Accounts of debates in the House of Commons, March– April 1731, supplementary to the diary of the first earl of Egmont

John Perceval (1685–1748), 1st Viscount Perceval and (from 1733) 1st Earl of Egmont, was an assiduous recorder of his own life and times. His diaries, published by the Historical Manuscripts Commission from manuscripts in the British Library, are the best source for parliamentary debates at Westminster in the 1730s. For the years 1730-1733, when Perceval sat in the Commons (as an Irish peer) they are remarkably full. His practice seems to have been to prepare two versions (presumably on the basis of notes taken in the House), the first attributing speeches to individuals, and the second, entered up in the diary, which listed speakers and summarized all arguments on each side. His letterbooks for 1731 contain accounts of five debates that embody his first editing process, with speeches attributed to individuals. They were sent to an Irish correspondent, Marmaduke Coghill, and largely omitted from the diary because Perceval had already transcribed them elsewhere. They are new to historians and cast light on two main issues: the unsuccessful attempts by Perceval and the ‘Irish lobby’ to persuade the British parliament to settle the Irish woollen trade, a question bedevilling Anglo-Irish relations in this period; and an attempt by the opposition to stir up anger against perceived Spanish aggression against Gibraltar. One of the most interesting features is the insight afforded into the Commons performances of Sir Robert Walpole: his management of debates, his own style of speaking, and his sharp exchanges with opponents like William Pulteney.

A Zoologist with a Taste for the Past: The Earl of Cranbrook’s Contribution to Zooarchaeological Research in Southeast Asia

The Earl of Cranbrook (V) (then Lord Medway) was fi rst introduced to archaeological research in 1958 when he participated in excavations at the Niah Caves, Sarawak Borneo. In that same year he published a paper entitled ‘Food bone in Niah Cave excavations (-1958)’ in the Sarawak Museum Journal. Unbeknownst to him at the time, his individual and intuitive research was on a par with, if not methodologically ahead of, burgeoning studies in the fi eld of zooarchaeology that were taking place at leading academic institutions in Europe and the United States. This paper recounts and lauds the signifi cant contributions the Earl of Cranbrook has made to the establishment and furtherance of a discipline over more than 50 years. 

Interventions to improve the appropriate use of polypharmacy in older people: a Cochrane systematic review

Objective: To summarise the findings of an updated Cochrane review of interventions aimed at improving the appropriate use of polypharmacy in older people. Design: Cochrane systematic review. Multiple electronic databases were searched including MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (from inception to November 2013). Hand searching of references was also performed. Randomised controlled trials (RCTs), controlled clinical trials, controlled before-and-after studies and interrupted time series analyses reporting on interventions targeting appropriate polypharmacy in older people in any healthcare setting were included if they used a validated measure of prescribing appropriateness. Evidence quality was assessed using the Cochrane risk of bias tool and GRADE (Grades of Recommendation, Assessment, Development and Evaluation).
Setting: All healthcare settings. 
Participants: Older people (≥65 years) with ≥1 long-term condition who were receiving polypharmacy (≥4 regular medicines).
Primary and secondary outcome measures: Primary outcomes were the change in prevalence of appropriate polypharmacy and hospital admissions. Medication-related problems (eg, adverse drug reactions), medication adherence and quality of life were included as secondary outcomes.
Results: 12 studies were included: 8 RCTs, 2 cluster RCTs and 2 controlled before-and-after studies. 1 study involved computerised decision support and 11 comprised pharmaceutical care approaches across various settings. Appropriateness was measured using validated tools, including the Medication Appropriateness Index, Beers’ criteria and Screening Tool of Older Person’s Prescriptions (STOPP)/ Screening Tool to Alert doctors to Right Treatment (START). The interventions demonstrated a reduction in inappropriate prescribing. Evidence of effect on hospital admissions and medication-related problems was conflicting. No differences in health-related quality of life were reported.
Conclusions: The included interventions demonstrated improvements in appropriate polypharmacy based on reductions in inappropriate prescribing. However, it remains unclear if interventions resulted in clinically significant improvements (eg, in terms of hospital admissions). Future intervention studies would benefit from available guidance on intervention development, evaluation and reporting to facilitate replication in clinical practice.

Select Document: Sir George Radcliffe’s “Original of Government” (1639) and Absolutist Political Theory in Stuart Ireland

A seventeenth-century manuscript miscellany, which once belonged to Archbishop James Ussher of Armagh, contains a short treatise on the origins of government by Sir George Radcliffe. Radcliffe was legal assistant to Sir Thomas Wentworth, lord deputy of Ireland (from January 1640 earl of Strafford and lord lieutenant). The treatise insisted on the divine origin of all human political power and implied that the best form of government was absolute monarchy, in which the monarch was free of all human law and subject to divine restraint alone. It will be suggested below that the composition of this treatise can be dated to the summer of 1639. This introduction will offer an outline of Radcliffe’s education and political career, explain the genesis of his treatise on government, point out some pertinent aspects of its argument, and finally assess the document’s significance.

The effects of blood pressure lowering on development of cognitive impairment and dementia in patients without apparent prior cerebrovascular disease

BACKGROUND: Hypertension and cognitive impairment are prevalent in older people. It is known that hypertension is a direct risk factor for vascular dementia and recent studies have suggested hypertension also impacts upon prevalence of Alzheimer's disease. The question is therefore whether treatment of hypertension lowers the rate of cognitive decline. OBJECTIVES: To assess the effects of blood pressure lowering treatments for the prevention of dementia and cognitive decline in patients with hypertension but no history of cerebrovascular disease. SEARCH STRATEGY: The trials were identified through a search of CDCIG's Specialised Register, CENTRAL, MEDLINE, EMBASE, PsycINFO and CINAHL on 27 April 2005. SELECTION CRITERIA: Randomized, double-blind, placebo controlled trials in which pharmacological or non-pharmacological interventions to lower blood pressure were given for at least six months. DATA COLLECTION AND ANALYSIS: Two independent reviewers assessed trial quality and extracted data. The following outcomes were assessed: incidence of dementia, cognitive change from baseline, blood pressure level, incidence and severity of side effects and quality of life. MAIN RESULTS: Three trials including 12,091 hypertensive subjects were identified. Average age was 72.8 years. Participants were recruited from industrialised countries. Mean blood pressure at entry across the studies was 170/84 mmHg. All trials instituted a stepped care approach to hypertension treatment, starting with a calcium-channel blocker, a diuretic or an angiotensin receptor blocker. The combined result of the three trials reporting incidence of dementia indicated no significant difference between treatment and placebo (Odds Ratio (OR) = 0.89, 95% CI 0.69, 1.16). Blood pressure reduction resulted in a 11% relative risk reduction of dementia in patients with no prior cerebrovascular disease but this effect was not statistically significant (p = 0.38) and there was considerable heterogeneity between the trials. The combined results from the two trials reporting change in Mini Mental State Examination (MMSE) did not indicate a benefit from treatment (Weighted Mean Difference (WMD) = 0.10, 95% CI -0.03, 0.23). Both systolic and diastolic blood pressure levels were reduced significantly in the two trials assessing this outcome (WMD = -7.53, 95% CI -8.28, -6.77 for systolic blood pressure, WMD = -3.87, 95% CI -4.25, -3.50 for diastolic blood pressure).Two trials reported adverse effects requiring discontinuation of treatment and the combined results indicated a significant benefit from placebo (OR = 1.18, 95% CI 1.06, 1.30). When analysed separately, however, more patients on placebo in SCOPE were likely to discontinue treatment due to side effects; the converse was true in SHEP 1991. Quality of life data could not be analysed in the three studies. There was difficulty with the control group in this review as many of the control subjects received antihypertensive treatment because their blood pressures exceeded pre-set values. In most cases the study became a comparison between the study drug against a usual antihypertensive regimen. AUTHORS' CONCLUSIONS: There was no convincing evidence from the trials identified that blood pressure lowering prevents the development of dementia or cognitive impairment in hypertensive patients with no apparent prior cerebrovascular disease. There were significant problems identified with analysing the data, however, due to the number of patients lost to follow-up and the number of placebo patients given active treatment. This introduced bias. More robust results may be obtained by analysing one year data to reduce differential drop-out or by conducting a meta-analysis using individual patient data.

Infection control strategies for preventing the transmission of meticillin-resistant Staphylococcus aureus (MRSA) in nursing homes for older people

Background

Statins for the treatment of dementia

The use of statin therapy in established Alzheimer's disease (AD) or vascular dementia (VaD) is a relatively unexplored area. In AD ss-amyloid protein (Ass) is deposited in the form of extracellular plaques and previous studies have determined Ass generation is cholesterol dependent. Hypercholesterolaemia has also been implicated in the pathogenesis of VaD. Due to the role of statins in cholesterol reduction it is biologically plausible they may be efficacious in the treatment of AD and dementia.