BRITISH MEDICAL JOURNAL

1 JANUARY 1977

redress such an imblance, but little has been achieved in this field as yet. One can appreciate that protests will come from those threatened with cuts in their luxurious standards, but how can they justify the fact that our patients in the North pay the same taxes yet receive very different services ? Were we in an idealistic world then the obvious solution would be extra funding to the underprivileged regions, but the financial crisis of the day surely demands a fairer spread of the resources currently available. RICHARD HESLOP Department of Urology, Hull Royal Infirmary (Sutton), Hull

Mobile chest radiography

SIR,-In 1967 mass miniature radiography was discontinued in the Bournemouth area owing to the low yield from a large number of examinations. A mobile unit continued (at weekly intervals for general practitioner referrals), visiting 16 sites from Amesbury in the north-east to Portland in the west. In addition, the unit is used for contact examination when a case of tuberculosis occurs in a factory or other sizeable institution. Although essentially a screening procedure, the abnormality rate is appreciableapproximately 90 per 1000 for GP referrals. It is not suggested that all these patients would never have been x-rayed, but certainly they reach the consultant much more rapidly than through the usual means of referring for a chest x-ray, waiting for the report, and waiting once again for a hospital appointment. Among the less common abnormalities discovered by this method are coarctation of the aorta, arteriovenous fistula, right aortic arch, Meigs's syndrome, medullary carcinoma of the thyroid, and Hodgkin's disease. It is now suggested that these units should be phased out on the grounds that there is an increased dose of radiation, but this is so small that it can be disregarded. It is said that they are expensive to run, but looked at from a broad point of view this is not true. The load taken off the hospitals is considerable, as is the saving of x-ray film. If a unit travels to the patients it saves petrol and decreases traffic congestion and car parking problems. The saving in production at a factory employing hundreds of people is considerable, as if the employees travelled to the hospital it would mean a day's loss of work. Another important factor is the small amount of space required to store the films, thus enabling them to be kept for a much longer period, and we all know the value of comparison with a previous film when an abnormality is detected. A mobile chest radiography unit is of great benefit to the community and, so long as the yield remains as high as at present, it should not be curtailed in any way whatsoever. Chest Department, Poole General Hospital, Poole, Dorset

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latest technological hardware and staffed with a galaxy of talent. However, the Hospital for Tropical Diseases in London is one of the genuine examples of a "centre of excellence." Tragic medical mistakes are frequently made in the management of tropical diseases in general hospitals. In Britain doctors have been sued over the past few years for negligence concerning patients who have died from malaria; patients die when ulcerative colitis rather than amoebic dysentery is diagnosed; and cases of leprosy and leishmaniasis are often missed. This hospital, the only hospital in Britain primarily devoted to the treatment of tropical diseases, is a centre of excellence for the management of amoebiasis, filariasis, intestinal infections, leishmaniasis, malaria, leprosy, parasitic diseases, other protozoan infections, schistosomiasis, and other worm infections. The term "centre of excellence" is valid when applied to certain units throughout the world. ANTHONY HALL Hospital for Tropical Diseases, London NW1

SIR,-Your edition of 4 December (p 1376) carried an open letter from Dr Terry Davies to Sir Alec Merrison, chairman of the NHS Royal Commission, in which he rightly reiterated the singular contribution of teaching hospitals as centres of excellence and initiation in research and treatment. It has suddenly become fashionable to decry the lead such centres have given and so it is as well to list the result of a random survey of contributions in the same edition of the BMJ. Of the 15 signed articles, 10 were from teaching or university hospitals, two from other hospitals, and three from abroad. In the Lancet of the same date there were six from teaching hospitals, three from others, and two from abroad. It all seems to prove Dr Davies's point, and one the public at large may not fully appreciate. NIGEL D W WEAVER District Administrator, South Hammersmith Health District

Charing Cross Hospital, London W6

Propranolol absorption

SIR,-We were interested to read the suggestion of Dr B T Cooper and others (6 November, p 1135) that changes in the intestinal microclimate may affect drug absorption. While accepting this possibility, we feel that alternative explanations are more likely to account for reports of altered plasma propranolol concentration-time curves in coeliac and Crohn's diseases. Plasma propranolol concentrations measured after oral dosing are affected by many factors which include: (1) the site and extent of drug absorption; (2) gastric and intestinal motility; (3) extraction and metabolism occur0 D BERESFORD ring in the liver (first-pass effect); and (4) plasma protein binding.

Higher than usual plasma propranolol concentrations in patients with intestinal disease cannot be attributed to improved overall absorption of the drug, since only 0 7-4 6% of a "4C-labelled dose can be recovered in the faeces, and urinary recovery amounts to 90% or greater.1 Together, these observations indicate that absorption of propranolol is virtually complete in patients with normal intestinal function. An alternative explanation for high plasma propranolol concentrations seen in patients with coeliac disease is an increased rate of absorption. This would be difficult to prove without cannulation of the portal vein since mathematical analyses are distorted by the first-pass effect. Nevertheless, accelerated gastric emptying has been described in coeliac disease2 and we have recently found that metoclopramide (10 mg intravenously) elevates plasma propranolol concentrations in the first 2 h after dosing (see table below). The most important source of individual variability in plasma propranolol concentrations appears to be the extent of metabolism at the first-pass. The most accurate way of measuring this effect is to compare the areas under the concentration-time curves in the same subject after both oral and intravenous administration. This was not done in the studies reported by Parsons et al3 or in those reported by Dr R E Schneider and his colleagues (2 October, p 794). There are, however, several groups of patients in whom reduced first-pass metabolism and increased bioavailability have been reported, including the elderly4 and those with hepatic disease.5 Since hepatic may complicate intestinal disease it remains a possible explanation for the differences reported in coeliac and Crohn's disease. Finally, as propranolol is extensively bound to plasma proteins the volume of distribution and thus the plasma concentration may be increased when protein binding is diminished. C F GEORGE M CASTLEDEN Department of Clinical Pharmacology, University of Southampton

Paterson, J W, et al, European Journal of Clinical Pharmacology, 1970, 2, 127. ' Moberg, S, and Carlberger, G, Scandinavian Journal of Gastroenterology, 1974, 9, 17. ' Parsons, R L, et al, Gut, 1976, 17, 139. 'Castleden, C M, Kaye, C M, and Parsons, R L, British J'ournal of Clinical Pharmacology, 1975, 2, 303. Branch, R A, James, J, and Read, A E, British Journal of Clinical Pharmacology, 1976, 3, 243.

General practitioner's role in management of labour

SIR,-Had Professor Peter Curzen and Dr Ursula M Mountrose (11 December, p 1433) advanced their valuable figures in support of a conclusion that delivery in a unit where specialised monitoring in labour and afterwards was necessary one could not but have agreed with them. But they do not. Instead, they conclude that there is no place for the general practitioner to care for his own

Mean (and range) of plasma propranolol concentrations (ng/ml) following an 80 mg oral dose in four fasting normal subjects

The end of excellence?

SIR,-Dr J W Todd writes sensibly in his letter (6 November, p 1130) in which he asserts that most patients are not helped by being treated in an institution filled with the

After intravenous physiological saline After intravenous metoclopramide 10 mg

26 (0-59) 65 (18-106)

Time after dosing lh I h 39 (0-88) 45 (0-88) 60 (13-107) 64 (22-113)

2h 49 (16-83) 65 (33-113)

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BRITISH MEDICAL JOURNAL

patients in labour. True, the general practitioner cannot physically be present throughout the labours of all his patients. The midwife, as the authors state, is the right person to do that. Do they mean to imply in their discussion, I wonder, that in order to detect 3 30o of fetal distress all patients should have cardiotocography and fetal blood pH determinations ? What else is one to assume? The maternal complications and cord prolapse can be detected by any competent midwife. The authors do not state in what types of case fetal distress developed. I suspect long labour or other easily recognisable factors entered into a number of them-again factors within the competence of midwife and GP to determine. It is interesting, too, that 3-3O, of fetal distress resulted in only 06° infants in poor condition. Presumably all these survived. And are we to infer that a doctor was there for every normal birth ? I submit that the GP can and should be able to care for his own patients in labour. These figures serve only to underline the need for specialist help to be readily available, which is quite different. It is typical of the short-term thinking of hospital consultants not to see the positive value of the GP in labour. Faced with the uncertainties of labour and the care of a newborn baby, and given the supreme importance of establishing a good mother-baby relationship in the first hours of life, this is just the time when the GP should not lose any more contact with them than the demands of other work necessitate. Intensive care by the GP now pays dividends in his later dealings with them both. It will be the worse, not only for general practice but for the patients of two generations, if the authors have their way. I fear that their conclusion is based more on prejudice than on the facts they produce. J M ENGLISH Northwood, Middx

SIR,-I was interested to read the article by Professor Peter Curzen and Dr Ursula M Mountrose (11 December, p 1433). The studies clearly prove what every practising obstetrician, consultant or general practitioner, already knows-that unforeseen emergencies occur during labour. However, I am alarmed by the statistics it does not give. There is no evidence on the morbidity or mortality of the emergencies mentioned in both obstetric units and general practitioner maternity beds. The statistics appear to relate solely to those cases selected by the obstetric unit in the hospital by technical classification. A general practitioner can take into consideration other factors, known to him about a particular case, before deciding that it is a low-risk case. The discussion that follows the presentation of the statistics in the article ignores any consideration of the wishes or feelings of the patients. The reference to studies on the actual attendance of general practitioners in labour is offensive, as no studies have been quoted regarding the actual attendance of consultants or registrars at low-risk labours in their obstetric units nor on the number of junior hospital doctors to whose skill and judgment the management of these low-risk cases, with emergencies, may be delegated. The opinion, based on these debatable points, that there is no place in modern hospital obstetric practice for the independent

general practitioner to provide care for his own patients in labour is unjustified. Even more important is that it completely ignores the patient as an individual human being and the effect of forcing almost 93("( of low-risk patients unnecessarily into the strange and sometimes impersonal environment of a hospital obstetric unit. I believe that a more reasonable opinion is that, in order to obtain the best statistical results with humanity, it is essential for general practitioners and consultant obstetric units to be prepared to co-operate with this end in view. These conditions, I am happy to say, appear to exist in the area of my practice. H R CHAPMAN Penn, Wolverhampton

1 JANUARY 1977

of the past 20 years to the sophisticated current care of today with the use of the oxytocin pump, epidural analgesia, and fetal monitoring, I submit that there is still a place for the experienced, trained, and willing GP. To suggest that GP care should be on a session basis is ludicrous; babies do not as yet arrive on a sessional basis and I trust never will. D G MAY Leatherhead, Surrey

SIR,-The article by Professor Peter Curzen and Dr Ursula M Mountrose (11 December, p 1433) was both tendentious and misleading. By excluding 3790, of women who "had undergone induction of labour for various obstetric indications" the authors effectively distort their total for low-risk cases, giving an inflated incidence of all emergencies in labour in this group of 70oo (or, putting it another way, a non-emergency rate of 93°0). Is Mother Nature really so poor at the birth business that nearly 400, of women require induction ? I suggest that the evidence presented merely confirms general practitioners' suspicions that some obstetricians are unable to keep their hands off their own patients-let alone those of their colleagues.

SIR,-Professor Peter Curzen and Dr Ursula Mountrose have identified 7 1 0 as the incidence of unexpected emergencies occurring among 2549 patients booked for hospital delivery but estimated as at "low risk" of complications. Their report would be further enhanced if they listed the original criteria for hospital booking. The lay public find it difficult to understand the problem of predicting hazard in normal childbirth. It is the young multigravida having HENRY MEADOWS a second, third, or fourth pregnancy who may ask her general practitioner for advice on the Wellesbourne, necessity for a hospital confinement. Can the Warwick work at Queen Mary's Hospital further identify the risk of unexpected complications Managing mild hypertension in such a woman or were "normal" multiparae not included in the population being studied ? SIR,-As your recent leading article (30 October, p 1025) points out, the management GILLIAN MATTHEWS of mild hypertension is controversial. Attempts Kent Area Health Authority, are being made to evaluate antihypertensive Maidstone medication in this condition in several largescale controlled trials.' Meanwhile doctors SIR,-What a pleasure to find that teachers at have to make decisions in the course of their my alma mater have at long last recognised day-to-day practice. The consequences of the existence of the general practitioner. But decisions that some make are shown by recent they do so only in order to then declare him observations in a provincial Australian centre. A group of 50-59-year-olds was seen in redundant. Your journal, sir, rightly enjoys worldwide Albury, New South Wales, in 1971,2 when the respect for its high standards of scientific only notifications made were of those with reporting. It is disappointing therefore to diastolic blood pressure (DBP) over 109 mm read the article by Professor Peter Curzen Hg. In 1975 1060 of the group were seen and Dr Ursula M Mountrose (11 December, again.3 In the intervening years the number on p 1433) who give figures merely confirming antihypertensive medication had increased that "low risk is not no risk" and use them as a from 115 (110o) to 232 (22%o) (100 had vehicle for their opinion that there is no place continued on treatment, 15 had stopped, and for the independent general practitioner to 132 were newly begun). In 1971 the DBP of provide care to patients in labour. There is the 132 newly treated subjects had been less thus no need to argue with them but only to than 90 mm Hg in 22 cases, 90-109 mm Hg point out that they have produced not a shred in 59, and greater than 109 mm Hg in 51. Allowing for some rise in DBP with age since of evidence for or against their conclusions. 1971, it is apparent that many subjects with MALCOLM AYLETT mild hypertension had been started on treatment. Whether or not the increased therapeutic Pickwick, activity had benefited health and mortality, it Corsham, Wilts had certainly lowered the blood pressure effectively in the 132 newly treated subjects: SIR,-Professor Peter Curzen and Dr Ursula between 1971 and 1975 their mean DBP fell Mountrose's figures are no doubt true (11 from 105 to 96 mm Hg. The mean DBP of the December, p 1433). Figures, however, take no 813 persons who had remained untreated account of personalities, either of patients or throughout was unchanged at 89 mm Hg. doctors. In a well-run GP unit liaising with Treatment of people with mild hypertension consultants in a district hospital GP care is a has presumably contributed to an estimated viable and worthwhile proposition; in this area increase of 40-50% in the number of prescrip(Kingston) we are fortunate in having this. tions written for antihypertensive drugs in Patients invariably prefer the care of their own Australia between 1972 and 1975. Identification GP to that of unknown hospital staff. of epidemics of treatment wherein one person As a GP who has made the transition from in five in the sixth decade may be sentenced the so-called "blood and thunder" obstetrics to life-long medication underlines the urgent

General practitioner's role in management of labour.

BRITISH MEDICAL JOURNAL 1 JANUARY 1977 redress such an imblance, but little has been achieved in this field as yet. One can appreciate that protests...
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