The USA and the UK have differed substantially in approaches to health care and especially in intensive care provision. We have compared the health care systems, clinical justification for intensive care, selection of patients likely to benefit from such care, and the performance of the systems. The differences are lessening. Both countries are moving away from clinical autonomy as the driving force of medical decision-making. There is increasing recognition that not all patients will benefit from intensive care and that the doctor's obligation to the patient can be limited by constraints set by society.

We describe a distinctive epilepsy syndrome in six families, which is the first partial epilepsy syndrome to follow single gene inheritance. The predominant seizure pattern had frontal lobe seizure semiology with clusters of brief motor attacks occurring in sleep. Onset was usually in childhood, often persisting through adult life. Misdiagnosis as night terrors, nightmares, hysteria, or paroxysmal nocturnal dystonia was common, and the inheritance pattern was often not appreciated. This autosomal dominant epilepsy syndrome is ideal for identification of partial epilepsy genes.

Many studies have shown that screening for breast cancer can reduce mortality from the disease. Mammography has come to be regarded as the screening method of choice, but evidence suggests that physical examination (PE) is at least as effective in reducing mortality. Mammography detects many non-infiltrating and small, non-palpable tumours, but we do not know whether these would ever cause symptoms or threaten the woman's life. It is doubtful whether the time gained by early mammographic detection confers any survival benefit over PE detection. PE has substantial advantages over mammography in terms of human and economic costs. The question we should be asking is not how to refine mammographic screening but whether we need it at all.

The characteristic pathophysiological changes in pre-eclampsia are thought to be related to abnormalities of the maternal vascular endothelium. We suggest that the blood components that affect the risk of such damage are very-low-density lipoproteins (VLDL), which injure the endothelium, and toxicity-preventing activity (the pl 5.6 form of plasma albumin), which protects against VLDL-induced injury.

The Epstein-Barr virus (EBV) has been implicated in the aetiology of many human lymphoid and epithelial malignancies. Although EBV is B lymphotropic in vitro, it has been hypothesised that oropharyngeal epithelium is important in primary EBV infection, replication, and persistence in vivo, and that infection of B lymphocytes is secondary. This hypothesis has been challenged by several recent studies. On the basis of current evidence, we propose that primary EBV infection and virus persistence are mediated through B lymphocytes, and that latent infection of epithelial cells is accidental and irrelevant to virus persistence, although important in the development of certain carcinomas. To what extent T cells are involved in EBV persistence remains uncertain. Clarification of the possible part played by EBV in the development of virus-associated tumours requires a better understanding of the mode of EBV persistence and the identification of the stage in the carcinogenic process at which EBV infection occurs.

Large randomised trials have demonstrated that fibrinolytic therapy can reduce mortality in patients with suspected acute myocardial infarction (AMI). The indications for, and contraindications to, this treatment in some categories of patient are disputed, examples being late presentation, elderly patients, and those in cardiogenic shock. This overview aims to help resolve some of the remaining uncertainties. From all trials of fibrinolytic therapy versus control that randomised more than 1000 patients with suspected AMI, information was sought and checked on deaths during the first 5 weeks and on major adverse events occurring during hospitalisation. The nine trials included 58,600 patients, among whom 6177 (10.5%) deaths, 564 (1.0%) strokes, and 436 (0.7%) major non-cerebral bleeds were reported. Fibrinolytic therapy was associated with an excess of deaths during days 0-1 (especially among patients presenting more than 12 h after symptom onset, and in the elderly) but this was outweighed by a much larger benefit during days 2-35. This "early hazard" should not obscure the very clear overall survival advantage that is produced by fibrinolytic therapy. Benefit was observed among patients presenting with ST elevation or bundle-branch block (BBB)--irrespective of age, sex, blood pressure, heart rate, or previous history of myocardial infarction or diabetes--and was greater the earlier treatment began. Among the 45,000 patients presenting with ST elevation or BBB the relation between benefit and delay from symptom onset indicated highly significant absolute mortality reductions of about 30 per 1000 for those presenting within 0-6 h and of about 20 per 1000 for those presenting 7-12 h from onset, and a statistically uncertain benefit of about 10 per 1000 for those presenting at 13-18 h (with more randomised evidence needed in this latter group to assess reliably the net effects of treatment). Fibrinolytic therapy was associated with about 4 extra strokes per 1000 during days 0-1: of these, 2 were associated with early death and so were already accounted for in the overall mortality reduction, 1 was moderately or severely disabling, and 1 was not. This overview indicates that fibrinolytic therapy is beneficial in a much wider range of patients than is currently given such treatment routinely.