1030
Hospital Accreditation (a peculiarly North American institution) presumably to measure and improve the quality of medical care. However it either did not realise or was incapable of understanding that, in order to measure anything, a fairly precise set of standards was an absolute uecessity. Without such a set, serious evaluation of the mode of investigation and treatment of a disease entity is a slow, involved, and expensive process amounting in fact to the writing of a paper. If it is neither measurement against a on
set
of standards nor an effort to write a paper, the whole is a waste of time. All the Commission on Hospital
thing
Accreditation seem to care about are the minutes of audit committee meetings. Recently the American College of Surgeons (not the Commission) came up with a set of reasonable standards for about a dozen surgical entities. But then, do we know what we should audit-the process of care or its outcome ? The mythologists themselves are still at
loggerheads. Does our experience allow us to say that a better kind of medicine is practised on the North American continent than in Britain, the Scandinavian countries, &c., without making ourselves look like a bunch of fools ? Certainly not. Has anybody compared the extent of medical care improvement here and in the above countries over the past twenty years ? I can assure you that no one ever thought about it. I think I can say without too many reservations that the audit is as useful as a plague. It would be indeed advisable for Britain and other countries where this myth is not endemic to try to quarantine those who show clinical evidence of infection as well as its carriers. Department of Pathology, North Bay Civic and St. Joseph’s Hospitals, North Bay, Ontario, Canada.
P. N. KARNAUCHOW.
SCREENING FOR BREAST CANCER
SIR,-Dr Wright (April 26, p. 983), writing from the B.U.P.A. Medical Centre, says " we continue to use and expand the activities of nurses-our three breast-screening units, one of which is mobile, are entirely operated by them ". Did it escape his notice that in the recent series in The Lancet on screening for disease the process of screening for breast cancer was not very highly regarded by the relevant experts ? Professor Hollandsummed it up with: " In Britain the Health Department have lately been advised not to introduce mass screening for breast cancer; all the same this area will probably repay further efforts " (i.e., research). Dr Irwig2 stated: " On present evidence it would seem wise to await these further developments before considering the introduction of mass screening for breast cancer." Why then the expansion to which Dr Wright refers ? In reporting his experience of the Kaiser Permanente system in California, Dr Wright writes that " the future, for the imaginative’development of this type of (paramedical) help, including the dilution of the nursing care of the sick with intelligent’tender loving care ’, &c., is limitless ". How does nursing care of the sick differ from intelligent " tender loving care " ? In just what sense does the one " dilute " the other ? In his immediately succeeding paragraph Dr Wright highly commends history-taking by computer. May I ask just how he reconciles the use of what is certainly a non-human and might be thought to be an alienating mechanism for history-taking with intelligent, tender, 1. 2.
Holland, W. W. Lancet, 1974, ii, Irwig, L. M. ibid. p. 1307.
1494.
loving care ? Or has the computer been programmed supply some of this commodity too ? Garraway House, How Caple, Hereford.
to
JOHN S. BRADSHAW.
SCREENING FOR SICKLING SIR,-As topic of screening for disease is so relevant to present-day practice, perhaps further comments may still be made on your recent series. Sooner or later, the economically less developed sickle belts of the world may contemplate setting up mass the
screening programmes for sickling. Judging by previous experience,l it seems almost certain that, on the African scene also, misconceptions about the sickle-cell trait would arise, and hitherto unexplained deaths might soon be popularly attributed to the " new disease " of sickle-cell trait. Another important considerarion is that genetic counselling is unlikely to find a place for some time among the people of the sickle-endemic countries of the Third,World, not only because they have children for different reasons, but also because their family pattern, traditional customs, and beliefs are entirely different from those in advanced countries. There has been less emphasis recently on mass screening programmes. Despite the scepticism that has been expressed on the overall values, some form of screening will always be required to detect sickling in certain well-defined groups of patients and individuals, in order to establish the diagnosis of a sickling syndrome, or to identify trait carriers amongst potential sicklers2 fot the special circumstances of general anaesthesia and high-altitude flying. Outside the defined groups, screening for sickle-cell trait per se now seems unjustified,3except for genetic counselling purposes, which, as many would now agree, should be undertaken only at the specific request of high-risk individuals who are able to grasp the implications. However, even judiciously conducted screening and genetic counselling may still produce psychosocial side-effects,4which are yet to be fully assessed. Department of Clinical Pathology, General Hospital,
Ilorin, Nigeria.
I. MAMMAN.
BLOOD-BRAIN BARRIER IN THE HUMAN FETUS SIR,-We should like to make a short addendum to the
interesting paper by Dr Thorley and his collaborators (March 22, p. 651) on the presence of maternal diphtheria and tetanus antitoxins in the cerebrospinal fluid (c.s.F.) of infants from 1 to 6 days old. In the course of an investigation on the origin of oc-fetoprotein (A.F.P.) in the amniotic fluid of fetuses with neural-tube defects, we have estimated the levels of this protein in the C.S.F. of six " normal"" fetuses. The amount of A.F.P. in C.s.F. was found to decrease from 1220 jjg. per ml. in a 16!-week-old fetus to 52-70 tg. per ml. in three fetuses 25 weeks old, while the levels of albumin increased with age. Maternal IgG was detected in all c.s.F. tested, with values ranging from 60 to 117 jg. per ml. These findings, which are to be published in detail elsewhere,5 and preliminary results in laboratory animals using 1251-labelled plasma-proteins (Adinolfi and Petrakis, N. L. Lancet, 1974, ii, 1368. Oduro, K. A., Searle, J. F. Br. med. J. 1972, iv, 596. Motulsky, A. G. in Genetic Polymorphisms and Diseases in Man (edited by B. Ramot et al.); p. 215. New York, 1974. 4. Whitten, C. F., Fischhoff, J. Archs intern. Med. 1974, 133, 681. 5. Seller, M. J., Adinolfi, M. Archs Dis. Childh. (in the press).
1. 2. 3.
’
Hospital Accreditation (a peculiarly North American institution) presumably to measure and improve the quality of medical care. However it either did not realise or was incapable of understanding that, in order to measure anything, a fairly precise set of standards was an absolute uecessity. Without such a set, serious evaluation of the mode of investigation and treatment of a disease entity is a slow, involved, and expensive process amounting in fact to the writing of a paper. If it is neither measurement against a on
set
of standards nor an effort to write a paper, the whole is a waste of time. All the Commission on Hospital
thing
Accreditation seem to care about are the minutes of audit committee meetings. Recently the American College of Surgeons (not the Commission) came up with a set of reasonable standards for about a dozen surgical entities. But then, do we know what we should audit-the process of care or its outcome ? The mythologists themselves are still at
loggerheads. Does our experience allow us to say that a better kind of medicine is practised on the North American continent than in Britain, the Scandinavian countries, &c., without making ourselves look like a bunch of fools ? Certainly not. Has anybody compared the extent of medical care improvement here and in the above countries over the past twenty years ? I can assure you that no one ever thought about it. I think I can say without too many reservations that the audit is as useful as a plague. It would be indeed advisable for Britain and other countries where this myth is not endemic to try to quarantine those who show clinical evidence of infection as well as its carriers. Department of Pathology, North Bay Civic and St. Joseph’s Hospitals, North Bay, Ontario, Canada.
P. N. KARNAUCHOW.
SCREENING FOR BREAST CANCER
SIR,-Dr Wright (April 26, p. 983), writing from the B.U.P.A. Medical Centre, says " we continue to use and expand the activities of nurses-our three breast-screening units, one of which is mobile, are entirely operated by them ". Did it escape his notice that in the recent series in The Lancet on screening for disease the process of screening for breast cancer was not very highly regarded by the relevant experts ? Professor Hollandsummed it up with: " In Britain the Health Department have lately been advised not to introduce mass screening for breast cancer; all the same this area will probably repay further efforts " (i.e., research). Dr Irwig2 stated: " On present evidence it would seem wise to await these further developments before considering the introduction of mass screening for breast cancer." Why then the expansion to which Dr Wright refers ? In reporting his experience of the Kaiser Permanente system in California, Dr Wright writes that " the future, for the imaginative’development of this type of (paramedical) help, including the dilution of the nursing care of the sick with intelligent’tender loving care ’, &c., is limitless ". How does nursing care of the sick differ from intelligent " tender loving care " ? In just what sense does the one " dilute " the other ? In his immediately succeeding paragraph Dr Wright highly commends history-taking by computer. May I ask just how he reconciles the use of what is certainly a non-human and might be thought to be an alienating mechanism for history-taking with intelligent, tender, 1. 2.
Holland, W. W. Lancet, 1974, ii, Irwig, L. M. ibid. p. 1307.
1494.
loving care ? Or has the computer been programmed supply some of this commodity too ? Garraway House, How Caple, Hereford.
to
JOHN S. BRADSHAW.
SCREENING FOR SICKLING SIR,-As topic of screening for disease is so relevant to present-day practice, perhaps further comments may still be made on your recent series. Sooner or later, the economically less developed sickle belts of the world may contemplate setting up mass the
screening programmes for sickling. Judging by previous experience,l it seems almost certain that, on the African scene also, misconceptions about the sickle-cell trait would arise, and hitherto unexplained deaths might soon be popularly attributed to the " new disease " of sickle-cell trait. Another important considerarion is that genetic counselling is unlikely to find a place for some time among the people of the sickle-endemic countries of the Third,World, not only because they have children for different reasons, but also because their family pattern, traditional customs, and beliefs are entirely different from those in advanced countries. There has been less emphasis recently on mass screening programmes. Despite the scepticism that has been expressed on the overall values, some form of screening will always be required to detect sickling in certain well-defined groups of patients and individuals, in order to establish the diagnosis of a sickling syndrome, or to identify trait carriers amongst potential sicklers2 fot the special circumstances of general anaesthesia and high-altitude flying. Outside the defined groups, screening for sickle-cell trait per se now seems unjustified,3except for genetic counselling purposes, which, as many would now agree, should be undertaken only at the specific request of high-risk individuals who are able to grasp the implications. However, even judiciously conducted screening and genetic counselling may still produce psychosocial side-effects,4which are yet to be fully assessed. Department of Clinical Pathology, General Hospital,
Ilorin, Nigeria.
I. MAMMAN.
BLOOD-BRAIN BARRIER IN THE HUMAN FETUS SIR,-We should like to make a short addendum to the
interesting paper by Dr Thorley and his collaborators (March 22, p. 651) on the presence of maternal diphtheria and tetanus antitoxins in the cerebrospinal fluid (c.s.F.) of infants from 1 to 6 days old. In the course of an investigation on the origin of oc-fetoprotein (A.F.P.) in the amniotic fluid of fetuses with neural-tube defects, we have estimated the levels of this protein in the C.S.F. of six " normal"" fetuses. The amount of A.F.P. in C.s.F. was found to decrease from 1220 jjg. per ml. in a 16!-week-old fetus to 52-70 tg. per ml. in three fetuses 25 weeks old, while the levels of albumin increased with age. Maternal IgG was detected in all c.s.F. tested, with values ranging from 60 to 117 jg. per ml. These findings, which are to be published in detail elsewhere,5 and preliminary results in laboratory animals using 1251-labelled plasma-proteins (Adinolfi and Petrakis, N. L. Lancet, 1974, ii, 1368. Oduro, K. A., Searle, J. F. Br. med. J. 1972, iv, 596. Motulsky, A. G. in Genetic Polymorphisms and Diseases in Man (edited by B. Ramot et al.); p. 215. New York, 1974. 4. Whitten, C. F., Fischhoff, J. Archs intern. Med. 1974, 133, 681. 5. Seller, M. J., Adinolfi, M. Archs Dis. Childh. (in the press).
1. 2. 3.
’
