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The incidence of adverse drug reactions increases with aging, and the elderly are more likely to suffer serious or fatal reactions. Thus, morbidity and mortality are considerable in old patients, with 15% of those in hospital suffering a reaction, and many admitted as a consequence of one. The greater propensity of older patients for adverse drug reactions largely reflects the prescription of drugs to them, although over-the-counter purchases must also play a part. The elderly take more drugs per se (which is a reflection of multiple pathology), and more drugs with a narrow therapeutic index associated with a high risk of dangerous adverse reactions and drug interactions. They also have a reduced ability to withstand any reactions due to concomitant disease, and an altered pharmacokinetic and -dynamic response which tends to increase drug effects. The recommendation must be to use fewer drugs in older patients, perhaps trying alternative medicine first in nonacute conditions. Starting doses can often be reduced in the elderly, and clinical and therapeutic monitoring of effect is mandatory. The use of diuretics, antihypertensives, anti-Parkinsonian drugs and anticoagulants emphasise these points, and is discussed in detail together with digoxin, analgesics and nonsteroidal anti-inflammatory drugs. Clear guidelines are given for the use of each of these classes of drug.

The ATLAS Level-1 Calorimeter Trigger is one of the main elements of the first stage of event selection for the ATLAS experiment at the LHC. The input stage consists of a mixed analogue/digital component taking trigger sums from the ATLAS calorimeters. The trigger logic is performed in a digital, pipelined system with several stages of processing, largely based on FPGAs, which perform programmable algorithms in parallel with a fixed latency to process about 300 Gbyte/s of input data. The real-time output consists of counts of different types of physics objects and energy sums. The production of final modules started in 2006, and installation of these modules and the necessary infrastructure at ATLAS has been underway for some time, with the intention of having a full system in situ during 2007, before first collisions at the LHC. The first experiences of commissioning and running the full scale system will be presented, along with results from integration tests performed with the upstream calorimeters, and the downstream trigger and data flow systems.

The detector at CERN's large hadron collider (LHC) was exposed to proton-proton collisions from beams crossing at 40 MHz. A three-level trigger system will select potentially interesting events in order to reduce this rate to 100- 200 Hz. A trigger decision is made by the Level-1 central trigger processor (CTP) reducing the incoming rate to less than 100 kHz. The Level-1 decision is based on calorimeter information and hits in dedicated muon trigger detectors. The final Level-1 trigger system is currently being installed in the experiment with completion expected in autumn 2007. Cosmic ray data are regularly recorded as an increasing fraction of the trigger system comes online. We present an overview of the Level-1 trigger system architecture and report on the installation and commissioning process at the ATLAS experimental site. Emphasis is put on the integration of the CTP with the calorimeter and muon trigger systems. We show results from analyses of cosmic ray data recorded in situ and verify, where possible, that the Level-1 trigger meets the requirements and will be ready for data taking.

1. The effects of 4-6 weeks treatment with placebo, potassium chloride 32 mmol 12 hourly, and spironolactone 25 mg 12 hourly upon the plasma potassium concentration-time profile were examined in hypertensive patients taking bendrofluazide 5 mg daily. 2. When compared with placebo, potassium chloride increased peak plasma potassium concentration (P less than 0.05), 12 h AUC for plasma potassium (P less than 0.1), and 12 h urine potassium excretion (P = 0.002). Spironolactone increased peak plasma potassium concentration (P less than 0.05), and 12 h AUC for plasma potassium (P less than 0.05), compared with placebo values. 3. Potassium chloride and spironolactone did not differ significantly in any respect other than 12 h urine potassium excretion. The 12 h AUC for plasma potassium was 35% larger with spironolactone than potassium chloride (not significant). 4. With both active drugs peak plasma potassium was observed 2-3 h after dosing, and efficacy tended to wane towards 12 h. However, variability of plasma potassium within the dose interval was not increased markedly, and 12 hourly dosing is probably satisfactory for both potassium chloride and spironolactone at the doses studied.

Summary It has been proposed that idiopathic retroperitoneal fibrosis may be a consequence of ‘healed’ retroperitoneal lesions of systemic Weber-Christian disease. However ureteric obstruction which is the hallmark of idiopathic retroperitoneal fibrosis, has not been described in systemic Weber-Christian disease. We report a patient with systemic Weber-Christian disease who, during a relapse, developed bilateral ureteric obstruction which resolved when the Weber-Christian disease remitted. The radiological appearances were consistent with a diagnosis of idiopathic retroperitoneal fibrosis, but the clinical course was slightly atypical in that the ureteric obstruction resolved completely and rapidly. Ureteric obstruction can complicate systemic Weber-Christian disease and this observation gives support to the hypothesis that idiopathic retroperitoneal fibrosis is related to systemic Weber-Christian disease.

1. The metabolism of orally administered timolol (T) to its ring cleavage ethanolamine (TE) and glycine (TG) products was studied in 108 unrelated hypertensive patients. 2. Statistically significant correlations between the 0-8 h urinary debrisoquine/4-hydroxy-debrisoquine ratio and the T/TE (rs = 0.74, P less than 0.001), T/TG (rs = 0.42, P less than 0.001) and T/TE + TG (rs = 0.49, P less than 0.001) ratios were found. 3. The log10 T/TE, T/TG and T/TE + TG ratios from poor metabolisers of debrisoquine (PMs) were grouped at the upper end of a unimodal distribution. 4. These results indicate that timolol metabolism is partly under monogenic control of the debrisoquine-type. 5. The mean +/- s.d. plasma timolol concentration in PMs (82 +/- 43 ng ml-1) was double that in extensive metabolisers (45 +/- 19 ng ml-1) (P = 0.011). The clinical significance of this observation remains to be established.

Summary Spontaneous spinal epidural haematoma is of unknown aetiology, but it has been associated with hypertension. Treatment is surgical decompression but three cases of spontaneous recovery have been reported. We report the fourth such recovery in a 68 year old hypertensive woman.

Arterio-venous shunting has been demonstrated in the limbs of ten subjects with traumatic quadriplegia, as shown by increased venous oxygen concentration and a Doppler sonogram pattern indicative of continuous forward flow. This phenomenon is similar to that seen in the diabetic neuropathic foot, suggesting that autonomic dysfunction is a major factor in the development of foot ulceration in the quadriplegic and in the diabetic.