166 An important question posed by Dr Carter and his colleagues is how to provide the variety of established diagnostic procedures and the associated interpretative skills which are necessary for the modern practice of
medicine. The automation of the " bread-and-butter " work is the least of our problems. Can the small laboratory in the small hospital with a small staff provide the skills and experience to perform the wide range of tests which the clinicians demand ? The day is long past when a single chemical pathologist can cover adequately all branches of his subject. For him as for the clinician " no doctor can know in depth, or have had experience in, all branches of medicine ", as Dr Carter and his colleagues point out. Their conclusions in respect of a pathologist’s duties and of the departmental size are wise and sound, but there is the underlying assumption that the chemical pathologist should remain a " jack of all trades ". For people entering and training in the profession this counsel certainly must not be allowed to prevail if the best biochemical advice on patient care is to be ensured now and in the future. Chemical pathology is divisible into at least eight branches,2 the mastery of each of which may need upwards of ten years’ careful dedication and training in the ward and in the laboratory. In many of the best laboratories in Britain and abroad the need is stressed for the necessary variety of experts to provide a comprehensive clinical service.2,3 Only the very largest of centres can afford to have sub-units with experts in charge of each branch; elsewhere this could be achieved by neighbouring hospitals arranging for each of their senior biochemists to specialise in a particular branch. The hardest task which a chemical pathologist or clinical biochemist faces is to provide a service which is clinically relevant. He (or she) is likely to find the work more satisfying if it permits a degree of specialisation. Division of Clinical Chemistry, Clinical Research Centre and Northwick Park Hospital, Harrow, Middlesex HA1 3UJ.
paper
case
for the
"
6
"
more difficult and parathyroid-hormone assays available needs them. The recruitment, training, and retention of high calibre medical and scientific staff now depend on their having a corner they may call their own-for example, in the clinical biochemistry of enzymology, toxicology, or endocrinology. The " general-practitioner chemical pathologist " can have little real job satisfaction in a modern hospital, where so many clinicians with their own beds and clinics have scientific (often biochemical) interests and tend to ask one another rather than the G.P. chemical pathologist for advice. Department of Chemical Pathology, Walton and Fazakerley Hospitals, I. J. L. GOLDBERG. Merseyside L9 7AL.
assay service
has, for the first time, made
tests like gastrin to everyone who
Goldberg, I. J. L., Mitchell, F. L. Lancet, 1970, ii, 1240. Mitchell, F. L. Ann. clin. Biochem. 1974, 11, 149. 4. Goldberg, I. J. L., Mitchell, F. L. Lancet, 1970, ii, 1240. 5. Young, D. S. Clin. Chem. 1972, 8, 850. 6. Lancet, 1974, ii, 87. 2. 3.
SIR,—In his report on mortality from malignant diseases in patients with asthma (Dec. 21, p. 1475) Professor Alderson states that it seems unlikely that conventional treatment of asthma plays a part in the observed reduction of death from cancer. I would not agree with this assumption, since agents such as aminophylline and the catecholamine derivatives are known stimulators of the cyclic-A.M.P. system. There is growing evidence that cyclic A.M.P. or agents which stimulate its production can inhibit the proliferation of malignant cells, and the possibility that the conventional anti-asthmatic treatment might act in this way cannot be discarded a priori. Medical Department F, Gentofte County Hospital, 2900 Hellerup, Denmark.
S. NISTRUP MADSEN.
SCREENING FOR HYPERTENSION SiR,—The points raised by Professor Sackett (Nov. 16, p. 1189) in his article, which cautions against " premature screening " for hypertension, are certainly well taken and thought-provoking. However, " the journey of a thousand miles begins with the first step", and it is our impression that he takes too pessimistic a view. In conjunction with our local heart association, we have been conducting a high-school hypertension screening programme for 11 years. As Professor Sackett might well imagine, it is indeed disappointing to realise that only 32% of the students who were found to have high blood-pressures returned for two rechecks of their initial blood-pressure measurement. It is even more disconcerting that doctors often ignore high blood-pressure and do not even recommend that the students return for yearly rechecks. If the only service we were
F. L. MITCHELL M. G. RINSLER.
by Dr Carter and his colleagues return to the small general-purpose laboratory. Unfortunately they seem to ignore an important development which goes some way to answering their criticisms of supra-hospital laboratories. This development is specialisation within chemical pathology, long proving significant in this practised in Scandinavia and country4 and the U.S.A.55 By some form of cooperation between two or three hospitals, it is easy to ensure that such tests as digoxin, IgE, and T.S.H. are done well locally with an appropriate consultative service available as of right. The supraregional SiR,—The
argues the
ASTHMA AND CANCER
providing
was
to measure
blood-pressure,
we are
certain that we would have abandoned this project long ago, but, in association with our screening programme, we also have an educational programme with a didactic lecture, films, pamphlets, and a question-and-answer period designed to acquaint the students with the hazards of hypertension, the benefits of early diagnosis and treatment, and the significance of other cardiovascular risk factors. Thus, it is our belief that screening without education has little chance of success, and we shall be undaunted in our efforts to continue to educate the public (lay and professional) in the hazards of undiagnosed and untreated
hypertension. Georgetown University Medical Division, District of Columbia General Hospital, Washington, D.C. 20003, U.S.A.
WILLIAM J. MROCZEK MARGENE MARTIN.
SCREENING FOR DIABETES MR,—1am concerned that the article
on
diabetes
(Dec. 7, p. 1367) by my much respected friend, John Malins, directs our actions concerning glucose-tolerance testing into outmoded practices. Perhaps two specific comments will illustrate the need for a truly comprehensive review of this complex subject. We cannot accept both statements that " for venous blood the upper limit for the two-hour level is 100 mg. per 100 ml." and " the prevalence of diabetes (age range 45-70) is around 5 % ". The review by Andres,2 concerning changes in glucose tolerance with the normal process of ageing makes it clear that a screening level for glucose of 100 mg. per 100 ml. in whole blood two hours after a standard glucose challenge in patients age 50 would force one to diagnose at least 75% of these patients as diabetic. 1. Posternak, T. A. Rev. Pharmac. 1974, 2. Med. Clins N. Am. 1971, 55, 835.
14,
23.
medicine. The automation of the " bread-and-butter " work is the least of our problems. Can the small laboratory in the small hospital with a small staff provide the skills and experience to perform the wide range of tests which the clinicians demand ? The day is long past when a single chemical pathologist can cover adequately all branches of his subject. For him as for the clinician " no doctor can know in depth, or have had experience in, all branches of medicine ", as Dr Carter and his colleagues point out. Their conclusions in respect of a pathologist’s duties and of the departmental size are wise and sound, but there is the underlying assumption that the chemical pathologist should remain a " jack of all trades ". For people entering and training in the profession this counsel certainly must not be allowed to prevail if the best biochemical advice on patient care is to be ensured now and in the future. Chemical pathology is divisible into at least eight branches,2 the mastery of each of which may need upwards of ten years’ careful dedication and training in the ward and in the laboratory. In many of the best laboratories in Britain and abroad the need is stressed for the necessary variety of experts to provide a comprehensive clinical service.2,3 Only the very largest of centres can afford to have sub-units with experts in charge of each branch; elsewhere this could be achieved by neighbouring hospitals arranging for each of their senior biochemists to specialise in a particular branch. The hardest task which a chemical pathologist or clinical biochemist faces is to provide a service which is clinically relevant. He (or she) is likely to find the work more satisfying if it permits a degree of specialisation. Division of Clinical Chemistry, Clinical Research Centre and Northwick Park Hospital, Harrow, Middlesex HA1 3UJ.
paper
case
for the
"
6
"
more difficult and parathyroid-hormone assays available needs them. The recruitment, training, and retention of high calibre medical and scientific staff now depend on their having a corner they may call their own-for example, in the clinical biochemistry of enzymology, toxicology, or endocrinology. The " general-practitioner chemical pathologist " can have little real job satisfaction in a modern hospital, where so many clinicians with their own beds and clinics have scientific (often biochemical) interests and tend to ask one another rather than the G.P. chemical pathologist for advice. Department of Chemical Pathology, Walton and Fazakerley Hospitals, I. J. L. GOLDBERG. Merseyside L9 7AL.
assay service
has, for the first time, made
tests like gastrin to everyone who
Goldberg, I. J. L., Mitchell, F. L. Lancet, 1970, ii, 1240. Mitchell, F. L. Ann. clin. Biochem. 1974, 11, 149. 4. Goldberg, I. J. L., Mitchell, F. L. Lancet, 1970, ii, 1240. 5. Young, D. S. Clin. Chem. 1972, 8, 850. 6. Lancet, 1974, ii, 87. 2. 3.
SIR,—In his report on mortality from malignant diseases in patients with asthma (Dec. 21, p. 1475) Professor Alderson states that it seems unlikely that conventional treatment of asthma plays a part in the observed reduction of death from cancer. I would not agree with this assumption, since agents such as aminophylline and the catecholamine derivatives are known stimulators of the cyclic-A.M.P. system. There is growing evidence that cyclic A.M.P. or agents which stimulate its production can inhibit the proliferation of malignant cells, and the possibility that the conventional anti-asthmatic treatment might act in this way cannot be discarded a priori. Medical Department F, Gentofte County Hospital, 2900 Hellerup, Denmark.
S. NISTRUP MADSEN.
SCREENING FOR HYPERTENSION SiR,—The points raised by Professor Sackett (Nov. 16, p. 1189) in his article, which cautions against " premature screening " for hypertension, are certainly well taken and thought-provoking. However, " the journey of a thousand miles begins with the first step", and it is our impression that he takes too pessimistic a view. In conjunction with our local heart association, we have been conducting a high-school hypertension screening programme for 11 years. As Professor Sackett might well imagine, it is indeed disappointing to realise that only 32% of the students who were found to have high blood-pressures returned for two rechecks of their initial blood-pressure measurement. It is even more disconcerting that doctors often ignore high blood-pressure and do not even recommend that the students return for yearly rechecks. If the only service we were
F. L. MITCHELL M. G. RINSLER.
by Dr Carter and his colleagues return to the small general-purpose laboratory. Unfortunately they seem to ignore an important development which goes some way to answering their criticisms of supra-hospital laboratories. This development is specialisation within chemical pathology, long proving significant in this practised in Scandinavia and country4 and the U.S.A.55 By some form of cooperation between two or three hospitals, it is easy to ensure that such tests as digoxin, IgE, and T.S.H. are done well locally with an appropriate consultative service available as of right. The supraregional SiR,—The
argues the
ASTHMA AND CANCER
providing
was
to measure
blood-pressure,
we are
certain that we would have abandoned this project long ago, but, in association with our screening programme, we also have an educational programme with a didactic lecture, films, pamphlets, and a question-and-answer period designed to acquaint the students with the hazards of hypertension, the benefits of early diagnosis and treatment, and the significance of other cardiovascular risk factors. Thus, it is our belief that screening without education has little chance of success, and we shall be undaunted in our efforts to continue to educate the public (lay and professional) in the hazards of undiagnosed and untreated
hypertension. Georgetown University Medical Division, District of Columbia General Hospital, Washington, D.C. 20003, U.S.A.
WILLIAM J. MROCZEK MARGENE MARTIN.
SCREENING FOR DIABETES MR,—1am concerned that the article
on
diabetes
(Dec. 7, p. 1367) by my much respected friend, John Malins, directs our actions concerning glucose-tolerance testing into outmoded practices. Perhaps two specific comments will illustrate the need for a truly comprehensive review of this complex subject. We cannot accept both statements that " for venous blood the upper limit for the two-hour level is 100 mg. per 100 ml." and " the prevalence of diabetes (age range 45-70) is around 5 % ". The review by Andres,2 concerning changes in glucose tolerance with the normal process of ageing makes it clear that a screening level for glucose of 100 mg. per 100 ml. in whole blood two hours after a standard glucose challenge in patients age 50 would force one to diagnose at least 75% of these patients as diabetic. 1. Posternak, T. A. Rev. Pharmac. 1974, 2. Med. Clins N. Am. 1971, 55, 835.
14,
23.
