is spent in only three cities. As the result of such patterns of

(25) expenditure, over half of the people in villages and urban slums have no access to organized health services, nor are they likely to get them in the near future . Yet, despite the poor conditions of the present urban slums, the people who live in them are usually better off than the villagers, their infant mortality is lower, they are richer, they have cleaner water and better sanitation, they are more likely to go to school, and they have more personal health services. The situation is thus the reverse of that in England during the industrial revolution, when health was better in the villages. · Trade, Aid, Arms, and Energy 6. The health of the absolute poor can only be improved by relieving their poverty. This requires much more international trade for the benefit of everyone, the investment of more private capital in the developing world, and better domestic development strategies designed specially to reduce absolute poverty. Although just what these strategies should be, under particular circumstances, is far from being fully understood, much can be done, and much more must be done.

7. As evidence of our priorities, there can be no greater indictment of our generation than to compare the resources we devote to arms with those we spend on helping the poor Global defence expenditures have now grown so large that it is difficult to grasp their full dimensions . The overall total is now $450 billion each year, or about a million dollars a minute. The world's military expenditure of only half a day could finance WHO's entire malaria eradication programme. A modern tank costing about $1 million could provide 1000 classrooms for 30,000 children. A jet fighter for $20 million is the equivalent of 40,000 village pharmacies. A single Trident submarine costs more than the entire overseas aid expenditure of all the churches of North America, and there are presently 13 more on order. Public expenditure on weapons research approaches $30 billion a year and occupies half a million scientists and engineers throughout the world. This is a greater research effort than on anything else on Earth, and is more than that on the problems of energy, health, education, and food combined. Only about $20 billion is spent annually on development aid, and even this declined as a percentage of the combified GNP of the donors from 0.52 in 1960 to 0.31 percent in 1977.

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Of the $ 75 billion spent every year on health care in the developing world, only about 0.5 per cent comes as aid from the richer countries .

•

Enlarged 0. 75 times Nuclear arsenals. If the small circle {radius 1. 4mm) represe11ted all the explosives used in the second world war, the larger circle would represent the size ofpresent day nuclear arsenals. From the Effects of Nuclear War on Health Services. WHO 1984 Fig 1. 8. Few things are going to have greater influence on what can or cannot be done for the sick than their access to energy. Every time the price of oil · rises by $1 per barrel, the non-oil producing developing countries have to find an extra $2 billion a year to pay for their oil imports. Part of this section was written in Tanzania, 40 per cent of whose foreign exchange is now required to buy its meagre supply of oil. Where there is no foreign exchange left for health care, there are no drugs, no X-ray films, no surgical sutures, and no spares. For lack of fuel, supplies cannot reach distant hospitals and dispensaries, electricity cannot be generated, nor can water be pumped to enable a surgeon to wash his hands. Mostly for the lack of fuel to cook with, the forests of the developing world are being cleared at the rate of 50 acres a minute, with the result that it will be as treebare as the Middle East in two generations, with all the ecological implications that this will have for health. Land which could grow food is increasingly being used to produce tea, coffee, or motor fuel.

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Part I. Reading Comprehension A. Using the information in the text, decide whether the followi11g sentences are true or false.

-----1. Per capita GNP has a positive correlation with health care practice. -----2. More than 3/4 of the world population increase in 2000 will be in developing countries. -----3. Latin American countries are among the poorest countries. -----4. Places in the GNP league vary according to the development of countries. -----5 . 24 countries had more GNP than the United Kingdom when this article was written. -----6. One fourth of the world population consumes four fifth of the world's income. -----7. According to fig 1. low income countries are improving their condition compared to the past. -----8. There has been no considerable change of GNP in middle income countries between 1960 and 1980. -----9. The writer is criticizing poor countries because of their inability to improve health care. ----10. In developing countries health care is poorer in cities than in villages. ----11 . In most developing countries the urban population exceeds the rural population. ----12. In today's world more budget is devoted to destrnctive weapons than health care. B. Circle the letter next to the best answer.

1. According to the first paragraph, the world population will be about ----------- billion in 2000. A. 4.6 B. 8 C. 6 D. 6.5 2. Practice in line 5 of paragraph 1 refers to---------- . A. health care B. low income D. GNP in poor countries C. work in the developing world

..

(28) 3. GNP in Saudi Arabia and Kuwait is ----------. A. less than$ 300 B. between$ 300 and$ 3000 C. almost $ 3000 D. more than $ 3000 4. Its (in paragraph 3 line 2) refers to -----------. A. patient's B. world's C. people's

D . income's

5. Figure 1 shows that per capita GNP in poor countries has -------whereas it has ------in developed countries. A. risen/ fallen B. changed / remained constant C. fallen/ risen D. remained constant/ gone up 6. This (paragraph 3 line 7) refers to the---------- sentence in the same paragraph. A. first B. second C. third D. fourth 7. Malnutrition, illiteracy, disease, etc. ( paragraph 3) are said to be ---A. inevitable

B. irrelevant

C. sparse

D . provisional

8. According to paragraph 4 the population of a city like Tehran may amount to------ in 2000. A. one billion B. 30 million C. half of its present population D. the population ofNew York 9. All of the following are found in slums except ---------. A. poor health care B. overcrowdedness C. low population D. inadequate housing 10. Yet in paragraph 5 line (2) has all of the following meanings EXCEPT: A. up to now B. nevertheless C. however D . but

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11. Paragraph 5 is mostly about --------- . A. high level of life standards in towns. B. why villagers are usually poorer than people in the cities. C. more health care and health services in the cities. D. why many villagers migrate to the cities. 12. The author in paragraph 6 discusses some ---------- poverty. A. obstacles in B. remedies to

C. disadvantages of

D. consequences of

13. The writer is mostly critical of---------- countries. A. industrialized B. low-income C. overpopulated D. developing 14. According to paragraph 8, it seems that ------------ and health care

have a close link. A. overcrowdedness C. education

B. population D. access to energy

Part II: Language Practice

A. Circle the letter next to the best answer. 1. Is it probable to ---------- all infectious diseases in the world some day? A. modify B. elevate C. aggregate D. eradicate 2. It is beneath human ---------- to live in dirty slums. A. decency B. appropriateness C. precision D. significance 3. In spite of public sanitation, life expectancy has --------- in some poor countries. A. declined B. risen C. improved D. lengthened 4. All countries should cooperate to------- health care in the world. A. minimize B. remove C. promote D. internalize

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5. The doctor advised the patient to keep his ----------- of energy as low as possible if he wants to recover more quickly. A. exploitation B. expenditure C. perseverance D. utilization

6. Taking such drugs may have some adverse effects and may not---------- your pam. A. aggravate B. retain C. reliev.e D . sustain 7. Many women feel they cannot apply for the top jobs because of------- commitments. A. illegal B. sequential C. domestic D. ethical 8. The doctors could not -------- his trouble because there were no symptoms. A. compensate for B. account for D. provoke C. protect 9. It's a bit --------- to think all kinds of disease can be cured in the near future. B. problematic A. optimistic D. conservative C. honorable 10. His chronic illness is a heavy--------- for him to bear. A. burden B. labor C. responsibility D. label 11 . WHO was very surprised by the --------- of malaria in that rich country. B. prevention C. prevalence D. eradication A. interruption 12. He is suffering from a------------- illness and may die very soon. 8. curable C. mild D. desperate A. vital 13 . Shweitzer was a man of --------- goodness. His great help to Africans is never forgotten. C. eminent D. ordinary A. trivial B. endurable

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14. Developing countries are trying to -------- themselves out of poverty. A. leave B. lift C. pick D. raise

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Section Two Further Reading The Health of the World 1. Despite what has just been said about the present prevalence of

absolute poverty and the slow pace of development, both the health and the wealth of mankind are better than they were. Even in the developing world, the health conditions of many communities have improved considerably in recent decades. Since this has usually been accompanied by economic progress, there is now a marked association between the per capita income of a developing country and the state of its health. The best measure of this is life expectancy at selected ages. For the developing countries as a whole, life expectancy at birth increased from about 32 years before the Second World War, to about 49 years in the 1960s, compared with about 70 years for the industrial world. Unfortunately, the rate of improvement in the developing world is declining. These are moreover averages, and disguise the much lower expectations of the poor within a country. 2. Figure I shows the overall differences in patterns of disease between a typical developing country with a life expectancy at birth of only 40 years, and a young population, nearly half of whom are under 15 years, and an industrial country, with an older population, nearly half of whom are over 40 years. A developing country has about four times as many deaths from infectious, parasitic, and respiratory diseases, only a quarter as many deaths from cancer, and only about half as many from cardiovascular disease or trauma. Developing Country Cancer 4% Disease of the circulation 15%

infections,parasitic and · diseases 41 %

... ---

Ii;¾

- -,, .-

,,

1'~~%

Trauma 3% All other causes 34%

,,,,.

! 7% I 35%

Industrial Country

Fig 1 Causes of death in a model developing country and a model industriai country. (From Table 3, Health Sector Policy Paper, 1975, World Bank, Washington.)

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The Burden of Preventable Disease 3. In the world as a whole, the mere numbers of the sick with preventable diseases soon overwhelm us by their magnitude. 4. Fifty million people were living in England and Wales in 1975 and 600,000 of them died. Half of them did so from diseases ofthe cardiovascular system, with cancer and respiratory diseases killing most of the rest. Of these deaths, over 10 per cent, and perhaps as many as 100,000 were due to smoking. In spite of this, nearly half the population of Britain, including one doctor in five, still smokes. If only it were possible to control tobacco, 40-50 per cent of all cancer deaths in males would be prevented. Although the tobacco companies are doing their utmost to promote the sale of cigarettes in the developing wotld, their major effect on mortality here has yet to come. 5. In spite of the "green revolution" more people are hungry, even starving, than at any time in the past. A billion people are said to be malnourished, and 400 million on the brink of starvation. The mortality rate of children between one and five years which is perhaps the best indicator of nutrition, is l O to 40 times higher in parts of Asia, Africa, and Latin America, than it is in Europe or the United States. 6. Human faeces transmit some of the most important diseas~s of the developing world, particularly the diarrhoeas of childhood, but also ' poliomyelitis, typhoid, cholera, and the worms of the gut. These and the airborne respiratory infections are the main cause of death in poor communities. Both the prevalence and severity of most of them are increased by malnutrition. In the developed world economic progress has fortunately controlled them by providing enough food, clean water, safe sanitation, and decent houses. 7. In 1975 there were about 500 million episodes of diarrhoea in the children of Asia, Africa, and Latin America, causing 5-18 million deaths, a situation comparable to that in the industrial world at the end of the last century. It is fortunate, therefore, that one of the great recent advances has been the use of oral rehydration fluids by simply trained workers. These can reduce the case mortality of even severe cases o'f dehydrating diarrhoea to less than 1 per cent A major task now is to see that all the world's children benefit from them.

(34) 8. About a billion people have worms. Studies in Sri Lanka, Bangladesh, and Venezuela found that over 90 per cent of six-year-old children were infected. About 700 million people are said to have hookworms and probably even more have Ascaris. The airborne infections include pneumonia, bronchitis, whooping cough, measles, influenza, diphtheria, meningitis, and tuberculosis. One study in Latin America found that, between them, these diseases accounted for betwe~n 20 and 30 per cent of all deaths. There are at least 7 million cases of infectious tuberculosis in the world, more than three-quarters of them in the developing countries. Although diagnosis is usually easy, and the drugs both effective and cheap, there are more than 3.5 million new infectious cases each year, and more than half a million people die.

9.

10. At a conservative estimate there are 10 million leprosy patients in the world. 11. In sub-Saharan Africa alone, about 270 million people remain exposed to malaria without any organized protection, with the result that it kills nearly a million children each year. Over the past five years the total number of cases in the world has doubled, and in some countries it has increased 40 times. As the result of air travel there is now more malaria in Europe than there was when the global eradication programme began. , 12. Once a community has overcome malnutrition and the infectious diseases, the "backward child" is one of its next urgent problems. There are at least 80-100 million mentally handicapped people in the world, most of whom could lead happy and socially useful lives. if only they received adequate care, support, and education, particularly during childhood. Much of this handicap is preventable by better perinatal care, and even such an eminently preventable disease as iodine embryopathy is still endemic in some areas. 13. Since the distribution of health manpower tends to follow that of money, it will merely be observed that in 1976 the doctor to population ratio ranged from I :84,000 in Ethiopia to l :410 in Israel. For the low income countries overall it is l: l O 300, and for the indusuial ones

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1:630. For nursing staff the ratios are even less favourable. Thus the low income countries have 16 times fewer doctors per head than the industrial ones, but 46 times fewer "nursing persons" with all that this means for the care of the sick. The inequality with which health staff are distributed within developing countries is no less serious. Thus about three-quarters of the doctors are in the cities where only a quarter of the people live. Part 1: Comprehension Exercises

A. Using the information in the text, decide whether the following sentences are true or false.

-- . J. The per capita income of a country is an indication of its state of health. ----2. The life expectancy is about 70 years in developed countries. ----3. Cancer causes fewer deaths than infectious diseases in developing countries. · --- 4. The number of sick people suffering from preventable diseases is decreasing. ···- 5. Cardiovascular diseases take more deaths than other diseases in most developed countries. -- -- 6. The "green revolution" has contributed to the reduction of hungry people. ----7. Malnutrition accelerates the transmission of many diseases. ~---8. All of the children of the world have now access to rehydration fluids. --· -9. Overcoming malnutrition and infectious diseases removes almost all of the problems of the children in developing countries. -· · - 10. The unequal distribution of health staff is one of the problems in the world. B. Circle the letter next to the best answer. 1. According to the first paragraph the world has witnessed ------------A. improvement in wealth but not in health B. improvement in both wealth and health ··c. degeneration in health but not in wealth D. degeneration in both health and wealth

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2. since (paragraph 1 line 5) means: A. up to now C. because

B. until D . but

3. This (paragraph 1 line 5) refers to: A. the pace of economic development throughout the world B. health improvement in the world C. health improvement in the developing world D. the pace of economic development in the developing world 4. This (paragraph 1 line 7) refers to: A. association C. a developing country

B. per capita income D. state of health

5. After the 1960's the life expectancy has ----------- in the third world . A. increased B. remained constant C. doubled D . reduced 6. The number of old people in proportion to the whole population is ------- in the developing countries as compared to the developed countries. A. smaller B. almost the same C. rising D. greater 7. The number of deaths from infectkms, parasitic and respiratory diseases in industrial countries is ----------that in the developing world . A. 4 times as many as B. a quarter of C. half of D. 2 times as many as 8. In the developed world people die more from -----------. A. infections, parasitic and respiratory diseases B. different kinds of cancer C. diseases of the circulation D. different kinds of trauma 9. Paragraph 4 is mostly about the problems produced by---------A. ,cancer B.cardiovascular diseases C. smoking D. respiratory diseases

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10. The topic of paragraph 5 is-----------. A. the shortage of food in some parts of the world B. the results of the "green revolution" C. the achievements of the "green revolution" in some parts of the world D. the causes of malnutrition in Asia, Afiica and Latin America 11. Paragraph 6 argues that the main cause of death in poor communities is ---------. A. diarrhoea B. human faeces C. cholera D. infections 12. The topic of paragraph 7 is the ----------- of diarrhoea. A. treatment B. mortality C. prevention D. both a and b 13. Next to the infections and malnutrition in the third world is the problem of-------. A. worms B. tuberculosis D. backwardness C. malaria 14. Health manpower is more where-----------. A. people are poorer B. there is more wealth C. more people need it D. more cases are found Part II: Language Practice

A. Choose the correct word f om, to fit into each sentence. 1. prevent A. Test tubes containing different materials must be labeled to --

-------- confusion. B. Many doctors believe that.cigarette smoking is the most-------------- cause of heart attacks.

e. This organization is committed to AIDS ----------------- and education.

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D. --------------actions are intended to stop something before it happens. 2. starve A. If the famine continues, there is a real danger of mass -------. B. Many children in the world are neglected and----------. C. Many people---------- to death during the long drought. D. A------------ diet is the very small amount of food eaten by a person who wishes to lose weight quickly. 3. mortal A. AIDS is a --------- threat to human beings. B. ------------ is the number of deaths within a particular society and within a particular period of time. C. He was---------------- wounded in the accident. 4. advance A. We have ----------- greatly in our knowledge of the universe. B. Recent ---------- in medical science have stopped the spread of many infectious diseases. C. The student was advised not to take that------------- course. D. All most people are interested in is the---------- of their own career. E. If you want to start mountain climbing; consult a physician in

5. distribute A...The ------------ of cancer cases across the world is not at all even.

(39) B. The world's wealth is not fairly------------------- among the countries. B. Using the words given in the list, fill in the following blanks.

a. disease c. reduced e. whereas g. where i. controlled k. disposed

b. technique d. tend to f. doubles h. head j . alternating

Health promotion applies both to noninfectious diseases and to infectious diseases. Infectious diseases are ---1---- in frequency and seriousness ---2--- the water is pure, liquid and solid wastes are ---3--of in a sanitary manner, and arthropod and animal vectors of disease are ---4---. Crowding promotes the spread of infectious diseases, ---5--adequate housing and working environments ---6--- minimize the spread of ---7--. In the barracks of soldiers, .,for example, even a ----8-----as simple as requiring some soldiers to sleep with their pillows at the ---9--- of the bed and others to sleep with their pillows at the foot of the bed, in an ---10--- pattern, can reduce the spread of respiratory diseases because it ---11--- the distance between noses during sleeping time. 1.-----6.----11 .-----

2.------

3.------

4.------

7 .------

8.------

9.------

5.-----10.-----

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Unit 3 Section One: Reading Comprehension

Malnutrition of Affluent Societies

Overnutrition Ovemutrition in the sense of excessive energy (calorie or joule) intake is virtually universal in affluent societies. Few retain their youthful slimness and many spend their lives struggling to control their weight. Those who fail are not necessarily big eaters. They may simply have "thrifty" metabolism, that is they are efficient at utilising dietary energy and at storing any surplus as fat. This would have survival value in times of food shortage, but renders them susceptible to the high energy value of modem, processed foods.

I.

2. A consistently high energy intake leads not only to obesity but also to faster growth, earlier puberty, greater fertility and earlier aging. Ovemutrition disturbs metabolism in many ways. Synthesis of cholesterol as well as of triglycerides is increased, and levels of lipids rise in the blood and bile. Insulin secretion is increased, but insulin resistance develops so that glucose tolerance is impaired . Uric acid levels in the blood increase, ,and blood pressure rises. All these changes are reversible. Unfortunately, the tendency to develop some malignant neoplasms is also increased.

Obesity Definition 3. The excess storage of fat is surpassingly difficult to define and to measure accurately. In practice, an experienced eye is a good judge of the presence of obesity especially in the unclothed patient. To measure it one requires data on weight and height. Life insurance companies have published tables showing the desirable or ideal weights of men and women of different heights, that is the weights associated with the best life expectancy. A person with a body weight of IO per cent greater than this ideal is said to have a relative weight of 110 per cent. Obesity can be defined arbitrarily as a relative weight greater than 110 per cent: some say 120 per cent. Various obesity indices

(42) have been invented, the best being W/H2, where Wis the weight in kg and H is the height in metres. Epidemiology

4. Prevalence of obesity increases with age but the very old are not often obese because most of their fat contemporaries have already died. There is a well - marked familial tendency. The sex and social class distribution of obesity vary in different countries and at different times.In Britain today obesity is commoner in the lower socioeconomic classes. 1n developing countries it is a disease of the upper classes. Aetiolo~ical Factors

Aetiological factors in obesity Genetic susceptibility {" thrifty trait") Physical inactivity Social pressures (or lack) Sweetness 'addiction' Failure to breast feed Eating for emotional reasons

Refined carbohydrates (high energy, low satiety food) Carbohydrate drinks Invisible, added fat in prepared foods Constant availability of palatable, convenient food

5. Their relative importance is controversial. Contrary to popular belief, most overweight people eat no more than average (though of course they have taken in more calories than they need). This emphasises the importance of individual susceptibility. Ovemutrition often begins in infancy with the use of overconcentrated milk formulae laced with sugar and with too early introduction of solid foods especially cereals. A taste for sweet, refined foods is encouraged through childhood, and may be set for life. Poorer people eat more refined foods and less fresh ones than those who are better off. Physical exercise contributes relatively little to overall energy output. Despite its popular acceptance, the theory that lack of exercise causes obesity lacks evidence. Psychosocial factors can be important - in different cultures and in different levels of society,. obesity is admired, tolerated, shunned or feared. Mass circulation magazines are very influential in determining women's figures. In pregnancy, a woman becomes fatter in physiological preparation for the demands of breast feeding. She may fail to recover her non-pregnant figure if she feeds her baby ~ificially.

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6. Very few cases of obesity are due to endocrine disease. Endocrine causes include hypothyroidism, Cushing's syndrome and, in men, feminising syndromes.

Associated Disease 7. Obesity contributes to and aggravates many of the major diseases of atlluent, western societies. Most cases of diabetes (Type 2, or the non-insulin dependent variety) are related to obesity, as are many cases of gallstones. Hypertension and hyperlipidaemia are commoner in the obese, which helps to explain why fat people are excessively prone to ischaemic heart disease and cerebrovascular disease. Increased risk of ..... .............. suicide Strokes

Respiratory failures ·- · ......:::.·::::.- Corona~ artery disease Hypertension

Varicose veins .... .. Th'romboembolism

.. ctumsiness, hence . increased susceptibility to accidents

Fig 1 Disorders associated with obesity.

(44)

These diseases are the main reason for the shorter life expectancy of the obese. A man who reaches his 50th birthday carrying 251b ( 11.3kg) of excess fat has 25 per cent less life ahead of him than if he were slim. The obese are also more prone to develop cancer, especially cancer of the breast, uterus and colon. Surgical operations are more difficult and more hazardous, with increased risk of venous thromboembolism and respiratory infections. The locomotor system also suffers, with increased osteoarthritis, especially of hips and knees, and gout. The obese move slowly and clumsily and are accident-prone. Gross or morbid obesity hinders respiratory movement and can lead to ventilatory insufficiency. Finally, there are psychological problems. Fat people cannot dress smartly or fashionably. They are often depressed by their deformity and are afraid to go out.

Part I: Comprehension Exercises A. Using the information in the text, decide whether the following senlenc:es are /rue or false. ----1. Ovemutrition is a universal phenomenon. ----2. Few youth remain slim in affluent societies. ----3. In affluent societies a lot of people go on a diet. ----4. Modem processed foods have very little energy. ----5. Consistent consumption of foods rich in calorie is a factor in looking youthful. ----6. Obesity can be measured accurately with an experienced eye. especially in the unclothed patient. ----7. Obesity can be indexed in terms of the relations between weight and height. ----8. More people of the upper-class in developed countries are obese. ----9. The most important factor of obesity is over-eating. ----10. People from lower socioeconomic classes consume more processed foods. ----11. It is certain that physical exercise prevents ohesity. ----12. In some societies, fat people are praised. ----13. Breast feeding can contribute to reducing fat. ----14. Fat people go out more often than slim people.

(45)

B. Circle the letter next to the best answer. 1. Consistent consumption of high energy foods leads to all of the following EXCEPT: B. earlier puberty A. thrifty metabolism D. faster growth C. obesity 2. Which of the following is not reversible? A. Increase in uric acid levels. B. Development of malignant neoplasm. C. Increase in the synthesis of cholesterol. D. Impairment of glucose tolerance. 3. "Their" in the first line of paragraph 5 refers to : A. etiologic factors in obesity B. carbohydrate drinks C. popular beliefs D. the diseases of upper class people

•

4. By 'individual susceptibility' the writer means: A. more emphasis should be put on individuals who are susceptible. B. the relative importance of each of the factors depends on the individual. C. all individuals are susceptible to obesity . D. susceptible individuals are more obese. 5. Fewer cases of obesity are caused by-------. A. pregnancy B. refined foods C. endocrine diseases D. psychological factors 6. The best obesity index divides------------A. weight by height B. height by weight C. weight by height squared D. two times weight by height

(46)

7. An overweight person, most probably cannot be a good professional A weight lifter

B . wrestler

C. boxer

D. sprinter

8. The obese have a shorter life expectancy mainly because----------. A. they are afraid to go out. B. they move slowly and clumsily. C. surgical operations are more difficult and hazardous on them. D . they are excessively prone to ischaemic heart and

cerebrovascular diseases. 9. Life insurance companies base their ideal weights of men and women

on ---------. A actors and actresses B. athletes C. those who have reached very old age D. those who have a very healthy diet 10. Which

of the following topics is not discussed in this passage? A Socioeconomic consequences of prevalence of obesity in a society. B. Diseases associated with ovemutrition C. Factors involved in causing obesity D. Distribution of obesity among people in developed societies.

Part TI: Language Practice A. Circle the letter next to the best answer. Do this part after reading the second passage in this unit.

1. Some African tribes try to prevent ---------- by actions such as rites and prayers for the fertility of soil and animals. A ignorance B. addiction C. famine D. taboos 2. Obesity and overweight are strongly conditioned by available------food. A digestible B. palatable C. dirty D. staple

(47)

3 A kwashiorkor- state may develop even in ----------- societies. B. affluent C. deprived D. thrifty

A. tropical

In marasmus, anemia may be present but is usually-----------. A. mild B. severe C. hazardous D. endemic

4.

5. Most clinical and anatomic changes induced by protein-energy malnutrition are totally --------- with restoration of a normal diet, although there is still uncertainty about their long-term effects on physical growth or intellectual development. A. exacerbated B. adaptive C. reversible D. retained 6. Despite exhortations in advertisements, there is almost certainly no ------- that vitamin E supplementation in reasonably nourished individuals has any beneficial effect. A. evidence B. strife C. prejudice D. controversy 7. Primary deficiency of vitamin B6 is very rare in adults. However, secondary hypovitaminosis B6 may be -------- by the increased requirement for the nutrients during pregnancy and lactation. A. precipitated B. retarded C. aggregated D. complicated 8. Intestinal conjugases required for splitting polyglutamates into absorbable mono or diglutamates may be ---------- inactive by inhibitors found in beans and other legumes.' A. proved B. rendered C. trained D. developed 9. A remarkable feature of adiposity is its ----------. Small increases in adiposity occur regularly with age. A. constancy B. distribution C. repletion D. deformity 10. Psychosocial consequences of obesity are very damaging. Selfesteem and body image are----------. A. recovered B. retained C. admired D. impaired 11 . Protein malnutrition occurs whenever ---------- protein is taken to meet an individual's nutritional requirements. A. inadequate B. excessive C. surplus D. available

(48)

12. Most individuals can -------- a loss of up to 10 percent of body weight without any significant consequences. However, losses greater than 40 percent are almost always fatal. A. prevent B. tolerate C. incur D. demand 13. Of the 28 amino acids found in human proteins 20 can be manufactured within human cells, but 8 cannot. These essential amino acids must be provided in the ------A. crop B. diet C. gruel D. concentrates I 4. The energy stored in the different classes of food substances ------------, there being 4 Kcal per gram in protein, 4 Kcal per gram m carbohydrates, and 9 Kcal per gram in fats. A. circulates B. shrinks C. increases D. varies 15. When caloric intake from absorbed nutrients ------------ caloric expenditure, weight gain is the inescapable consequence. A. exceeds B. supplements C. substitutes D. involves 16. Vitamin C is rapidly and readily absorbed in the small intestine, and only extensive mucosal disease ----------- this process. A. leads to B. spares C. hinders D. worsens 17. In conditional malnutrition the body is unable to utilize the ingested nutrients, and a ----------- state results, despite the intake of adequate amounts and kinds of food. A. deficiency B. desirable C. reversible D. controversial 18. It is estimated that 400 million preschool children in developing nations ---------- from protein- energy malnutrition. A. resist B. demand C. attack D. suffer 19. When large doses of vitamin C are added to food, the amount of vitamin B 12 that can be assayed in it drops significantly. Thus. the current fad for ingestion of large doses of vitamin C may have highly ------- side effects. A. unde~irable B. apathetic C. reversible D. characteristic

(49)

20. The marasmic child is obviously ----------- with broomstick arms and legs from which the skin hangs pathetically loose. A. irritable

B. wasted

C. obese

D. hyperactive

21. Factors in the diet may interfere with absorption of trace elements, as was first noted among inhabitants of Egypt and Iran. ---------phylic acid and fiber were present in the diet to bind zinc and block absorption. A. Digestible B. Artificial

C. Invisible

D. St\fficient

22. Obesity is the result of the ------------ of calories in excess of utilization. A. intake

B. deficiency C. loss

D. tolerance

23. Regrettably, the world is now divided into "haves", constantly surrounded by an excess of food and often obese, and the "have nots", largely in third- world countries, who die by the thousands from -------

A. civil strife

B. drought

C. infantile marasmus

D. starvation

24. The most important physiological basis of therapy in diarrhoea is simply to --------- the fluid and electrolytes as rapidly as they are lost, mainly by giving the patient saline and glucose solutions. A. retain

B. reserve

C. reduce

D. replace

25 . Bums and sores sometimes---------- gangrene and amputation. A. recover from

B. draw on

C. lead to

D. associate with

..

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- - - - - --

-

-

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-···" ~

-

,,,-....,.

---

(50) Section Two : Further Reading Malnutrition in Poor Countries

Starvation 1. Crop failures and droughts still lead to famine in the poor countries of Africa and the East. Overpopulation, poverty and civil strife can all play a part.

When food supplies fail, the body draws on its energy reserves (Table l).These are mostly triglycerides in the adipose tissue. 2.

Table 1 Energy stores and rates of utilisation in a normal man . h'mg 65 k:g we1g (g)

Carbohvdrate

Fat Protein

rso

6 soo 2400

Available

store

MJ

Used daily (g)

Exhaustion time (days)

2.. 5 24S 40

~I used in first

ISO

Las than l 40

60

40

kcal 600 S8,SOO 9600

Healthy young men and women in the West are about 12 per cent and 26 per cent fat respectively, but many Bangladeshi for instance have much smaller fat stores. Once 25 per cent of body weight has been lost death is increasingly likely to occur, though survival of 50 per cent loss is possible. · 3. Wasting of all tissues occurs, except for the brain. The heart can shrink to half or even a third of its normal weight, and this can lead to irreversible cardiac failure. The small intestine can become paper thin and almost transparent. The resulting loss of absorptive function can negate the effects of re-feeding and prejudice recovery. Up to a point these changes may be considered adaptive. Together with reduced physical activity, they allow most efficient use of limited energy supplies. As further adaptation the brain learns to obtain energy from keto acids instead of the usually obligatory glucose, which reduces the need for gluconeogenesis and so spares protein breakdown in the liver. Famine oedema of the legs is very characteristic of starvation from any cause. It is probably due to loss of elasticity of the connective tissue more than to a fall in serum albumin. It is associated with nocturia.

(51)

4.0ther clinical features include dry skin with brown patches, peripheral cyanosis, slow pulse and hypotension. Loss of sexual powers and amenorrhoea are common, and the subject becomes irritable, egocentric and apathetic, even psychopathic. Infections of all kinds are common. Diarrhoea is a tenninal sign. 5. Treatment is simply the provision of food, but advanced cases may need to begin with easily digestible skimmed milk feeds.

/11fa11tile Marasmus 6. This is simply starvation of babies; It is usually caused by early weaning from breast milk on to fonnula feeds which, through ignorance, are too dilute and often dirty. Maternal deprivation can also cause it. The baby is wasted and weak and often has signs of vitamin deficiencies, anaemia and dehydration. Diarrhoea 1s common. This disease can overlap with kwashiorkor. Kwashiorkor (Protein-Energy Mal11utritio11) 7. On a world scale this disease must ~.ill more people than all other nutritional diseases put together. It is children who die -- 5 million every year - mainly in Africa, Latin America and the Far East. In the language of the Ga tribe of Ghana, Kwashiorkor means first - second. It is the sickness of a child displaced from the mother's breast because a n,ew baby is expected, and weaned on to gruel which is deficient in protein. It is a very common disease in tropical countries where the population lives on a staple food, such as plantains, cassava or maize, that provides enough energy as carbohydrate, but not enough protein for a growing child. Added factors are poverty, ignorance and taboos against giving milk, eggs, fish or meat to children. It begins usually between 9 months and 2 years and by presentation the child is often desperately ill. He is stunted, miserable or listless, and anorexic, and usually has diarrhoea (Fig l ). Oedema due to hypoalbuminaemia hides severe muscle wasting. The liver is grossly fatty. Virtually every organ,

(52)

~·

it ·············

,, .

-,,·/··:

to grow ·4······ Failure Unhappy, apathetic

······••· Sparse, thin hair Anemia

Smooth tongue ····· ·· angular stomatitis ......... Muscle wasting Skin peeling ......... Depigmentation or patchy pigmentation Watery diarrhoea Oedema

Fig 1 Kwashiorkor - the physical signs. tissue and biochemical process is abnormal, but all the changes are reversible. One possible exception is that mental development may be permanently retarded. Secondary infections are important because they increase the need for protein and so worsen the deficiency. Overt ill health is often precipitated by an attack of gastroenteritis, measles or pneumonia and may be exacerbated by endemic tropical diseases such as malaria, hookworm and roundworm. Severe cases are often complicated by vitamin and trace element deficiencies. The mortality of cases admitted to hospital varies from IO to 60 per cent. 8. Treatment of mild cases is simply provision of adequate food or the addition to the home diet of milk or milk substitutes. Diarrhoea from lactose intolerance may be a problem. Severe cases need electrolyte repletion before beginning small frequent feeds of milk or other protein sources. Many concentrates of vegetable protein are available, based on maize (com), peanuts, soya bean flour, etc. After recovery, the mother must be trained to supplemep! the family diet with a high protein vegetable such as beans. Prevention requires government action and involves education in good agriculture and good nutrition .

(53)

Part I: Comprehension Exercise

A. Using the information in the text, decide whether the following sentences are true or false.

----1. According to the first paragraph, war among people in poor brings about famine. countries possibly ----2. Triglycerides are the main energy reserves in the body. ----3 . Women in the West have more than two times fat compared to men. ----4. The small intestine may get thinner during starvation. ----5 . The small intestine absorbs more during starvation. ----6. Keto acids are the usual sources of energy for the brain. ----7. A fall in serum albumin is the major cause of famine edema. ----8. Infantile marasmus and kwashiorkor are the diseases of children older than two years. ----9. The treatment of severe cases of kwashiorkor can begin with small amount of milk or other protein sources. ---10. Famine brings about crop failure~ and droughts in the poor countries. B. Circle the letter next to the best answer.

1. Reading Table 1, we understand that in a man weighing 65 kg,-----. A. 150 grams carbohydrate is utilized daily. B. fat is utilized three times more than protein. C. all energy reserves are exhausted in less than one day. D. fat and protein reserves get exhausted sooner than carbohydrate reserves. 2. 'They' in paragraph 3 line 6 refers to: A. changes B. The heart and the small intestine. C. the effects of re-feeding and recovery. D. reduced physical activity.

(54)

3. In the last stage of starvation, the patient starts suffering from -------

A. hypotension C. peripheral cyanosis

B. diarrhoea D. amenorrhoea

4. Which of the following is not a feature of infantile Marasmus? A. nocturia B. anaemia C. diarrhea D. dehydration

5. 'It' in the last sentence of paragraph 3 refers to: A. B. C. D.

famine oedema of the legs loss of elasticity of the connective tissue fall in serum albumin nocturia

6. Which of the following is not mentioned as a factor in kwashiorkor'? A. early weaning on protein-deficient foods. B. living in tropical regions with hot and humid climate. C. living on a staple food low in protein. D. cultural superstitions. • 7. With regard to kwashiorkor, which of the following topics is talked least about? A. epidemiology of the disease. B. clinical manifestations of the disease. C. treatment of the disease. D. prevention of the disease.

8. This passage could be best described as -----------. A. distressing B. persuasive C. joyful

D. biased

Part II: Language Practice A. Choose the correct word form to fit into each sentence 1. provide A.Plants are _ _ _ _ _ of oxygen for man. B.The best explanation of what takes place is the _ _ _ _ _ _ of good examples. C. Animals _ _ _ _ _ us with meat we need.

(55)

2.concentrate A. A convex lens can be used to-------------- the sun s rays and thus burn a hole in a piece of paper. B. Lipids are an organism's most highly------------- source of energy. C. Diffusion is the movement of molecules from a region of higher---------------------- to a region of lower---------------------. 3. appear A. If you are travelling forwards in a train, surrounding objects outside --------------- to be moving backwards. B. The structure of cells as seen through an electron microscope is vastly more complicated than is ------------ through a light microscope. C. Cellular membranes are ----------------- fluid. D. Species are defined both in terms of------------ and mating behavior. 4.circulation A. An infant's blood --------------- changes at birth. B. When a stone is dropped into a smooth lake. the surface is covered with --------------- waves moving outwards from the center point. C. The lymphatic system conducts fluid that has leaked out of blood capillaries back into the ------------------ system. D. Malnutrition decreases the ability of the body to form----------------antibodies against certain bacterial and viral antigens. 5. diet A. A small calorie is defined as the amount of heat energy needed to raise the temperature of one gram of water one degree centigrade. The unit commonly used in physiology and --------------- is the calorie ( with a capital C ) or kilocalorie ( K Cal ), which equals 1000 calories. B. For optimal health, about 45 to 48 -------------- nutrients are thought to be essential. C. Primary malnutrition is caused by lack of a reasonably balanced-----

6. various A. There is now a large ---------------- of synthetic products.

(56)

B. A major problem confronting the preterm infant is the functional immaturity of-------- organs. C. Deformations are common problems affecting approximately 2% of newborn infants to -------------- degrees. D. The anatomic changes in cystic fibrosis are highly ------------ and depend on which glands are affected and on the severity of the environment. E. Different countries -------------- in the death rate from gastric carcinoma. F. The diseases and disorders causing malabsorption are both numerous and --------------- classified. G. Many species of animals exhibit geographical -------------- in external color as an adaptation to their environment 7. resistance A. Vitamin C is richly abundant in many food stuffs and is quite ---------

--------- to most methods of food processing. B. The amount of-------------- offered by a copper wire depends on its thickness. C. An amphibian's skin helps it ------------------ dehydration. 8. nutritional A. Nitrogenous compounds are available in the soil for the ------:----- of plants. B. Plasma is mostly water carrying dissolved inorganic ions, --------------------, waste products, and a number of proteins. C. An infant's initial -------------- needs can be entirely met by a healthy mother's breast milk. 9. disturb A. A nerve cell impulse is a wave of transitory electrochemical ------------------- that travels along an axon. B. Man's activities have ------------------- the balance of nature. 10. popular A. If the insidious effects of tobacco could have been predicted before it gained ------------, there is little doubt that its use would have been prohibited by law.

(57)

B. Soccer is a-------------- game in that country. 1I. occur A. Amoeboid movement is a. process of widespread ------------ that depends on the interaction of actin and myosin. B. Once fertilization--------------- an embryonic plant begins to grow.

B. Using the words given in the list, fill in the following blanks.

a. avitaminoses b. primary c. diet d. sufficient

e. threat f. origin g. starving h. plenty i. survive

j . sporadic k. endemic I. deprivation m. affluent

It is a sad commentary on our world when the effort to avoid or reduce caloric consumption preoccupies vast segments of some societies, less fortunate populations, mainly in developing countries, are dying for want of food. Indeed, over half the entire population of the world struggles to ---1---- on diets grossly inadequate in calories or proteins. This ----2---- exacts its heaviest toll from infants and children. Half of all deaths in these ---3---- populations occur in children unde.r 5 years of age, yieldi!}g infant mortality rates many times higher than those encountered in -----4--- countries. In addition to such gross malnutrition, specific deficiency states, such as the ----5--- , often accompany protein- ·energy malnutrition, but may also occur despite a ---6--- caloric intake. Nutritional disease in humans may be of primary dietary ----7--- or may result from secondary malnutrition. Primary malnutrition is caused by lack of a reasonably balanced ----8--- and is largely a socioeconomic problem that tends to be ---9---- in the underprivileged and war-torn societies of the earth. The malnutrition found in Africa, Asia, and central and South Africa, for example, is largely of ----10---- origin. In these regions of the world the precarious and marginal food supply, caused by drought and poverty, and the disruptions of war render starvation a daily ---11--- to survival. Secondary or conditioned

(58)

malnutrition is usually a ---12---- condition that arises in the midst of dietary ---13---. 1.-----6.------

7.------

3.-----8.------

11.-----

12.-----

13.-----

2.------

4.------

9.------

5.-----10.-----

(59)

Unit4 Section One:

Reading Comprehension

Agency Nurses and Violence in Psychiatric Wards 1. Violence is an ever-present hazard of working with the mentally ill, especially in hospitals. However, quantitative studies have concentrated on the characteristics of violent patients. the setting in which violence occurs, and the outcome of the violence. The investigation reported here was prompted by an increase in violent incidents on the acute admission ward of our psychiatric unit. We looked for characteristics of the ward population and of the staff that might be associated with this increase. 2. This retrospective study, of a 12-bed high-dependency ward in the psychiatric wing of a London teaching hospital, covered the 15 months January, 1986, to March, 1987. We recorded the number of incidents of physical violence noted by nurses, the type of violence (whether to self, staff, other patients, or property), and the number of untoward incidents not involving violence; bed occupancy and sex ratio; the number of admissions, both informal and compulsory; diagnoses; the average weekly nursing provision, including the number of permanent staff "units" (of 37 1/2 hours ) and agency staff units and the number of agency shifts worked; and medical staff provision. As in other studies violent incidents at night were rare so staffing data were collected for day shifts only. The number of violent incidents for each month was then correlated with the other factors, using Kendall's rank correlation. 3. Violence increased over the 15 months (figure) with no concomitant rise in non-violent incidents. The increase was distributed between all four categories of violent behaviour. Violence against staff (44 incidents) and other patients (24) ranged from blows with the fist to 1 case of rape. Incidents of self-harm comprised selfpoisoning (4), self-laceration (6), and attempts at hanging (4). Those against' property (20) consisted of destruction of furniture, fabric, or

(60) fittings and the setting of fires (5). The non-violent incidents were minor accidents. 4. Permanent nursing provision was halved during the last 12 months of the study whereas agency provision almost trebled, both in units and in numbers of shifts. There was a positive correlation between the number of violent incidents and both agency nursing provision (r=0.56) and number of agency shifts (r=0.63); and there was a negative correlation with permanent nursing provision (r= - 0.62). There were only small correlations between violence and total occupancy (r=0.22), percentage male occupancy (r=0.17}, total admissions (r=0.20), or compulsory admissions (r=0.01). The diagnostic distribution remained fairly stable with a consistent majority of schizophrenics. 5. Medical staff changeovers were in February and August and peak leave months were in January and June, and there is no obvious relation between these times and increases in violence (figure). 12

so 45

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20 15

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JfMAMJJASONOJ W16 1987

10

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Violence and Staffing Levels. Histogram shows numbers of violent incidents.x ---x = pe_rmanent nurse "units" (weekly average). o---o= agenc. nurse shifts.

(61) 6. The significance of time-series data is difficult to assess. Nonetheless, there is a significant positive correlation between the number of violent incidents and the proportion of agency staff (P