268 Forum1 reviews the ways in which doctors learn about drugs. Because progress is so rapid, drug therapy is clearly a particularly important subject for continuing educationbut, according to the report, the attention it receives in journals and at postgraduate centres is disproportionately low.
correlation between the maintenance of satisfactory reduction and a good ultimate result. Another longterm investigation 15 showed that most patients regained painless useful movement in time and that assessments of function under one year could be mis-
leading. A method of preventing the seemingly inevitable collapse at the fracture site in the comminuted Colles’ fracture and many of its sequelse has been described by Sarmiento and his co-workers at the University of Miami School of Medicine. 16 Sarmiento has shown that the pull of the brachioradialis muscle is a major factor in the typical deformity after Colles’ fracture. 17 This muscle is the only one attached to the distal fragment of the radius and acts as a deforming force when the wrist is in a position of pronation, as is the case with the conventional method of immobilisation in plaster. In order effectively to eliminate the pull of brachioradialis a method has been designed to hold the wrist in supination while allowing freedom of palmar flexion and dorsiflexion. The fractures are initially reduced and splinted in an above-elbow plaster cast with the elbow flexed to 90°, the forearm in supination, and the wrist in ulnar deviation and slight palmar flexion. A week later the cast is removed and replaced by a special’Orthoplast ’ splint which limits pronation and supination and does not allow full extension of the elbow. The wrist portion is hinged to allow for dorsiflexion and palmar flexion. The effectiveness of this type of functional treatment has already been proved by Sarmiento et al. in dealing with fractures of the femoral and tibial shafts.18, 19
Not all new drugs represent important advances, but it is not easy for the practising clinician to discriminate between them. He must rely heavily on personal advice and on published reports, which are often scattered among journals that he may not see. It seems incongruous that, for months after a new drug is marketed, almost all the information reaching the doctor should come from the manufacturer and next to nothing from disinterested sources. One of the most important recommendations in the report is that doctors should be provided with early impartial appraisals of new products in relation to the alternatives available. These should be updated at intervals to form a readily accessible and reliable source of reference. Of course it may be two years or more before a final evaluation can be made, but it would surely be better if independent experts were to make a preliminary assessment of what information there is. More difficult to implement in the existing economic climate is the recommendation that district hospitals should appoint physicians with a special interest in clinical pharmacology and therapeutics. An outline job specification has been drawn up,3 but the process could usefully be taken further. The crucial test will be whether the first appointees convincingly demonstrate their value. If they do, a new career structure in clinical pharmacology will be created and the present impasse may be resolved, with great benefit to the development of the discipline.
The results of this new method of treating Colles’ fractures are impressive. Whereas in a carefully documented survey by Gartland and Werley 2081 % of patients with intra-articular fractures had residual dorsal tilt, 61 % of the Miami patients healed in either anatomical position or slight deformity. Gartland and Werley graded 68-3% of their results as satisfactory (i.e., excellent or good) as against the 82% of Sarmiento et al. This new technique seems to be an advance in a previously stationary area of fracture treatment. It is attractive because it produces good function at an early stage. It should avoid the sometimes protracted struggle by patients to overcome the stiffness and swelling of their deformed wrists and so lighten the burden on physiotherapy departments.
HYPOTENSIVE ANÆSTHESIA
Furthermore,
HOW DO DOCTORS LEARN ABOUT DRUGS? AT least two-thirds of doctors now practising in the U.K. were never taught the basic principles of clinical pharmacology, so that many are ill-equipped to use medicinal therapy to full advantage: there is enormous scope for suboptimal prescribing, through inappropriate choice or use of drugs. Efforts to improve the general standard of prescribing might result in great public benefit and possibly a net saving on the national drug bill. A recent report from the Medico-Pharmaceutical ‘
15. 16. 17. 18. 19. 20.
Casselbaum, W. H. J. Am. med. Ass. 1950, 143, 963. Sarmiento, A., Pratt, G. W., Berry, N. C., Sinclair, W. F. J. Bone Jt Surg. 1975, 57A, 311. Sarmiento, A. Clin. Orthop. 1965, 38, 86. Sarmiento, A. J. Bone Jt Surg. 1970, 52A, 295. Sarmiento, A. Clin. Orthop. 1972, 82, 2. Gartland, J. J., Werley, C. W. J. Bone Jt Surg. 1951, 33A, 895.
SUCCESSFUL management of deliberate hypotension during anaesthesia-to produce a relatively bloodless operative field-requires considerable anaesthetic skill and is not without danger to the patient. Though the clinical aspects of hypotensive anaesthesia have been developed over about 25 years, little is generally known about the fundamental physiological and biochemical changes in the patient whose circulation has been reduced to a critical level. The boundaries of existing knowledge of these changes were defined at a symposium just published.4. Cerebral ischaemia is the principal hazard of hypotensive anaesthesia and we are reminded that general underperfusion of the brain will particularly affect certain border-zones between the distribution territories of the major cerebral arteries, with the result that unexpected focal defects may occur in the brain. Reduced oxygen supply to the brain as a whole can cause progressive biochemical changes that include Party on the Continuing Education of Therapeutics. Medico-Pharmaceutical Wimpole Street, London W1M 8AE. 50p plus
1. Report of the Working Doctors in Medicinal
Forum,
1
postage 5p per copy. 2. See Lancet, 1974, i, 1027. 3. Report of the Clinical Pharmacology of Physicians, London, 1975. 4. Br. J. Anœsth. 1975, 47, 743.
Committee, Royal College
269 of energy stores, institution of anaerobic metabolism, and accumulation of waste-productsall of which may adversely affect the capacity of the brain to revive when normal circulation is re-established. Full restitution of the deprived brain will require replacement of stores of neuronal transmitters as well as reaccumulation of energy stores. It may be important in clinical practice that certain anxsthetic agents, including barbiturates and halothane, can actually increase the resistance of the brain to relative ischaemia. The mechanism of this protective effect is unknown, but these agents may reduce energy requirements by depressing metabolism, in much the same way as does hypothermia. This is an interesting area for further research. It is suggested, as a rough guide from pooled results, that after hypotensive anaesthesia as many as 1 in 39 patients have non-fatal complications and 1 in 167 patients die. Whilst these figures are debatable they do testify to the wisdom of those non-expert anaesthetists who eschew any but the lightest degrees of deliberate hypotension. Whilst the degree of risk will depend upon the constitution of the patient, on the nature of the surgery, and on the method employed to control the circulation, the most important single safety factor is the use of a reliable instrument to record low tensions of blood-pressure, which in general means an oscillotonometer rather than the invasive techniques used in specialised units.
depletion
THERMOGRAPHY IN BREAST CANCER
WITHOUT accurate physical aids to diagnosis, mass screening for breast cancer may lead to needless anxiety and a high proportion of unnecessary breast biopsies. X-ray examination of the breasts can help to clarify the clinical findings and may even detect some tumours which are not palpable, but the radiation dosage is such that repeated mammography or xeroradiography may be inadvisable in women under 50.1 An alternative is thermography, which has just had its first European congress.2 By infra-red scanning, surfacetemperature distributions can be displayed on paper or on a cathode-ray tube, and the patterns of a woman’s breast are almost as distinctive as her finger-print. About twenty years ago, Lawson 3 showed an increased skin temperature in the vicinity of breast cancers, and subsequently Lloyd-Williams et al.tried to relate the degree of temperature increase to the degree of malignancy of the tumour. The cause of this raised temperature is still far from clear. The thermal pattern over the breast surface corresponds closely to the subcutaneous venous distribution as shown by infra-red photography,5 and in the presence of breast cancer the superficial veins are often both increased in number and engorged. However, several investigators have shown raised skin temperatures in the vicinity 1.
2.
3. 4.
5.
Samuel, E. in Modern Trends in Oncology (edited by R. W. Raven); p. 69. London, 1973. Thermography: Proceedings of the First European Congress on Thermography (edited by N. J. M. Aarts, M. Gautherie, and E. F. J. Ring). Basle: Karger. Chichester: Wiley. White Plains, N.Y.: Phiebig. 1975. Pp. 262. Sw.Fr. 98; S41. Lawson, R. N. Can. med. Ass. J. 1956, 75, 309. Lloyd-Williams, K., Lloyd-Williams, F. J., Handley, R. S. Lancet, 1961, ii, 1378. Jones, C. H., Draper, J. W. Br. J. Radiol. 1970, 43, 507.
of tumours less than a few millimetres in diameter. 6,7 The increase is thought to reflect vasodilatation associated’with the local reaction to the tumour, but the mechanism has so far attracted very little investigation. In screening for breast cancer, while mammography provides information about anatomical changes in the breast, thermography may reflect functional changes. Each method may therefore give distinctive information to supplement clinical palpation, and a combination of all three methods-thermography, mammography, palpation-may provide the highest rate of breast-cancer detection.’-10 In the massscreening trial organised by the American Cancer Society 11 the three methods are used in combination. But some authorities advise a combination of just thermography and clinical palpation in other than high-risk cases, with resort to mammography only if there is evidence of increased thermal activity in the breast.10 Thermography by itself is said to be particularly valuable for screening clinically nodular breasts in young women.1o This condition is common in young women taking the contraceptive pill, and thermography avoids repeated mammography or
biopsy. diagnosis, the value of thermography must ultimately depend on its efficacy in detecting small, non-palpable cancers and in being able to distinguish Conventional them from non-malignant tumours. techniques of thermography do not give as good resolution as does mammography, but newer automatic techniques of quantitative thermography may narrow the difference. 12 These can provide either a line scan displaying the temperature variation across a single plane, or else a series of isotherms whereby all areas at the same temperature are marked by a contour line. The most effective application of these techniques is likely to be in serial examinations of the breast, using In
cancer
the initial thermal pattern as a base-line. These techniques are expensive since they require not only scanning and recording equipment but also computer facilities for digitalisation, storage, and analysis of
sequential thermographs.13 In the patient with known breast cancer, Stoll 14 has used serial thermographs to assess the early response of breast cancer to hormonal therapy, and Gros et al." have likewise followed the progress of breast cancer after radiation therapy. Despite the difficulties presented by scarring and post-radiational fibrosis, thermography is better than most other methods for demonstrating tumour growth. Ring 16 has introduced a method of quantitation based on the thermographic index-a function of the area of specific isotherms. Such an index may prove useful for comparing the effects of different therapeutic agents in breast cancer. 14 Hoffman, R. L. Am. J. Obstet. Gynec. 1967, 98, 681. Freundlich, I. M., Wallace, J. D., Dodd, G. D. Am. J. Roentg. 1968, 102, 927. 8. Stark, A. M., Way, S. Lancet, 1970, ii, 407. 9. Lapayowker, M. S., Kundel, H. L., Ziskin, M. Cancer, 1973, 31, 777. 10. Davey, J. B., Pentney, B. H., Richter, A. M. Practitioner, 1974, 213, 365. 11. Strax, P. in Risk Factors in Breast Cancer (edited by B. A. Stoll). London (in the press). 12. Ring, E. F. J., Collins, A. J. Rheum. phys. Med. 1970, 10, 337. 13. Jones, C. H. in Thermography (edited by N. J. M. Aarts, M. Gautherie, and E. F. J. Ring); p. 61. Basle, 1975. 14. Stoll, B. A. ibid. p. 178. 15. Gros, C., Gautherie, M., Bourjet, P. ibid. p. 77. 16. Ring, E. F. J. ibid. p. 97. 6. 7.
correlation between the maintenance of satisfactory reduction and a good ultimate result. Another longterm investigation 15 showed that most patients regained painless useful movement in time and that assessments of function under one year could be mis-
leading. A method of preventing the seemingly inevitable collapse at the fracture site in the comminuted Colles’ fracture and many of its sequelse has been described by Sarmiento and his co-workers at the University of Miami School of Medicine. 16 Sarmiento has shown that the pull of the brachioradialis muscle is a major factor in the typical deformity after Colles’ fracture. 17 This muscle is the only one attached to the distal fragment of the radius and acts as a deforming force when the wrist is in a position of pronation, as is the case with the conventional method of immobilisation in plaster. In order effectively to eliminate the pull of brachioradialis a method has been designed to hold the wrist in supination while allowing freedom of palmar flexion and dorsiflexion. The fractures are initially reduced and splinted in an above-elbow plaster cast with the elbow flexed to 90°, the forearm in supination, and the wrist in ulnar deviation and slight palmar flexion. A week later the cast is removed and replaced by a special’Orthoplast ’ splint which limits pronation and supination and does not allow full extension of the elbow. The wrist portion is hinged to allow for dorsiflexion and palmar flexion. The effectiveness of this type of functional treatment has already been proved by Sarmiento et al. in dealing with fractures of the femoral and tibial shafts.18, 19
Not all new drugs represent important advances, but it is not easy for the practising clinician to discriminate between them. He must rely heavily on personal advice and on published reports, which are often scattered among journals that he may not see. It seems incongruous that, for months after a new drug is marketed, almost all the information reaching the doctor should come from the manufacturer and next to nothing from disinterested sources. One of the most important recommendations in the report is that doctors should be provided with early impartial appraisals of new products in relation to the alternatives available. These should be updated at intervals to form a readily accessible and reliable source of reference. Of course it may be two years or more before a final evaluation can be made, but it would surely be better if independent experts were to make a preliminary assessment of what information there is. More difficult to implement in the existing economic climate is the recommendation that district hospitals should appoint physicians with a special interest in clinical pharmacology and therapeutics. An outline job specification has been drawn up,3 but the process could usefully be taken further. The crucial test will be whether the first appointees convincingly demonstrate their value. If they do, a new career structure in clinical pharmacology will be created and the present impasse may be resolved, with great benefit to the development of the discipline.
The results of this new method of treating Colles’ fractures are impressive. Whereas in a carefully documented survey by Gartland and Werley 2081 % of patients with intra-articular fractures had residual dorsal tilt, 61 % of the Miami patients healed in either anatomical position or slight deformity. Gartland and Werley graded 68-3% of their results as satisfactory (i.e., excellent or good) as against the 82% of Sarmiento et al. This new technique seems to be an advance in a previously stationary area of fracture treatment. It is attractive because it produces good function at an early stage. It should avoid the sometimes protracted struggle by patients to overcome the stiffness and swelling of their deformed wrists and so lighten the burden on physiotherapy departments.
HYPOTENSIVE ANÆSTHESIA
Furthermore,
HOW DO DOCTORS LEARN ABOUT DRUGS? AT least two-thirds of doctors now practising in the U.K. were never taught the basic principles of clinical pharmacology, so that many are ill-equipped to use medicinal therapy to full advantage: there is enormous scope for suboptimal prescribing, through inappropriate choice or use of drugs. Efforts to improve the general standard of prescribing might result in great public benefit and possibly a net saving on the national drug bill. A recent report from the Medico-Pharmaceutical ‘
15. 16. 17. 18. 19. 20.
Casselbaum, W. H. J. Am. med. Ass. 1950, 143, 963. Sarmiento, A., Pratt, G. W., Berry, N. C., Sinclair, W. F. J. Bone Jt Surg. 1975, 57A, 311. Sarmiento, A. Clin. Orthop. 1965, 38, 86. Sarmiento, A. J. Bone Jt Surg. 1970, 52A, 295. Sarmiento, A. Clin. Orthop. 1972, 82, 2. Gartland, J. J., Werley, C. W. J. Bone Jt Surg. 1951, 33A, 895.
SUCCESSFUL management of deliberate hypotension during anaesthesia-to produce a relatively bloodless operative field-requires considerable anaesthetic skill and is not without danger to the patient. Though the clinical aspects of hypotensive anaesthesia have been developed over about 25 years, little is generally known about the fundamental physiological and biochemical changes in the patient whose circulation has been reduced to a critical level. The boundaries of existing knowledge of these changes were defined at a symposium just published.4. Cerebral ischaemia is the principal hazard of hypotensive anaesthesia and we are reminded that general underperfusion of the brain will particularly affect certain border-zones between the distribution territories of the major cerebral arteries, with the result that unexpected focal defects may occur in the brain. Reduced oxygen supply to the brain as a whole can cause progressive biochemical changes that include Party on the Continuing Education of Therapeutics. Medico-Pharmaceutical Wimpole Street, London W1M 8AE. 50p plus
1. Report of the Working Doctors in Medicinal
Forum,
1
postage 5p per copy. 2. See Lancet, 1974, i, 1027. 3. Report of the Clinical Pharmacology of Physicians, London, 1975. 4. Br. J. Anœsth. 1975, 47, 743.
Committee, Royal College
269 of energy stores, institution of anaerobic metabolism, and accumulation of waste-productsall of which may adversely affect the capacity of the brain to revive when normal circulation is re-established. Full restitution of the deprived brain will require replacement of stores of neuronal transmitters as well as reaccumulation of energy stores. It may be important in clinical practice that certain anxsthetic agents, including barbiturates and halothane, can actually increase the resistance of the brain to relative ischaemia. The mechanism of this protective effect is unknown, but these agents may reduce energy requirements by depressing metabolism, in much the same way as does hypothermia. This is an interesting area for further research. It is suggested, as a rough guide from pooled results, that after hypotensive anaesthesia as many as 1 in 39 patients have non-fatal complications and 1 in 167 patients die. Whilst these figures are debatable they do testify to the wisdom of those non-expert anaesthetists who eschew any but the lightest degrees of deliberate hypotension. Whilst the degree of risk will depend upon the constitution of the patient, on the nature of the surgery, and on the method employed to control the circulation, the most important single safety factor is the use of a reliable instrument to record low tensions of blood-pressure, which in general means an oscillotonometer rather than the invasive techniques used in specialised units.
depletion
THERMOGRAPHY IN BREAST CANCER
WITHOUT accurate physical aids to diagnosis, mass screening for breast cancer may lead to needless anxiety and a high proportion of unnecessary breast biopsies. X-ray examination of the breasts can help to clarify the clinical findings and may even detect some tumours which are not palpable, but the radiation dosage is such that repeated mammography or xeroradiography may be inadvisable in women under 50.1 An alternative is thermography, which has just had its first European congress.2 By infra-red scanning, surfacetemperature distributions can be displayed on paper or on a cathode-ray tube, and the patterns of a woman’s breast are almost as distinctive as her finger-print. About twenty years ago, Lawson 3 showed an increased skin temperature in the vicinity of breast cancers, and subsequently Lloyd-Williams et al.tried to relate the degree of temperature increase to the degree of malignancy of the tumour. The cause of this raised temperature is still far from clear. The thermal pattern over the breast surface corresponds closely to the subcutaneous venous distribution as shown by infra-red photography,5 and in the presence of breast cancer the superficial veins are often both increased in number and engorged. However, several investigators have shown raised skin temperatures in the vicinity 1.
2.
3. 4.
5.
Samuel, E. in Modern Trends in Oncology (edited by R. W. Raven); p. 69. London, 1973. Thermography: Proceedings of the First European Congress on Thermography (edited by N. J. M. Aarts, M. Gautherie, and E. F. J. Ring). Basle: Karger. Chichester: Wiley. White Plains, N.Y.: Phiebig. 1975. Pp. 262. Sw.Fr. 98; S41. Lawson, R. N. Can. med. Ass. J. 1956, 75, 309. Lloyd-Williams, K., Lloyd-Williams, F. J., Handley, R. S. Lancet, 1961, ii, 1378. Jones, C. H., Draper, J. W. Br. J. Radiol. 1970, 43, 507.
of tumours less than a few millimetres in diameter. 6,7 The increase is thought to reflect vasodilatation associated’with the local reaction to the tumour, but the mechanism has so far attracted very little investigation. In screening for breast cancer, while mammography provides information about anatomical changes in the breast, thermography may reflect functional changes. Each method may therefore give distinctive information to supplement clinical palpation, and a combination of all three methods-thermography, mammography, palpation-may provide the highest rate of breast-cancer detection.’-10 In the massscreening trial organised by the American Cancer Society 11 the three methods are used in combination. But some authorities advise a combination of just thermography and clinical palpation in other than high-risk cases, with resort to mammography only if there is evidence of increased thermal activity in the breast.10 Thermography by itself is said to be particularly valuable for screening clinically nodular breasts in young women.1o This condition is common in young women taking the contraceptive pill, and thermography avoids repeated mammography or
biopsy. diagnosis, the value of thermography must ultimately depend on its efficacy in detecting small, non-palpable cancers and in being able to distinguish Conventional them from non-malignant tumours. techniques of thermography do not give as good resolution as does mammography, but newer automatic techniques of quantitative thermography may narrow the difference. 12 These can provide either a line scan displaying the temperature variation across a single plane, or else a series of isotherms whereby all areas at the same temperature are marked by a contour line. The most effective application of these techniques is likely to be in serial examinations of the breast, using In
cancer
the initial thermal pattern as a base-line. These techniques are expensive since they require not only scanning and recording equipment but also computer facilities for digitalisation, storage, and analysis of
sequential thermographs.13 In the patient with known breast cancer, Stoll 14 has used serial thermographs to assess the early response of breast cancer to hormonal therapy, and Gros et al." have likewise followed the progress of breast cancer after radiation therapy. Despite the difficulties presented by scarring and post-radiational fibrosis, thermography is better than most other methods for demonstrating tumour growth. Ring 16 has introduced a method of quantitation based on the thermographic index-a function of the area of specific isotherms. Such an index may prove useful for comparing the effects of different therapeutic agents in breast cancer. 14 Hoffman, R. L. Am. J. Obstet. Gynec. 1967, 98, 681. Freundlich, I. M., Wallace, J. D., Dodd, G. D. Am. J. Roentg. 1968, 102, 927. 8. Stark, A. M., Way, S. Lancet, 1970, ii, 407. 9. Lapayowker, M. S., Kundel, H. L., Ziskin, M. Cancer, 1973, 31, 777. 10. Davey, J. B., Pentney, B. H., Richter, A. M. Practitioner, 1974, 213, 365. 11. Strax, P. in Risk Factors in Breast Cancer (edited by B. A. Stoll). London (in the press). 12. Ring, E. F. J., Collins, A. J. Rheum. phys. Med. 1970, 10, 337. 13. Jones, C. H. in Thermography (edited by N. J. M. Aarts, M. Gautherie, and E. F. J. Ring); p. 61. Basle, 1975. 14. Stoll, B. A. ibid. p. 178. 15. Gros, C., Gautherie, M., Bourjet, P. ibid. p. 77. 16. Ring, E. F. J. ibid. p. 97. 6. 7.
