BRITISH MEDICAL JOURNAL
1215
7 mAY 1977
"radiotherapy and oncology." The regional system for radiotherapy which is already established can form the foundation for the new oncology specialty, which should for the non-teaching hospital remain regionally based. It is particularly important that oncologists managing patients with "solid tumours" should be able to use all medical means of treatment, including radiotherapy and cytotoxic chemotherapy, and so serve the patient completely. For the general practice of oncology the technical knowledge required for good radiotherapy and good cytotoxic chemotherapy can be mastered by the same person. It is the clinical experience with patients with malignant disease which is paramount and which requires long years of training and this, of course, is common to the practitioners of both forms of treatment. All those who are concemed with the medical management of malignant disease, if unified, would be better able to make a sound and reasoned case for financial allocation in these difficult times. It could be that the financial problems of the day might break down the barriers and the prejudices between practitioners of the different forms of cancer treatment and make for a unified specialty and so to improved care for the patient with malignant disease. STANLEY DISCHE Regional Radiotherapy Centre, Mount Vernon Hospital, Northwood, Middx
tended to be clustered around the middle of the range and were often much better than in restaurants and cafes. After completion of the survey detailed recommendations were sent to each hospital and many improvements were made with the support of the regional catering officer. A code of practice, which has since been incorporated in the Department of Health and Social Security catering manual,' was prepared by a regional working party. Environmental health officers have a responsibility to enforce legislation which is orientated towards the physical environment. Structural changes are expensive and less important from the hygienic aspect than a careful control of procedures by means of adequate supervision and training. We agree that environmental health officers should be invited to visit hospital kitchens and to make recommendations but that the priorities must be decided by the hospital authorities. The greater involvement of environmental health officers not only in kitchens but also in other areas of hospital hygiene would be advantageous, particularly if more study of hospital problems was included in their training programme. Hospitals also differ from other establishments in that they have, or should have, an infection control committee and staff specialising in infection problems (microbiologist, technicians, infection control officer and nurse). These are responsible for advising the hospital authorities on all aspects of control of infection in all departments of the hospital.2 G A J AYLIFFE B J COLLINS
Hygiene in NHS hospitals SIR,-Although we agree with many of the comments made by Scrutator (26 March, p 851) and agree that hygienic standards in NHS hospitals should be high, we do not believe that legal enforcement is the method of choice, particularly if it involves certain areas of the hospital at the possible expense of the remainder. There is a risk that legal requirements will be based on the maximum possible rather than on commonsense measures. Recommendations should be made on the basis of actual risks of infection and on an assessment of the hazard throughout the service. Many of the new fire precautions recommendations for hospital pharmacy clean rooms, and the Health and Safety at Work Act regulations are tending to divert resources from essential patient areas where there are no statutory controls. Hospitals differ from hotels and restaurants in that there are many areas involving risk of infection to patients and, to a lesser extent, staff. In these times of budgetary restriction the individual hospital authority must decide on the allocation of money for provision of safe operating theatres, central sterile supply departments, intensive care units, isolation wards, etc as well as kitchens. However, we do agree that more finance is necessary to maintain the safety of these high-risk areas, particularly in older hospitals. Reports of outbreaks of food poisoning tend to exaggerate the incidence in hospitals, where microbiological services are more readily available and outbreaks are recognised more frequently than in the rest of the community. In collaboration with an environmental health officer we made a detailed survey of 28 hospital kitchens in the West Midlands in 1971, and visits were later made to local commercial establishments. It was found that hygienic practices and conditions in hospital kitchens
Hospital Infection Research Laboratory, Dudley Road Hospital, Birmingham
2
Hygiene in Catering Departments and Food Service Areas. Health Service Catering Manual, vol II. London, Catering and Dietetic Branch, DHSS, 1974. Control of Hospital Infection. A Practical Handbook, ed E J L Lowbury et al. London, Chapman and Hall, 1975.
Coronary heart disease and the menopause SIR,-Your interesting leading article (2 April, p 862) expresses doubts on the widely held view that female sex hormones are responsible for the relative immunity to coronary heart disease before the menopause. Your suggestion that alternative hypotheses are required prompts me to refer to studies pertaining to this problem in which we advanced the concept that the aging processes of mesenchymal tissues are interconnected. This applies in particular to involutionary osteoporosis and atherogenesis. Parish et all found no excessive coronary atherosclerosis in women castrated after the age of 41 in contrast to those castrated at an earlier age, who showed a high incidence of coronary heart disease 14-15 years after castration. This long interval between castration and the manifestation of coronary atherosclerosis raises doubts on a direct association of these processes. By contrast Young and Nordin,' using x-ray densitometry, have shown that reduced bone density develops within 1-2 years of induction of an artificial menopause. Similar results have been reported by other investigators. Thus osteoporosis precedes the development of atherosclerosis and its complications by a number of years.
The fundamental phenomenon of the paradox in nature is also reflected in the growth and decline of the human body. Calcium salts are essential for the development and maintenance of the skeletal system, but they also contribute to the aging of vital arteries. The skeletal system is the main storehouse not only for calcium but also for other minerals, in particular the heavy elements providing the alpha-ray activities. The latter, when acting over long periods in very small doses, are one of the most potent mutagenic agents. It has been shown for the first time that both calcium and the alpha-ray activities increase with age in those large human arteries which are prone to develop atherosclerosis.3 A statistically significant correlation between the ash concentrations and the alpha-ray activities has been found in aortas and in coronary arteries but not in the pulmonary arteries. The latter are rarely affected by significant atherosclerosis. The correlation is most marked in the coronary arteries of individuals who died of coronary artery disease.5 Too little attention has been paid to the distinct sex differences in the aging process. During the childbearing age the female cartilages, particularly the ventral costal cartilages, show a significantly greater affinity for calcium than those of males.6 By contrast the calcium concentrations in the aorta in women are lower than in men up to the seventh decade of life. Thereafter this sex difference is reversed. In no other group of patients of comparable age have we found a higher incidence of extensive calcified atherosclerosis in the abdominal aorta than in women with senile osteoporosis.7 Our findings have been confirmed by Dent et al.8 Atherogenesis is a multifarious process and only some aspects of our studies have been mentioned. Our results suggest that the skeletal system plays a major part in atherogenesis. The phenomenom of transmineralisation is connected with involutionary osteoporosis. Its rate of progress varies from individual to individual and is at least partly influenced by the degree of sex hormone deficiency. The sex differences in the tissue mineral metabolism referred to may explain why women before the menopause are relatively immune to coronary artery disease and why the rate of increase of atherosclerosis and its complications is greater in women than in men in the high age groups. A ELKELES Prince of Wales's General
Hospital,
London N15
Parish, A, et al, American Journal of Obstetrics and Gynecology, 1967, 99, 155. Young, M M, and Nordin, B E C, Proceedings of the Royal Society of Medicine, 1967, 60, 1137. a Elkeles, A, British Journal of Radiology, 1961, 34, 602. 'Elkeles, A, Journal of the American Geriatrics Society, 1966, 14, 895. Elkeles, A, Nature, 1969, 221, 662. Elkeles, A, Journal of the American Geriatrics Society. 1966, 14, 456. 7Elkeles, A, Lancet, 1957, 2, 714. 8 Dent, C E, et al, British Medical_Journal, 1968, 4, 76.
SIR,-In your leading article on this subject (2 April, p 862) you describe a Swedish study in which 76 % of women admitted to hospital with myocardial infarction had experienced the menopause by the age of 50, whereas only 48 % of controls had done so as "the best evidence yet of an association between an early menopause and coronary heart disease." You admit
1215
7 mAY 1977
"radiotherapy and oncology." The regional system for radiotherapy which is already established can form the foundation for the new oncology specialty, which should for the non-teaching hospital remain regionally based. It is particularly important that oncologists managing patients with "solid tumours" should be able to use all medical means of treatment, including radiotherapy and cytotoxic chemotherapy, and so serve the patient completely. For the general practice of oncology the technical knowledge required for good radiotherapy and good cytotoxic chemotherapy can be mastered by the same person. It is the clinical experience with patients with malignant disease which is paramount and which requires long years of training and this, of course, is common to the practitioners of both forms of treatment. All those who are concemed with the medical management of malignant disease, if unified, would be better able to make a sound and reasoned case for financial allocation in these difficult times. It could be that the financial problems of the day might break down the barriers and the prejudices between practitioners of the different forms of cancer treatment and make for a unified specialty and so to improved care for the patient with malignant disease. STANLEY DISCHE Regional Radiotherapy Centre, Mount Vernon Hospital, Northwood, Middx
tended to be clustered around the middle of the range and were often much better than in restaurants and cafes. After completion of the survey detailed recommendations were sent to each hospital and many improvements were made with the support of the regional catering officer. A code of practice, which has since been incorporated in the Department of Health and Social Security catering manual,' was prepared by a regional working party. Environmental health officers have a responsibility to enforce legislation which is orientated towards the physical environment. Structural changes are expensive and less important from the hygienic aspect than a careful control of procedures by means of adequate supervision and training. We agree that environmental health officers should be invited to visit hospital kitchens and to make recommendations but that the priorities must be decided by the hospital authorities. The greater involvement of environmental health officers not only in kitchens but also in other areas of hospital hygiene would be advantageous, particularly if more study of hospital problems was included in their training programme. Hospitals also differ from other establishments in that they have, or should have, an infection control committee and staff specialising in infection problems (microbiologist, technicians, infection control officer and nurse). These are responsible for advising the hospital authorities on all aspects of control of infection in all departments of the hospital.2 G A J AYLIFFE B J COLLINS
Hygiene in NHS hospitals SIR,-Although we agree with many of the comments made by Scrutator (26 March, p 851) and agree that hygienic standards in NHS hospitals should be high, we do not believe that legal enforcement is the method of choice, particularly if it involves certain areas of the hospital at the possible expense of the remainder. There is a risk that legal requirements will be based on the maximum possible rather than on commonsense measures. Recommendations should be made on the basis of actual risks of infection and on an assessment of the hazard throughout the service. Many of the new fire precautions recommendations for hospital pharmacy clean rooms, and the Health and Safety at Work Act regulations are tending to divert resources from essential patient areas where there are no statutory controls. Hospitals differ from hotels and restaurants in that there are many areas involving risk of infection to patients and, to a lesser extent, staff. In these times of budgetary restriction the individual hospital authority must decide on the allocation of money for provision of safe operating theatres, central sterile supply departments, intensive care units, isolation wards, etc as well as kitchens. However, we do agree that more finance is necessary to maintain the safety of these high-risk areas, particularly in older hospitals. Reports of outbreaks of food poisoning tend to exaggerate the incidence in hospitals, where microbiological services are more readily available and outbreaks are recognised more frequently than in the rest of the community. In collaboration with an environmental health officer we made a detailed survey of 28 hospital kitchens in the West Midlands in 1971, and visits were later made to local commercial establishments. It was found that hygienic practices and conditions in hospital kitchens
Hospital Infection Research Laboratory, Dudley Road Hospital, Birmingham
2
Hygiene in Catering Departments and Food Service Areas. Health Service Catering Manual, vol II. London, Catering and Dietetic Branch, DHSS, 1974. Control of Hospital Infection. A Practical Handbook, ed E J L Lowbury et al. London, Chapman and Hall, 1975.
Coronary heart disease and the menopause SIR,-Your interesting leading article (2 April, p 862) expresses doubts on the widely held view that female sex hormones are responsible for the relative immunity to coronary heart disease before the menopause. Your suggestion that alternative hypotheses are required prompts me to refer to studies pertaining to this problem in which we advanced the concept that the aging processes of mesenchymal tissues are interconnected. This applies in particular to involutionary osteoporosis and atherogenesis. Parish et all found no excessive coronary atherosclerosis in women castrated after the age of 41 in contrast to those castrated at an earlier age, who showed a high incidence of coronary heart disease 14-15 years after castration. This long interval between castration and the manifestation of coronary atherosclerosis raises doubts on a direct association of these processes. By contrast Young and Nordin,' using x-ray densitometry, have shown that reduced bone density develops within 1-2 years of induction of an artificial menopause. Similar results have been reported by other investigators. Thus osteoporosis precedes the development of atherosclerosis and its complications by a number of years.
The fundamental phenomenon of the paradox in nature is also reflected in the growth and decline of the human body. Calcium salts are essential for the development and maintenance of the skeletal system, but they also contribute to the aging of vital arteries. The skeletal system is the main storehouse not only for calcium but also for other minerals, in particular the heavy elements providing the alpha-ray activities. The latter, when acting over long periods in very small doses, are one of the most potent mutagenic agents. It has been shown for the first time that both calcium and the alpha-ray activities increase with age in those large human arteries which are prone to develop atherosclerosis.3 A statistically significant correlation between the ash concentrations and the alpha-ray activities has been found in aortas and in coronary arteries but not in the pulmonary arteries. The latter are rarely affected by significant atherosclerosis. The correlation is most marked in the coronary arteries of individuals who died of coronary artery disease.5 Too little attention has been paid to the distinct sex differences in the aging process. During the childbearing age the female cartilages, particularly the ventral costal cartilages, show a significantly greater affinity for calcium than those of males.6 By contrast the calcium concentrations in the aorta in women are lower than in men up to the seventh decade of life. Thereafter this sex difference is reversed. In no other group of patients of comparable age have we found a higher incidence of extensive calcified atherosclerosis in the abdominal aorta than in women with senile osteoporosis.7 Our findings have been confirmed by Dent et al.8 Atherogenesis is a multifarious process and only some aspects of our studies have been mentioned. Our results suggest that the skeletal system plays a major part in atherogenesis. The phenomenom of transmineralisation is connected with involutionary osteoporosis. Its rate of progress varies from individual to individual and is at least partly influenced by the degree of sex hormone deficiency. The sex differences in the tissue mineral metabolism referred to may explain why women before the menopause are relatively immune to coronary artery disease and why the rate of increase of atherosclerosis and its complications is greater in women than in men in the high age groups. A ELKELES Prince of Wales's General
Hospital,
London N15
Parish, A, et al, American Journal of Obstetrics and Gynecology, 1967, 99, 155. Young, M M, and Nordin, B E C, Proceedings of the Royal Society of Medicine, 1967, 60, 1137. a Elkeles, A, British Journal of Radiology, 1961, 34, 602. 'Elkeles, A, Journal of the American Geriatrics Society, 1966, 14, 895. Elkeles, A, Nature, 1969, 221, 662. Elkeles, A, Journal of the American Geriatrics Society. 1966, 14, 456. 7Elkeles, A, Lancet, 1957, 2, 714. 8 Dent, C E, et al, British Medical_Journal, 1968, 4, 76.
SIR,-In your leading article on this subject (2 April, p 862) you describe a Swedish study in which 76 % of women admitted to hospital with myocardial infarction had experienced the menopause by the age of 50, whereas only 48 % of controls had done so as "the best evidence yet of an association between an early menopause and coronary heart disease." You admit
