The Pharmaceutical Journal
Vol 275 No 7363 p236
20 August 2005

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Send in the clowns more
Early arrivals in the New World detected more
Following the guidelines is not so simple more
Laugh and fall flat more

Send in the clowns

Any reference to clowns carries an undercurrent of contempt. Christopher Marlowe in his ‘Tamburlaine’ (1590) prologue remarks: “From jigging veins of rhyming mother wits / And such conceits as clownage keeps in pay / We’ll lead you to the stately tent of wars.” In our more enlightened times, of course, we cannot present wars as demonstrating any kind of stateliness, but clowns we retain in our midst, whether on a stage or in the House of Commons.

The word clown derives from Low German, and usually refers to a rustic, ill-bred person, a fool or a buffoon. It once had more sinister connotations, since circus and pantomime clowns are relics of the representation of the Devil in medieval miracle plays. By the 16th century a clown or cloyne was always a fool or jester. Modern usage implies something rustic or peasant — a sad reflection on the city dweller’s estimate of rural folk.

What is rather impressive, however, is the extent to which the adjective has entered into the vernacular names given to wild plants used in folk remedies. For example, we have clown’s all-heal (a species of woundwort), clown’s lungwort (a verbena), clown’s mustard (a candytuft), clown’s spikenard (an inula), clown’s treacle (a garlic) and plain clowns (a butterwort of Yorkshire). Throughout these plant names runs the assumption that to talk of clowns implies the simple remedies of lowly peasants. In its way it amounts to a slur on character which is quite unjustified.

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Early arrivals in the New World detected

There is an account in New Scientist for 9 July of a rather momentous discovery that has caused geoarchaeologists to reconsider the time when humans first made their appearance in Mexico.

An international team led by Silvia Gonzales of Liverpool John Moores University found a great number of footprints in a quarry floor near the city of Puebla, 100km south-east of Mexico City. They included both human and animal prints. Made along the shore of a lake, the footprints were submerged as the water level rose and preserved in a layer of ash from a nearby volcano. The size of the human prints indicates that about one third of them were made by children.

It is the dating of the prints that has aroused interest and some controversy. Shells in the surrounding lake sediments have been carbon-dated to some 38,000 years ago, an estimate supported by a luminescence study of sand grains baked into volcanic ash. Several other techniques have reinforced the conclusion that the footprints were made more than 38,000 years ago.

It has long been the conventional view that humans first arrived in the Americas by way of the Beringia land bridge from Siberia, about 11,000 years ago, and the recent findings are bound to stir controversy. Precisely how the settlers made their way into Mexico is speculative, but they may have moved along the Pacific coasts of Asia and North America.

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Following the guidelines is not so simple

A review article from two clinical pharmacologists from California, in the New England Journal of Medicine for 4 August, considers some of the problems that arise between patients and doctors when a course of drug treatment is agreed.

A health care provider draws up a prescription schedule, and it then remains for the patient to co-operate in seeing it through. The word “compliance”, which suggests that the patient is passive, has now been displaced in favour of “adherence” and “concordance”. The degree of adherence is typically higher in patients with acute as opposed to chronic ailments. In the latter situation adherence is disappointingly imperfect, and shows a dramatic weakening after the first six months of treatment. And the ability of physicians to detect non-adherence is poor. Interventions to overcome it tend to be difficult.

Both direct and indirect methods are used to check medication adherence. Direct methods involve direct observation of the patient, measurements of a drug or its metabolites in blood or urine or addition of a biological marker to the formulation. But such methods are expensive and burdensome. Indirect methods include asking the patient how medication is progressing, assessing clinical response, counting units consumed and frequency of repeating prescriptions and requiring a medication diary. It is recognised that questioning a patient regularly may bring false reports. Within an organisation, the rate of refilling prescriptions is accurate in assessing adherence.

Among patients with chronic illnesses about one sixth are calculated to conform closely, one sixth take nearly all doses but at irregular times, one sixth take holidays from treatment three or four times every year, one sixth take a monthly drug holiday and frequently miss doses and one sixth take few or no doses but pretend good adherence.

When a patient’s sickness does not appear to respond as it should, poor adherence should be suspected and tactful questioning undertaken. Patients should also be asked about possible side effects of drugs and whether they know why they are being prescribed. Poor adherence is prompted when prescribing regimens are complex and when the patient’s lifestyle is not being considered. Proper patient education and improved communications between doctor and patient offer a way of encouraging better adherence to medication systems.

Treatment of young children calls for close co-operation with the parent or caregiver. Adolescents may cause problems as they contend with psychosocial or lifestyle changes. In paediatric patients some form of motivation involving a reward of some kind may help in the process of ensuring medication.

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Laugh and fall flat

An interesting case report appears in The Lancet for 30 July. A man aged 63 was investigated when he related a 20-year history of syncope following a burst of intense laughter. He claimed to have fainted 10 times during that period, and had sometimes thought that he was on the point of fainting. He was suffering from well-controlled type-2 diabetes mellitus but no other condition.

According to his wife he sometimes laughed heartily when sitting at mealtimes and became momentarily unconscious and bent over the table, but recovered spontaneously and completely after a few seconds. He did not suffer bowel or bladder incontinence.

He learnt to control his laughter and so overcome temporary blurred vision and light-headedness.

When tested by the Valsalva manoeuvre he showed an inability of his autonomic nervous system to increase heart rate and peripheral vasoconstriction to maintain his blood pressure. This reaction frequently occurs in everyday life as a result of coughing, defaecating or laughing loudly, and might be misdiagnosed as narcolepsy or cataplexy.

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