51
increases potassium conductance, and this mechanism may mediate hyperpolarisation. Following NANC inhibitory nerve activity, many gastrointestinal muscles show "rebound excitation", a period in which contractile activity increases. Rebound may be mediated by a mechanism involving nitric oxide and prostaglandins. A prejunctional role for nitric oxide was also proposed, the substance acting in some tissues as a modulator of excitatory peptidergic transmission rather than as a mediator of inhibitory
neurotransmission. Besides a role in normal physiology, nitric oxide plays an important part in pathophysiological responses in peripheral organs. In many cells nitric oxide synthase is induced by agents such as y-interferon, endotoxins, and interleukin-lp. Molecular studies, now underway, of the genes that encode nitric oxide synthase should greatly enhance our understanding of the role of nitric oxide in many clinical disorders. Department of Physiology, University of Nevada School of Medicine, Reno, NV 89557, USA
KENTON SANDERS
Medicine and the Law Informed consent when
an
investigation is
interrupted After the
subarachnoid haemorrhage, a underwent two angiograms at a 49-year-old Canadian hospital. Her fully informed consent was obtained before the first. During the second procedure a week later, the woman became agitated and insisted that the test be stopped. It was subsequently completed but 10-15 min She afterwards quadriplegia ensued. sued the neurosurgeon, the hospital, and others, claiming $Can1800 000. Mr Justice Dupont dismissed her claim on all counts but the administrators of her estate (she had died after the trial) appealed, in particular against the judge’s finding that the second angiogram had been done with the plaintiff’s consent. Although the patient’s consent had been suspended when she asked for the test to be stopped, she had subsequently, after calming down, validly consented to completion of the procedure, the judge had said. The appeal was dismissed. The plaintiff had emigrated from Italy to Canada in 1955. On Dec 20, 1980, while at work at Mount Sinai Hospital, Toronto, she had a severe headache and a neurosurgeon in the emergency department, Dr 1. B. Schacter, diagnosed grade 1 subarachnoid haemorrhage. Medical evidence at trial was that there was a 20% likelihood of a re-bleed within 3 months if the aneurysm was not surgically treated, that 10% of those surviving a re-bleed will have another within 3-5 years, and that of those who do re-bleed at any time 67% will die. Before any surgery the site of the lesion has to be located, and the only procedure used in 1980 for that purpose was a cerebral angiogram. This investigation carries risks but they were far less than those of leaving the subarachnoid haemorrhage untreated. The rate of morbidity from angiography is 5% or less and most problems are transient. The plaintiff was transferred to Toronto General Hospital, where an angiogram was done on Dec 22, 1980, by Dr M. A. Keller. No aneurysm was located but the superior aspect of the right internal carotid artery termination was
identified
"area of suspicion". On Dec 29 a second angiogram was done by Dr R. A. Greco. While he was trying to position the catheter for injection the patient screamed and started to breathe very quickly and suddenly flexed her hips. Dr Keller, who was near by, went to investigate and found the patient "thrashing around on the table" and "wildly hyperventilating"; her fingers had become rigid and claw-like ("in tetany") and her arms were flexed at the elbows. Dr Keller testified that at this point the patient had said, "Enough. No more. Stop the test". Her right hand was numb and she could not move her right hand or grip with it; the left side of her hand was also weak. The doctors waited 10-15 min, by which time the right hand still had no grip but the left had returned to normal strength. Dr Keller, assisted by Dr Greco, inserted the catheter into the left vertebral artery and the angiogram procedure was completed, but no source for the subarachnoid haemorrhage was identified and the patient had no episode of re-bleeding. Immediately upon termination of the angiogram alarming symptoms developed. A neurosurgeon was summoned but complete quadriplegia rapidly ensued, and it was accepted that this had been caused by the final injection. The administrators of the patient’s estate claimed that there had been no informed consent to the continuation of the second angiogram. They took no issue with the consent given for the first procedure and for the initiation of the second. Giving the leading judgment in the Court of Appeal, Finlayson _7A reviewed the two episodes of informed as an
diagnosis of
consent.
woman
Blood in the patient’s CSF and a brain scan had confirmed subarachnoid haemorrhage and the patient and her daughter (who acted as interpreter) were informed of the need for angiogram before surgical repair. Dr Schacter had fully explained the diagnosis and the implications. The judge found that he advised the daughter that people could die or become temporarily or permanently paralysed and that she had understood this. As a rule Dr Schacter avoided telling patients with subarachnoid haemorrhage of the risk of death from angiography because of the agitation that usually results from that knowledge but he felt the family was entitled to know, and this policy was not unusual in dealing with patients with aneurysm. The daughter signed the consent forms on behalf of her mother. However, before the first angiogram, Dr Keller gained the impression that the patient was insufficiently informed and she referred her back to Mount Sinai Hospital where the procedure was again explained in the presence of the daughter. Dr Keller was then satisifed that the patient did understand the risks of blindness, paralysis, stroke, or death. When Dr Schacter had advised her to have a second angiogram the patient indicated she did not like the test but she agreed, and when she presented at the hospital on Dec 29 her conduct did not indicate refusal to submit to the procedure. Her consent was informed and the doctors had gone to considerable lengths to ensure this. The judge found that though consent had been suspended when the patient asked that the test be stopped she had, in agreeing that it be resumed, "freely reactivated her consent... There was no need to repeat the details of the procedure ... nor the attendant risks". Deciding, in circumstances such as this, whether to continue the test was a matter of medical judgment, the judge said, and the doctors had had to decide on the spot. Their evidence was that they weighed up the risks of stopping or continuing, and the decision to continue was in line with a responsible body of medical opinion.
52
For the patient it was submitted that the doctors should have interrupted the procedure for long enough to explain fully what had occurred and provide reasons for continuation or, in the face of the language problem and anxiety, it might have been better to have ended the process and consulted Dr Schacter as to whether a third angiogram should be attempted. However, the Court of Appeal ruled that in such a case "legal precision must give way to medical judgment... To have dumped the problem in her lap at this time would have been a complete abdication of professional responsibility". That judgment had been properly exercised. Ciarlariello et al v Schacter et al. Canada: Ontario, Court of Appeal: Fmlayson, McKinlay and Griffiths,71A. Jan 11, 1991.
Diana Brahams
Obituary A. G. L. Ives Glen Ives, who died on Oct 1, 1991, was secretary of the King’s Fund from 1938 to 1960-a period that included the blitz and the first twelve years of the National Health Service. Academic, congenial, and deeply respected by his colleagues, he had great influence in his day over the character of health provision. secretary of the King’s Fund coincided with changes in health provision. He was involved in the establishment of the Emergency Bed Service. Upon the outbreak of Ives’
Noticeboard Foxing the rabies virus Encouraging results from a Belgian field trial of a new oral rabies vaccine’ are good news for foxes, the main European reservoir of the rabies virus, which are at present being culled in an attempt to control the disease. Good news too for human populations world wide, for the new, live, vaccine (a recombinant vaccinia virus carrying the surface glycoprotein of the ERA strain of rabies virus) appears to be effective in a number of animal species, stable, and harmless to both domestic and wild animals, unlike vaccines derived from attentuated rabies virus strains, which are ineffective in some species (including the racoon, a common North American vector) and can also revert to virulence. Efforts to control the European rabies epidemic, which started in Poland in the 1940s, have been directed at reducing fox density to below the critical level required for persistence of the infection, thought to be around 0-4 animals per km2. But culling is expensive and has to be continued even when the disease is rare. Vaccination coverage needs to be at least 80% if fox culling is to be abandoned, and 90% where fox density is especially high, as in some suburban areas. In the Belgian trial, which covered a 2200 km2 area of high endemicity and an average fox density of 2 animals per km2, the vaccine (with a tetracycline marker) was distributed in bait, and mean vaccine uptake in foxes inspected was found to be 81 %. The trial ran for a year from November, 1989, and no cases of rabies in foxes or domestic animals were reported after June, 1990. If vaccination replaces culling, fox density is likely to rise as a consequence of the reduced incidence of rabies as well as the cessation of culling itself, and in these circumstances vaccination coverage may need to be maintained at over 80%.2
tenure as
momentous
1 Brochier B, Kieny P, Costy F, et al Large-scale eradication of rabies using recombinant vaccinia-rabies vaccine. Nature 1991; 354: 520-22.
the war, he continued his normal duties but took on additional work as secretary to the War Emergency Committee, which gave him a national responsibility. He helped to plan for the medical care of war casualties and to organise hospital supplies from America. He also wrote on the use of marginal land for food
2 Anderson RM. Immunization
production. When Bevan’s scheme for post-war reconstruction emerged, the Fund argued the cause of the voluntary hospitals. Ives warned of the dangers of management by remote control and the need to maintain a gap for charitable contributions in the new service. It was essential, in his view, that competition and variety be kept in the system; therefore, the hospitals should retain as much independence and local management as possible. Bevan’s concessions to the voluntary lobby, especially the retention of hospital endowments, and the independence granted to the teaching hospitals owed much to the pressure exerted by Ives and his
King’s
colleagues. Although he had argued against the nationalisation of the voluntary hospitals, Ives came to admire the NHS for extending equitable health provision to a wider population. What he sought after 1948 was a more effective partnership between charitable and government provision. When he helped to establish the Fund’s pioneering Hospital Administrative Staff College (the King’s Fund College today) he hoped that it would produce hospital managers who would promote flexibility and in the NHS. Ives was unusual among health in having a strong historical sense-a conviction that planning must pay due regard to individual institutions and inherited practices. In his retirement, Ives maintained a lively, humorous interest in many things, despite permanent handicaps stemming from the Lewisham train crash. He painted, in water-colour and oils; he was a great gardener; and above all, he was a family man, looking after his wife with great devotion until her death after a long illness in 1987 and taking great delight in his children and
decentralisation
commentators on
grandchildren. Robert Maxwell Frank Prochaska
in
the field. Nature 1991; 354: 502-03.
Vitamins and neural tube defects The Chief Medical Officer of the Department of Health has set up an expert group to consider the dietary implications of the report from the Medical Research Council Vitamin Study Research Group on the prevention of neural tube defects with vitamin supplements (Lancet 1991; 338: 131-37). Concise written submissions based on reasoned argument and scientific data from interested parties are invited. Submissions should be sent to Dr P. Clarke, Department of Health, Room 541, Wellington House, 133-155 Waterloo Road, London SE1 8UG.
Falls in the
elderly
A comprehensive service for elderly persons who fall is being designed for Camberwell Health Authority. Part of the preparatory work included an examination of existing service for these people in six similar health districts in Britain and of several centres elsewhere that are investigating innovative schemes.! The survey of British practice was hospital-based and showed that neither accident and emergency nor geriatric departments categorised elderly people who fall as a distinct group for easy identification, and that there was a tendency, especially in accident and emergency units, to concentrate on treatment of injuries sustained in the fall, without assessment of the underlying cause or adequate planning for aftercare and prevention of further falls. None of the innovative schemes was comprehensive, though each had good features. The project in Portland, Oregon, for example, includes group sessions on health education and health promotion aimed at getting patients to modify behaviour so as to minimise risk of fall. Preliminary results indicate that the education measures have led to a reduction in falls and admission rates. 1. Adams S, Askham J, Glucksman E, Swift C, Tinker A. Falls and elderly people: a study of current professional practice in England and innovations abroad. London Age Concern Institute of Gerontology, King’s College London, London SE1 8TX. 1991. Pp 55. £5(incl postage and packing). ISBN 1-872342558.
increases potassium conductance, and this mechanism may mediate hyperpolarisation. Following NANC inhibitory nerve activity, many gastrointestinal muscles show "rebound excitation", a period in which contractile activity increases. Rebound may be mediated by a mechanism involving nitric oxide and prostaglandins. A prejunctional role for nitric oxide was also proposed, the substance acting in some tissues as a modulator of excitatory peptidergic transmission rather than as a mediator of inhibitory
neurotransmission. Besides a role in normal physiology, nitric oxide plays an important part in pathophysiological responses in peripheral organs. In many cells nitric oxide synthase is induced by agents such as y-interferon, endotoxins, and interleukin-lp. Molecular studies, now underway, of the genes that encode nitric oxide synthase should greatly enhance our understanding of the role of nitric oxide in many clinical disorders. Department of Physiology, University of Nevada School of Medicine, Reno, NV 89557, USA
KENTON SANDERS
Medicine and the Law Informed consent when
an
investigation is
interrupted After the
subarachnoid haemorrhage, a underwent two angiograms at a 49-year-old Canadian hospital. Her fully informed consent was obtained before the first. During the second procedure a week later, the woman became agitated and insisted that the test be stopped. It was subsequently completed but 10-15 min She afterwards quadriplegia ensued. sued the neurosurgeon, the hospital, and others, claiming $Can1800 000. Mr Justice Dupont dismissed her claim on all counts but the administrators of her estate (she had died after the trial) appealed, in particular against the judge’s finding that the second angiogram had been done with the plaintiff’s consent. Although the patient’s consent had been suspended when she asked for the test to be stopped, she had subsequently, after calming down, validly consented to completion of the procedure, the judge had said. The appeal was dismissed. The plaintiff had emigrated from Italy to Canada in 1955. On Dec 20, 1980, while at work at Mount Sinai Hospital, Toronto, she had a severe headache and a neurosurgeon in the emergency department, Dr 1. B. Schacter, diagnosed grade 1 subarachnoid haemorrhage. Medical evidence at trial was that there was a 20% likelihood of a re-bleed within 3 months if the aneurysm was not surgically treated, that 10% of those surviving a re-bleed will have another within 3-5 years, and that of those who do re-bleed at any time 67% will die. Before any surgery the site of the lesion has to be located, and the only procedure used in 1980 for that purpose was a cerebral angiogram. This investigation carries risks but they were far less than those of leaving the subarachnoid haemorrhage untreated. The rate of morbidity from angiography is 5% or less and most problems are transient. The plaintiff was transferred to Toronto General Hospital, where an angiogram was done on Dec 22, 1980, by Dr M. A. Keller. No aneurysm was located but the superior aspect of the right internal carotid artery termination was
identified
"area of suspicion". On Dec 29 a second angiogram was done by Dr R. A. Greco. While he was trying to position the catheter for injection the patient screamed and started to breathe very quickly and suddenly flexed her hips. Dr Keller, who was near by, went to investigate and found the patient "thrashing around on the table" and "wildly hyperventilating"; her fingers had become rigid and claw-like ("in tetany") and her arms were flexed at the elbows. Dr Keller testified that at this point the patient had said, "Enough. No more. Stop the test". Her right hand was numb and she could not move her right hand or grip with it; the left side of her hand was also weak. The doctors waited 10-15 min, by which time the right hand still had no grip but the left had returned to normal strength. Dr Keller, assisted by Dr Greco, inserted the catheter into the left vertebral artery and the angiogram procedure was completed, but no source for the subarachnoid haemorrhage was identified and the patient had no episode of re-bleeding. Immediately upon termination of the angiogram alarming symptoms developed. A neurosurgeon was summoned but complete quadriplegia rapidly ensued, and it was accepted that this had been caused by the final injection. The administrators of the patient’s estate claimed that there had been no informed consent to the continuation of the second angiogram. They took no issue with the consent given for the first procedure and for the initiation of the second. Giving the leading judgment in the Court of Appeal, Finlayson _7A reviewed the two episodes of informed as an
diagnosis of
consent.
woman
Blood in the patient’s CSF and a brain scan had confirmed subarachnoid haemorrhage and the patient and her daughter (who acted as interpreter) were informed of the need for angiogram before surgical repair. Dr Schacter had fully explained the diagnosis and the implications. The judge found that he advised the daughter that people could die or become temporarily or permanently paralysed and that she had understood this. As a rule Dr Schacter avoided telling patients with subarachnoid haemorrhage of the risk of death from angiography because of the agitation that usually results from that knowledge but he felt the family was entitled to know, and this policy was not unusual in dealing with patients with aneurysm. The daughter signed the consent forms on behalf of her mother. However, before the first angiogram, Dr Keller gained the impression that the patient was insufficiently informed and she referred her back to Mount Sinai Hospital where the procedure was again explained in the presence of the daughter. Dr Keller was then satisifed that the patient did understand the risks of blindness, paralysis, stroke, or death. When Dr Schacter had advised her to have a second angiogram the patient indicated she did not like the test but she agreed, and when she presented at the hospital on Dec 29 her conduct did not indicate refusal to submit to the procedure. Her consent was informed and the doctors had gone to considerable lengths to ensure this. The judge found that though consent had been suspended when the patient asked that the test be stopped she had, in agreeing that it be resumed, "freely reactivated her consent... There was no need to repeat the details of the procedure ... nor the attendant risks". Deciding, in circumstances such as this, whether to continue the test was a matter of medical judgment, the judge said, and the doctors had had to decide on the spot. Their evidence was that they weighed up the risks of stopping or continuing, and the decision to continue was in line with a responsible body of medical opinion.
52
For the patient it was submitted that the doctors should have interrupted the procedure for long enough to explain fully what had occurred and provide reasons for continuation or, in the face of the language problem and anxiety, it might have been better to have ended the process and consulted Dr Schacter as to whether a third angiogram should be attempted. However, the Court of Appeal ruled that in such a case "legal precision must give way to medical judgment... To have dumped the problem in her lap at this time would have been a complete abdication of professional responsibility". That judgment had been properly exercised. Ciarlariello et al v Schacter et al. Canada: Ontario, Court of Appeal: Fmlayson, McKinlay and Griffiths,71A. Jan 11, 1991.
Diana Brahams
Obituary A. G. L. Ives Glen Ives, who died on Oct 1, 1991, was secretary of the King’s Fund from 1938 to 1960-a period that included the blitz and the first twelve years of the National Health Service. Academic, congenial, and deeply respected by his colleagues, he had great influence in his day over the character of health provision. secretary of the King’s Fund coincided with changes in health provision. He was involved in the establishment of the Emergency Bed Service. Upon the outbreak of Ives’
Noticeboard Foxing the rabies virus Encouraging results from a Belgian field trial of a new oral rabies vaccine’ are good news for foxes, the main European reservoir of the rabies virus, which are at present being culled in an attempt to control the disease. Good news too for human populations world wide, for the new, live, vaccine (a recombinant vaccinia virus carrying the surface glycoprotein of the ERA strain of rabies virus) appears to be effective in a number of animal species, stable, and harmless to both domestic and wild animals, unlike vaccines derived from attentuated rabies virus strains, which are ineffective in some species (including the racoon, a common North American vector) and can also revert to virulence. Efforts to control the European rabies epidemic, which started in Poland in the 1940s, have been directed at reducing fox density to below the critical level required for persistence of the infection, thought to be around 0-4 animals per km2. But culling is expensive and has to be continued even when the disease is rare. Vaccination coverage needs to be at least 80% if fox culling is to be abandoned, and 90% where fox density is especially high, as in some suburban areas. In the Belgian trial, which covered a 2200 km2 area of high endemicity and an average fox density of 2 animals per km2, the vaccine (with a tetracycline marker) was distributed in bait, and mean vaccine uptake in foxes inspected was found to be 81 %. The trial ran for a year from November, 1989, and no cases of rabies in foxes or domestic animals were reported after June, 1990. If vaccination replaces culling, fox density is likely to rise as a consequence of the reduced incidence of rabies as well as the cessation of culling itself, and in these circumstances vaccination coverage may need to be maintained at over 80%.2
tenure as
momentous
1 Brochier B, Kieny P, Costy F, et al Large-scale eradication of rabies using recombinant vaccinia-rabies vaccine. Nature 1991; 354: 520-22.
the war, he continued his normal duties but took on additional work as secretary to the War Emergency Committee, which gave him a national responsibility. He helped to plan for the medical care of war casualties and to organise hospital supplies from America. He also wrote on the use of marginal land for food
2 Anderson RM. Immunization
production. When Bevan’s scheme for post-war reconstruction emerged, the Fund argued the cause of the voluntary hospitals. Ives warned of the dangers of management by remote control and the need to maintain a gap for charitable contributions in the new service. It was essential, in his view, that competition and variety be kept in the system; therefore, the hospitals should retain as much independence and local management as possible. Bevan’s concessions to the voluntary lobby, especially the retention of hospital endowments, and the independence granted to the teaching hospitals owed much to the pressure exerted by Ives and his
King’s
colleagues. Although he had argued against the nationalisation of the voluntary hospitals, Ives came to admire the NHS for extending equitable health provision to a wider population. What he sought after 1948 was a more effective partnership between charitable and government provision. When he helped to establish the Fund’s pioneering Hospital Administrative Staff College (the King’s Fund College today) he hoped that it would produce hospital managers who would promote flexibility and in the NHS. Ives was unusual among health in having a strong historical sense-a conviction that planning must pay due regard to individual institutions and inherited practices. In his retirement, Ives maintained a lively, humorous interest in many things, despite permanent handicaps stemming from the Lewisham train crash. He painted, in water-colour and oils; he was a great gardener; and above all, he was a family man, looking after his wife with great devotion until her death after a long illness in 1987 and taking great delight in his children and
decentralisation
commentators on
grandchildren. Robert Maxwell Frank Prochaska
in
the field. Nature 1991; 354: 502-03.
Vitamins and neural tube defects The Chief Medical Officer of the Department of Health has set up an expert group to consider the dietary implications of the report from the Medical Research Council Vitamin Study Research Group on the prevention of neural tube defects with vitamin supplements (Lancet 1991; 338: 131-37). Concise written submissions based on reasoned argument and scientific data from interested parties are invited. Submissions should be sent to Dr P. Clarke, Department of Health, Room 541, Wellington House, 133-155 Waterloo Road, London SE1 8UG.
Falls in the
elderly
A comprehensive service for elderly persons who fall is being designed for Camberwell Health Authority. Part of the preparatory work included an examination of existing service for these people in six similar health districts in Britain and of several centres elsewhere that are investigating innovative schemes.! The survey of British practice was hospital-based and showed that neither accident and emergency nor geriatric departments categorised elderly people who fall as a distinct group for easy identification, and that there was a tendency, especially in accident and emergency units, to concentrate on treatment of injuries sustained in the fall, without assessment of the underlying cause or adequate planning for aftercare and prevention of further falls. None of the innovative schemes was comprehensive, though each had good features. The project in Portland, Oregon, for example, includes group sessions on health education and health promotion aimed at getting patients to modify behaviour so as to minimise risk of fall. Preliminary results indicate that the education measures have led to a reduction in falls and admission rates. 1. Adams S, Askham J, Glucksman E, Swift C, Tinker A. Falls and elderly people: a study of current professional practice in England and innovations abroad. London Age Concern Institute of Gerontology, King’s College London, London SE1 8TX. 1991. Pp 55. £5(incl postage and packing). ISBN 1-872342558.
