practice was also interpreted by a few as exhibiting Journal bias in favour of community health centres. We respectfully suggest that the purported bias of the Journal, either for or against community health centres, does not exist. Our purpose is to provide the medical profession of Canada with an effective, interesting vehicle for communication, to explore all aspects and viewpoints on subjects of interest to the profession and to provide a forum for the dissemination of responsible, scientifically valid information and informed opinion. We welcome constructive criticism and suggestions as to how we may more effectively meet the needs and desires of Journal readers.D.A. Geekie] Coexistence of photochromogenic mycobacteria and carcinoma To the editor: The coexistence of pulmonary tuberculosis and bronchogenic carcinoma was first described by Bayle in 1810.1 Many later publications have dealt with the relation between tuberculosis and bronchogenic carcinoma. Snider and Placik in 19692 quoted 50 references concerning this relation. A total of 391 cases of concurrent pulmonary tuberculosis and bronchogenic carcinoma were reported by Fontenelle and Campbell,3 Madey et at. and Rabukhin and Upiter.5 On the other hand, the coexistence of photochi c.mogenic mycobacteria (Mycobacterium kansasii) and carcinoma is rarely reported. Goudemand and colleagues6 reviewed the literature between 1949 and 1970 and were able to find only 10 cases. Gradaus and colleagues7 in 1973 reported a single case. The nomenclature of mycobacteria is frequently confusing. For many years mycobacteria other than M. tuberculosis have been recognized and referred to as "atypical". Occasionally they have been described also as "anonymous". Tn 1959 Runyon8 recommended his classification, which divides all atypical
mycobacteria into four groups. In 1963 the American Thoracic Society proposed the name "unclassified" rather than "atypical" or "anonymous. "i' In 1970 Wayne10 suggested "atypical" was the best of the three old terms. British authors usually use the name "opportunist mycobacteria", which was introduced by Marks and Jenkins in 197 1." The terms "atypical", "anonymous", "unclassified" and "opportunist" refer to the same group of organisms. One member of the group of photochromogenic mycobacteria, M. kansasii, can be responsible for severe pulmonary disease in man. The lesions caused by this organism are clinically, radiologically and histologically indistinguishable from those produced by M. tuberculosis.3 M. kansasii has also been isolated from the spinal fluid, spleen, pancreas, hip joint, lymph nodes and urine.12 Over a period of 9 years (1964 to 1973) we have isolated photochromogenic mycobacteria from 429 patients. We have been able to obtain limited information about 159 patients; 18 of them (11 %) also suffered from carcinoma (Table I). Twelve (67%) of the 18 patients had photochromogenic mycobacteria in their sputum and 11 of them had pulmonary carcinoma or carcinoma in closely situated organs. Six of the 18 patients (33%) had photochromogenic mycobacteria in their urine and 5 of them had urinary tract carcinoma or carcinoma in nearby organs. In all 18 cases the organism was M. kansasii. On the basis of the present data it is difficult to suggest either an association or a cause and effect relation between photochromogenic mycobacteria and carcinoma; however, such possibilities cannot be entirely excluded and deserve further investigation. Z.K. EPNERS, M Sc Central Laboratories Ontario Ministry of Health Toronto, Ont.
Table I-Patients with carcinoma and photoobromogenic mycobacteria Source of bacteria Sputum Urine Type of carcinoma No. of patients Sex No. of patients Bronchogenic 5 Male Oral 2 Male Diffuse bony, with metastasis from unknown primary 2 Male Metastatic hypernephroma1 Male Lymphoma 1 Male Lymphoma 1 Female R.nal 1 Male Prostate 2 Bladder and cervical 1 Rectal 1 Metastatic breast 1 1164 CMA JOURNAL/MAY 17, 1975/VOL. 112
References 1. BAYLE GL: Researches on pulmonary phthtsis, translated by BARROW W, Longmans, Liverpool, 1815 2. SNIDER GL, PLACIK B: The relationship between pulmonary tuberculosis and bronchogenic carcinoma. Am Rev Resp Dis 99: 229, 1969 3. FONTENELLE LI, CAMPBELL D: Coexisting bronchogenic carcinoma and pulmonary tuberculosis. Ann Thorac Surg 9: 431, 1970 4. MADEY J, LAcHowlcz 0, SZYMAN5KA D, et al: [Bronchial carcinoma associated with pulmonary tuberculosis.] Gruzlica 40: 285, 1972 .. RABURHIN AE, UPITER MZ: [On the relationship between cancer and tuberculosis of the lung.] Vopr Onkol 17: 24, 1971 6. GOUDEMAND M, BAUTERS F, LEDUC A, et al: Mycobact6rioses g.n.ralis&s . manifestation hematologiques (infection mortelle h Mycobacterium kansasit avec reaction leuc6moide de type my.lo1de). Rev Tubere Pneumol (Paris) 34: 225, 1970 7. GRADAUS D, RIrrER 5, KIENECKER B, et al: Generalisierte atypische Mykobakteriose (M. kansasii) bet einer Lymphogranulomatose. Med Welt 42: 1611, 1973 8. RUNYON EH: Anonymous mycobacteria in pulmonary disease. Med Clin North Am 43: 273, 1959 9. CORPE FR, RUNYON EH, LEsTER W: Status of disease due to unclassified mycobacteria. Am Rev Resp Dis 87: 459, 1963 10. WAYNE LG: General term for mycobacteria other than Mycobacterium tuberculosis. Am Rev Resp Dis 102: 990, 1970 11. MARKS J, JENKINS PA: The opportunist mycobacteria - a 20-year retrospect. Postgrad Med 1 47: 705, 1971 12. RUNYON EH: Pathogenic mycobacteria. Adv Tuberc Res 14: 235, 1965
Nurse practitioners To the editor: The report of the paper "Surgical course for northern nurse practitioners", presented by Dr. G. W. Scott at the 1975 annual meeting of the Royal College of Physicians and Surgeons of Canada (Can Med Assoc J 112: 347, 1975), is misleading because it contains several inaccuracies. The nurse practitioner program at the University of Alberta is 4 months long and includes training in obstetrics, pediatrics and the assessment of medical and surgical patients, and includes 12 hours in the Surgical-Medical Research Institute, learning certain surgical skills such as suturing lacerations, intravenous and cutdown techniques and thoracentesis. I would like to correct the erroneous impression given in the Journal report that the graduates from this course are "surgeons". S. MILLER, MD, FRcP[Cj
Medical director Nurse practitioner program School of nursing The University of Alberta Edmonton, Alta.
The medical record Sex
Male Female Female Female
To the editor: The wording of the third paragraph of the Consumer Viewpoint "Shall I not ask for whom the medical record is kept?" (Can Med Assoc J 112: 508, 1975) invites ambiguity. Two separate questions are implied although only one is spelled out. Medical records are kept for "the benefit of" the patient but for "the use of" the doctor. R. MoluusoN MITChELL, MD
Sudbury, Ont.
mycobacteria into four groups. In 1963 the American Thoracic Society proposed the name "unclassified" rather than "atypical" or "anonymous. "i' In 1970 Wayne10 suggested "atypical" was the best of the three old terms. British authors usually use the name "opportunist mycobacteria", which was introduced by Marks and Jenkins in 197 1." The terms "atypical", "anonymous", "unclassified" and "opportunist" refer to the same group of organisms. One member of the group of photochromogenic mycobacteria, M. kansasii, can be responsible for severe pulmonary disease in man. The lesions caused by this organism are clinically, radiologically and histologically indistinguishable from those produced by M. tuberculosis.3 M. kansasii has also been isolated from the spinal fluid, spleen, pancreas, hip joint, lymph nodes and urine.12 Over a period of 9 years (1964 to 1973) we have isolated photochromogenic mycobacteria from 429 patients. We have been able to obtain limited information about 159 patients; 18 of them (11 %) also suffered from carcinoma (Table I). Twelve (67%) of the 18 patients had photochromogenic mycobacteria in their sputum and 11 of them had pulmonary carcinoma or carcinoma in closely situated organs. Six of the 18 patients (33%) had photochromogenic mycobacteria in their urine and 5 of them had urinary tract carcinoma or carcinoma in nearby organs. In all 18 cases the organism was M. kansasii. On the basis of the present data it is difficult to suggest either an association or a cause and effect relation between photochromogenic mycobacteria and carcinoma; however, such possibilities cannot be entirely excluded and deserve further investigation. Z.K. EPNERS, M Sc Central Laboratories Ontario Ministry of Health Toronto, Ont.
Table I-Patients with carcinoma and photoobromogenic mycobacteria Source of bacteria Sputum Urine Type of carcinoma No. of patients Sex No. of patients Bronchogenic 5 Male Oral 2 Male Diffuse bony, with metastasis from unknown primary 2 Male Metastatic hypernephroma1 Male Lymphoma 1 Male Lymphoma 1 Female R.nal 1 Male Prostate 2 Bladder and cervical 1 Rectal 1 Metastatic breast 1 1164 CMA JOURNAL/MAY 17, 1975/VOL. 112
References 1. BAYLE GL: Researches on pulmonary phthtsis, translated by BARROW W, Longmans, Liverpool, 1815 2. SNIDER GL, PLACIK B: The relationship between pulmonary tuberculosis and bronchogenic carcinoma. Am Rev Resp Dis 99: 229, 1969 3. FONTENELLE LI, CAMPBELL D: Coexisting bronchogenic carcinoma and pulmonary tuberculosis. Ann Thorac Surg 9: 431, 1970 4. MADEY J, LAcHowlcz 0, SZYMAN5KA D, et al: [Bronchial carcinoma associated with pulmonary tuberculosis.] Gruzlica 40: 285, 1972 .. RABURHIN AE, UPITER MZ: [On the relationship between cancer and tuberculosis of the lung.] Vopr Onkol 17: 24, 1971 6. GOUDEMAND M, BAUTERS F, LEDUC A, et al: Mycobact6rioses g.n.ralis&s . manifestation hematologiques (infection mortelle h Mycobacterium kansasit avec reaction leuc6moide de type my.lo1de). Rev Tubere Pneumol (Paris) 34: 225, 1970 7. GRADAUS D, RIrrER 5, KIENECKER B, et al: Generalisierte atypische Mykobakteriose (M. kansasii) bet einer Lymphogranulomatose. Med Welt 42: 1611, 1973 8. RUNYON EH: Anonymous mycobacteria in pulmonary disease. Med Clin North Am 43: 273, 1959 9. CORPE FR, RUNYON EH, LEsTER W: Status of disease due to unclassified mycobacteria. Am Rev Resp Dis 87: 459, 1963 10. WAYNE LG: General term for mycobacteria other than Mycobacterium tuberculosis. Am Rev Resp Dis 102: 990, 1970 11. MARKS J, JENKINS PA: The opportunist mycobacteria - a 20-year retrospect. Postgrad Med 1 47: 705, 1971 12. RUNYON EH: Pathogenic mycobacteria. Adv Tuberc Res 14: 235, 1965
Nurse practitioners To the editor: The report of the paper "Surgical course for northern nurse practitioners", presented by Dr. G. W. Scott at the 1975 annual meeting of the Royal College of Physicians and Surgeons of Canada (Can Med Assoc J 112: 347, 1975), is misleading because it contains several inaccuracies. The nurse practitioner program at the University of Alberta is 4 months long and includes training in obstetrics, pediatrics and the assessment of medical and surgical patients, and includes 12 hours in the Surgical-Medical Research Institute, learning certain surgical skills such as suturing lacerations, intravenous and cutdown techniques and thoracentesis. I would like to correct the erroneous impression given in the Journal report that the graduates from this course are "surgeons". S. MILLER, MD, FRcP[Cj
Medical director Nurse practitioner program School of nursing The University of Alberta Edmonton, Alta.
The medical record Sex
Male Female Female Female
To the editor: The wording of the third paragraph of the Consumer Viewpoint "Shall I not ask for whom the medical record is kept?" (Can Med Assoc J 112: 508, 1975) invites ambiguity. Two separate questions are implied although only one is spelled out. Medical records are kept for "the benefit of" the patient but for "the use of" the doctor. R. MoluusoN MITChELL, MD
Sudbury, Ont.
