1135 the existing contract and were detailed clearly under four headings in the British Medical_7ournal on June 23. Then they state that very few regional representatives had been given information before the Scottish Committee of Hospital Medical Services met on Sept. 25, at which time there was a "rush to put a decision through". In fact the SCHMS had met on June 22, and the minutes report a lengthy discussion on the principal decisions taken by the CCHMS, including the improvements in the existing contract. Committee members had before them Linkman Letter no. 8 (1978/79) which dealt with these matters and which had been sent out on June 18 to secretaries of the area committees for Hospital Medical Services and to at least eighty linkmen in Scotland. Finally, the SCHMS met on Sept. 25 and the minutes record "the Committee discussed at great length the effects of these proposals on Scottish Consultants and a motion to support them was put to the vote. The motion was carried by 27 votes to 13". As I recall it, the debate continued for some two hours and included contributions from very many speakers who reported from their respective areas. The SCHMS has not been informed of the results of the ballot other than by telephone or newspapers; however, we have asked the organisers if they could furnish the committee with an analysis of its significance from the Electoral Reform ments to

Society. It is reassuring, albeit curious, to read their last sentence -that the ballot was not held in an attempt to obtain a separate contract for Scottish consultants. Such a course would entail a risk which not even the universities are willing to con-

template. British Medical Association, Scottish Office, 7 Drumsheugh Gardens,

Edinburgh EH3

7QP

C. D. Scottish

FALCONER, Secretary,

B.M.A.

TRAINING OF DOCTORS IN DEVELOPING COUNTRIES

SIR,-Professor Cook’s provocative article (Aug. 11, p. 297) illustrates some of the major obstacles to changes in medical education and the delivery of health services-among which one could single out excessive emphasis on the care of hospital patients (who constitute less than 5% of all patients seen in most developing countries and are even less numerically significant when set against the unmet health problems) and strong resistance to the use of auxiliary personnel, the main professional providers of health care in many countries. The changing role of the doctor in developing countries has been much discussed in the past ten years’.2-and has lately been debated in your correspondence columns in the wake of Cook’s paper. For example Dr Haddock (Aug. 25, p. 418) has raised important reservations about Cook’s statements on the decline of quality in hospital care and on the "partial success" of medical auxiliaries, reservations with which we are in full agree-

is the conditions under which [medicine] is practised and the order of priorities in management" which make the third world and the Western world different.3 The study of conditions under which medicine is practised and the order of priorities in management are largely what community medicine is all about. Practical training in these matters does not require "very large numbers of well-trained physicians, surgeons,

obstetricians, pxdiatricians

Project Reinforcement des Services de Santé et Formation de Personnel, B.P. 457 Niamey, Niger

ment.

In the opinion of Cook and those who have supported his arguments (Sept. 8, p. 530; Sept. 22, p. 642) health care should be delivered by "first rate doctors" (undefined) with traditional training. There is indeed much wrong with the delivery of health care in developing (and other) countries. This may have a lot to do with the fact that our colleagues in developing countries, the "traditionally trained indigenous staff", usually receive no or little training in how "they [Cook’s italics] must bring medicine to the massess"; surely, this is a major deficiency in traditional medical education. Cook believes that "medicine in the rural areas of the developing world is practically the same as in developed countries"; that "medicine is basically the same the world over";3 and that "it 1. 2.

King M. Medicine in red and blue. Lancet 1972; i: 679-81. Bryant J. Health and the developing world Ithaca: Cornell University Press,

1969. 3. Cook GC. Book reviews. Trans

Roy Soc Trop Med Hyg 1978; 72: 447-48.

...

physiotherapists, nutritionists,

medical social workers and other paramedical staff" (Aug. 25). Groups of up to twenty-five students at a time learnt to apply their bedside training under conditions similar to those of the rural majority in West Africa with limited tutorial supervision amounting to four full-time staff (nurse, social science worker, physicians) through resident clerkships in the limited facilities of standard health centres.4.5 Bedside teaching has an important place in the training of physicians anywhere, provided it can really teach the fundamental skills-listening to the patients’ complaints, correctly noting their signs, and evaluating their responses to treatment. The diseases encountered in selected urban teaching hospitals do not necessarily allow the trainee to undertake those fundamental tasks under realistic conditions: all too often the patient has already been "worked over" and teaching will tend to concentrate on intellectually stimulating but occasionaly esoteric adjustments in diagnosis or therapy. These will rely on a technology, the status of which, outside the teaching hospital, ranges from unavailable to irrelevant. On the matter of the orientation of medical training away from the individual patient-doctor relationship towards the treating of the masses, we do not feel as disturbed as Cook does: we doubt if he could cite many instances where training is not centered on the doctor’s responsibility towards the individual patient. What teachers of community medicine try to do, in cooperation with their clinical colleagues and those in the basic sciences, is: (1) to provide students with an understanding under which health problems are met in the country, and this does include explicit discussion of living conditions in villages; (2) to present scientific and quantifiable approaches towards the definition and resolution of the major health problems ; and (3) to show how better management can improve efficiency in the doctor-patient relationship, in the doctor’s role as adviser to the local authorities, and in his/her role as teacher, supervisor, and co-learner to other participants in health activities (nurses, sanitarians, dressers, patients). Insofar as medicine is a science, community medicine is one too, based as it is on the far from amorphous requirements of epidemiology, biostatistics, and planning methodology. In developing countries community medicine makes essential contribution to the basic education of all doctors6 in delivering health care to the majority of the population. E. A. JEANNÉE M. C. THURIAUX

CIMETIDINE IN BLEEDING PEPTIC ULCER

by

SIR,-We read with interest the results of the trial reported Dr Hoare and colleagues (Sept. 29, p. 671). We have done

study in patients over 65 years old with severe upper. gastrointestinal haemorrhage. Patients were allocated, double blind, to one of three groups: cimetidine, cimetidine plus chlorpheniramine, and placebo. All categories received conventional supportive therapy and a uniform antacid regimen. An older population was studied because it is this group in which greater morbidity and mortality occur after upper gastrointesa

similar

4. Monekosso GL, Thuriaux M. Le rôle du C.U.S.S. de Yaoundé dans la formation du personnel: La formation en équipe. Méd Afr Noire 1974; 21: 813-17. 5. Joseph SC. The health care team demonstration: An experiment in rural health training for nursing and medical students in central Africa. Trop Pediatr Envir Child Health 1974; 21: 325-30. 6. Waters WE. Teaching epidemiology to medical students. Int J Epidemiol

1977;6:329-30.

1136 tinal

A third category of H1+H2 receptor antaadded because of evidence that combined receptor blockade may have a protective effect on the gastric mucosa.2 When 30 patients had completed the trial there had been an overall rebleeding rate of 20%. This rate suggested that more than 150 patients would be required to demonstrate benefit (at the 5% level of significance) even assuming that cimetidine::tchlorpheniramine reduced rebleed frequency overall by as much as 50%. Since an efficacy of this order seemed unlikely, the code was broken and the results were analysed up to that point. Of 18 patients on cimetidine with or without chlorpheniramine 5 re-bled compared with 1 out of 12 on placebo. For 21 patients with bleeding from gastric or duodenal ulcers the figures were 5/13 and 1/8, respectively; and for gastric ulcer alone they were 3/4 and 0/3. Since no trend had emerged the trial as originally designed was abandoned. Hoare et al. recorded an 85% reduction in re-bleed frequency in the group receiving cimetidine compared with that in those on placebo, as in a total study population of 19 elderly patients with bleeding gastric ulcers and a re-bleed rate (treated +placebo) of 37%, they were able to demonstrate significant benefit. Our results do not follow that trend, but numbers are too small to draw conclusions. If, however, an efficacy of 85% is a possibility for cimetidine in elderly patients with bleeding gastric ulcer, as suggested by Hoare et al., then this would be a very useful therapeutic measure indeed and certainly requires further investigation. ’Since the number of patients who re-bleed is small a large, probably multicentre, trial will be needed in any further investigations. The situation is analogous to that of antihypertensive treatment in the prophylaxis of cerebrovascular disease-large numbers are treated for the potential considerable benefit of a very few. S. J. La Brooy and colleagues (Gut 1979; 20: 892) have reported a multicentre trial in which the re-bleed rate was comparable with ours and Allan and Dykes" The re-bleed rate was not significantly reduced amongst the cimetidine-treated

hxmorrhage.1

gonists

(Spd) AND SPERMINE (Spm) LEVELS IN PATIENTS WITH MALIGNANT DISEASE

PLASMA AND ERYTHROCYTE SPERMIDINE

was

patients. Department of Medicine (Geriatrics), University of Newcastle upon Tyne, and Geriatric Unit, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE

A. F. MACKLON S. H. ROBERTS

O. JAMES

MARKERS Dr Takami and

colleagues (Oct. 27,

p.

912)

tlnvestlgated before and after treatment (see text).

chromatography

on an Aminco ’Aminalyzer’ (American Instrument Co., Silver Spring, Maryland) high-pressure liquid chromatograpb fit-

ted with a fluorimeter detection system. The system used an Aminco PA cation exchange resin column. The polyamines were detected fluorimetrically after formation of o-phthalaldehyde derivatives.5 The results were validated by comparison with an accurate and highly sen6 sitive gas-chromatographic/mass-spectrometric procedure

Erythrocyte spermidine concentrations were raised in all patients studied before treatment while spermine was increased in six of them (table). The plasma concentrations of spermidine were increased in only two and of spermine in only one. In the ten patients studied while on treatment there were increases in erythrocyte spermidine and spermine in four and five patients, respectively, while plasma concentrations of both spermidine and spermine were raised in three of the ten patients. In one patient with cancer of the breast studied before and during therapy with 5-fluoruracil there was an immediate and steady fall in spermidine concentration to below normal limits within 7 days of the start of therapy. The erythrocyte count did not change. In contrast, the plasma-spermidine, which had been high before therapy, rose sharply when treatment began and then fell to normal by 7 days. Spermine values in both plasma and erythrocytes were normal before therapy and did not change. Polyamine values are difficult to interpret in patients on treatment because of the effects of therapy on polyamine production: cancer therapy may affect not only the tumour polyamine production rate but also the erythrocyte membrane polyamine-binding affinity. An important consideration in the use of markers for malignancy is their specificity-i.e., the frequency of positive results in patients who are free of cancer. In patients with non-malignant diseases increased excretion of polyamines has been observed (pernicious and hsemolytic anaemias and pulmonary tuberculosis 7) and increased plasma concentrations have been seven cancer

POLYAMINES IN BLOOD-CELLS AS CANCER

SIR,-Like

*With metastasis.

we

have been

investigating the potential of blood-cell (erythrocyte) polyamine concentrations as cancer markers. Earlier workers3.4 had reported evidence of increased erythrocyte polyamine values in patients with cancer, and we have tried to validate these studies and to compare erythrocyte values with simultaneous plasma polyamine concentrations. Heparinised blood-samples were collected from twenty-five volunand from patients with histologically verified cancer (seven before therapy and ten during treatment). After centrifugation of the blood-samples, the plasma fraction was transferred into a fresh container and the buffy coat was aspirated and discarded. The packed erythrocytes were resuspended in an equal volume of normal saline and counted on a Coulter model S. To both the plasma fraction and the suspended erythrocytes 3,3’-iminobispropylamine was added as an internal standard; erythrocytes were haemolysed with ’Triton X-100’; proteins were precipitated with cold 10% trichloracetic acid in both plasma and hxmolysate. The protein-free filtrates were taken to dryness on a rotary evaporator and hydrolysed with 6 nol/1 HCI before

teers

1. Allan R, Dykes P. A study of the factors influencing mortality rates from gastro-intestinal hæmorrhage. Quart J Med 1976; 45: 533-50. 2. Rees WDW, Rhodes J, Wheeler MH, Meek EM, Newcombe RG. The role of histamine receptors in the pathophysiology of gastric mucosal damage. Gastroenterology 1977; 72:67-71. 3. Cooper KD, Shukla JB, Rennert OM. Polyamine compartmentalization in various human disease states. Clin Chim Acta 1978; 82:1-7. 4. Saeki Y, Uehara N, Shirakawa S. Sensitive fluorimetric method for the determination of putrescine, spermidine and spermine by high-performance liquid chromatography and its application to human blood. J Chromatogr 1978; 145: 221-29.

5.

Shipe JR, Savory J. High performance liquid chromatographic separation and fluorescence detection of polyamines in plasma and erythrocytes. Ann Clin Lab Sci (in press). 6. Shipe JR, Hunt DF, Savory J. Plasma polyamines determined by negative-

chemical ionization/mass spectrometry. Clin Chem 1979; 25: 1564-71. 7. Durie BGM, Salmon SE, Russell DH. Polyamines as markers of response and prognosis in cancer chemotherapy. Cancer Res 1977; 37: 214-21. ion

Cimetidine in bleeding peptic ulcer.

1135 the existing contract and were detailed clearly under four headings in the British Medical_7ournal on June 23. Then they state that very few regi...
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