1420 MANAGEMENT AND ADVICE AT THE GRASS ROOTS
SIR,-Mr Kirk and Professor Bennett (May 24, p. 1180) draw attention to the " gap between clinical practice and district management". This gap has been successfully closed in their community hospitals by a team consisting of a general practitioner, a senior nursing officer, and a local health service administrator. In the district general hospital a similar mechanism is needed and could perhaps be provided by an extension of the " information rooms " in service at Southampton. These rooms are situated beside the wards of a clinical specialty, undertake the management tasks for about one hundred beds, and organise the practices of four or five consultants. Secretarial and clerical services could be brought together in these rooms and daily control exercised by a meeting of the senior registrar, the nursing officer, and a higher clerical officer. This could be the first point in the information system with monthly reports going to the Cogwheel division and abstracts to the district medical committee and team. Conversely these committees would delegate short-term authority to the " information team " to interpret and act on the former’s instructions. The team and room would thereby become the daily executive arm, and make it possible to reconcile the contradictory needs of individualism in the medical and social care of the patient, and standardisation for administrative and financial gain. This of course goes against the present trend which is to centralise all administrative functions, with specified officers carrying out particular tasks for every clinical team. This centralisation has obvious administrative appeal but the individual officers cannot be expected to have insight into the total functioning of forty separate clinical teams. The secretaries will type the summaries and the clinic letters but know nothing of the admissions or of present problems in the wards. The admission officer knows little of the operating-list or of the ward policies. The ward sisters know the inpatients and the lists, but not the outpatients. This leaves the medical staff as the only general link and they might all be in theatre. This limitation of understanding militates strongly against the single hospital centre acting as the focal point for the daily reconciliation of possibly contradictory claims of medical effectiveness and administrative efficiency. The information rooms take more space and cost more money, but the investment makes a-priori sense in terms of a million-pound district specialty budget, as for instance in surgery, and the care of 5000 patients a year. At the very least a trial of the merits of the two systems would seem justified. Department of Community Medicine, St. Thomas’s Hospital Medical School, London SE1 7EH.
PETER SIMPSON.
COOPERATION BETWEEN DOCTOR AND NURSE
SIR,-We write from practical experience to support your leading article (April 12, p. 842) on the advantages of the provision of health care jointly by doctor and nurse. The main functions of the primary-care nurse as applied to a busy London N.H.S. general practice are, in our
opinion: (1) Standard nursing
duties (temperatures, most injections, testing, dressings, &c.). (2) Taking full routine medical history of new patients. (3) Taking history of presenting illness of children and infants. (4) Developmental screening of infants and pre-school
urine
children.
(5) Taking blood-pressure readings as a routine screening follow-up of hypertensive patients. of Assessment severity of overweight and supervision of (6)
examination and for
weight reduction. (7) Carrying out special investigations: venous blood sampling, electrocardiography, peak-flow-rate measurements, allergy testing, and urine dip-slide culturing of mid-stream specimens. (8) Ear syringing. (9) Home visiting (e.g., for house-bound patients, and to supervise dust-avoidance measures in cases of house-dust-mite allergy). The cooperation of doctor and nurse facilitates routine basic screening, health education, and first-line investigations, as well as attending to the patient’s immediate needs. 18 Anson
JEFFREY SEGALL
Road,
ELAINE LEE.
London NW2 3UU.
WHAT FUTURE FOR PERINATAL CARE?
SIR,—Your editorial is timely although half of
that
deaths
your estimate
nearly perinatal preventable by knowledge is optimistic. Superspecialism in neonatology is not new but inadequately developed and represented in the United Kingdom. In obstetrics, perinatal death and long-term morbidity are not yet clearly recognised as requiring full-time or nearly full-time clinical research effort. It is significant that in the United States, where perinatal medicine with endocrinology and oncology have specialty boards, it is in perinatal medicine that there is a real shortage of experts or of young doctors in training. Oncology and endocrinology are more defined and more recently popular. As you suggest, we must in obstetrics and paediatrics follow our American friends at least a good are
current
bit of the way. Department of Obstetrics and Gynæcology, Ninewells Hospital, Dundee DD1 9SY.
JAMES WALKER.
THE MELANCHOLY OF ANATOMY
SIR,-I have long been convinced that, if you scratch any member of the medical profession, you will discover a would-be expert on the teaching of anatomy, carrying a large blunt axe which he is anxious to grind. The letter from Dr Bull (June 7, p. 1290) provides further evidence for this notion. He is understandably pleased about the progress which has been made in the techniques of radiology, citing the fact that neuroradiologists have doubled the number of recognisable cerebral vessels. The relevance of this to the teaching of anatomy to undergraduates is not clear, unless Dr Bull is advocating that they should be taught more, rather than less, detail. He complains that anatomists are blind to radiology; in this department, which is not untypical, radiologists regularly lecture on the radiological aspects of the region which the students are dissecting, and appropriate radiographs are displayed in the dissecting-room and are discussed in tutorials. Anatomists do use radiology in their teaching and in their research when it is appropriate to do so. Dr Bull complains that anatomists are not trained to use radiology. It would be equally pointless for an anatomist to complain that radiologists are not trained to use electron microscopy, histochemistry, tissue culture, or autoradiography. I recall a discussion in the Board of Medicine here some years ago when the (then) professor of radiodiagnosis was urging us to teach gross anatomy by means of radiographs. The discussion was terminated when a member of the board
1421 out that " the substance ".
pointed
we
should
Department of Anatomy, University of Leeds, Leeds LS2 9NL.
not
confuse the shadow with
J. A. SHARP.
MASKED PRIMARY (OR TERTIARY) HYPERPARATHYROIDISM
SIR,-Having recently committed the therapeutic solecism of giving vitamin D to a patient from whom a large parathyroid adenoma was later removed, I was interested to read the paper by Professor Dent and his colleagues (May 24, p. 1161) and to find myself in such distinguished company. Now all can be told-and another case
of " masked
and alkaline
phosphatase
55
King-Armstrong units
per 100
ml.).
Plasma-bicarbonate remained low at 18 meq. per I. Although vitamin-D deficiency was not proven it seems very likely that this was present and masked coexistent primary hyperparathyroidism. The possibility of tertiary hyperparathyroidism secondary to Sjogren’s disease and hyperglobulinsemic renal tubular acidosis seems unlikely. The high-normal serum-calcium levels were in retrospect a pointer to the correct diagnosis. As Professor Dent and his colleagues suggest, a short course of vitamin D monitored by blood vitamin-D and calcium levels should confirm the presence of a parathyroid adenoma in these circumstances. Whittington Hospital, Archway Road, London N19.
B. I. HOFFBRAND.
primary (or tertiary) hyperparathyroid-
ism " reported. A 36-year-old vegetarian Kenyan Indian woman was found to be anaemic in November, 1973. Further inquiry revealed general ill health, vague thigh, shoulder, and calf pains, and loss of weight of about 6 kg. during the past year. She had also developed, more recently, nocturia and thirst. Since childhood she had had episodes of painful, bilateral parotid swelling after meals, and said that her four brothers were similarly afflicted. Apart from the anxmia, no abnormalities were found on physical examination. Blood-pressure 110/70 mm. Hg. Investigations.-Hb 9.0 g. per 100 ml., serum-iron 20 !-tg., total iron-binding capacity 405 g. per 100 ml., serum-B12 238 pg, per ml., folate 14-8 ng. per 100 ml. Sternal marrow : iron deficiency only. Serum calcium 10-2 mg. per 100 ml. (sp. gr. 1026), phosphorus 1-5 mg. per 100 ml., alkaline phosphatase 84 King-Armstrong units per 100 ml. (85% bone type), 24-hour urinary calcium 270 mg., phosphorus 450 mg., plasma sodium 139, potassium 4-3, bicarbonate 22, chloride 111 meq. per 1., urea 12 mg. per 100 ml. (repeat bicarbonates 15-20 meq. per 1.). Arterial pH 7-34, Pco. 36 mm. Hg, standard bicarbonate 19meq. per 1., base deficit 6 meq. per I. Lowest urinary pH with ammonium chloride test, 5-05. Maximum urinary osmolality after vasopressin, 606 mosmol per kg. Serum-creatinine 0-7 mg. per 100 ml. Creatinine clearance 83 ml. per min. Skeletal X-rays were considered within normal limits, but in retrospect probably show changes of hyperparathyroidism in hands and spine. Barium meal and follow-through, intravenous pyelogram, and bilateral parotid sialogram were normal. Stools contained no ova, cysts, or occult blood. Serum total-proteins 7-4, albumin 4-5 g. per 100 ml. Increase in gamma-globulin on strip. Rose-Waaler and antinuclear factor negative; gastric parietal cell antibodies positive; E.S.R. 8. No evidence of keratoconjunctivitis sicca on ophthalmological examination (Mr D. A. Langley). Dietary survey indicated deficiency of protein, iron, vitamin D, and vitamin C. Iliac crest biopsy showed poorly calcified fine trabeculae of woven bone in between stouter trabeculae of laminar structure with broad osteoid seams but centrally still well calcified and with no " moth-eaten " lesions. The appearances were considered consistent with a renal osteodystrophy perhaps complicated by dietary deficiency (Dr I. Magrath). A diagnosis of nutritional iron deficiency and osteomalacia with secondary hyperparathyroidism and renal tubular acidosis, with possible Sjogren’s disease, was made. The patient was discharged on ferrous sulphate and calcium-with-vitamin-D tablets, B.P.C. 3 a day. She left for a holiday in Kenya with instructions to have her serum-calcium measured. She was there found to be hypercalcaemic and the vitamin D was stopped. On her return in April, 1974, serum-calcium was 11-0 mg. per 100 ml. She was, however, eeling well, her weight had increased by 7 kg., and her anaamia was corrected. A hydrocortisone test in July, 1974, showed no suppression with serum-calcium levels of around 11 mg. Serum immunoreactive parathyroid hormone in November, 1974, was 3400 pg. per ml. (normal values for this assay < 200 pg. per ml.). In February, 1975, a large (3 x 1-8 x 1-7 cm.) chief-cell parathyroid adenoma was removed. Two other normal parathyroid glands were identified (Mr J. M. Davis). After operation she had prolonged tetany but on May 15, 1975, was well on no medication (serum calcium 87, phosphorus 3-5,
MEDICAL CARE OF CHILDHOOD LEUKÆMIA
SIR,-One may applaud Dr McCarthy’s intentions (May 17, p. 1128), and I appreciate that his article is an abbreviated form of his thesis, but the conclusions should not be allowed to pass without comment. " The survival of children given optimal regimens at local hospitals was equivalent to that of two of the three special centres. It is concluded that a regional policy for childhood leukaemia should be concerned to improve treatment regimens at local hospitals rather than an attempt to concentrate care at a few centres." That really will not do. For one thing, the figures, small as they are, still favour the two special centres against the better general hospital (7/10 survivors compared with 6/14), and it quite ignores the best results of all from the other special centre (16/17 survivors). An unprejudiced reader, on learning that " assessment of social, psychological, satisfaction or cost outcomes showed no difference between the groups " could only conclude that special centres should be preferred since they achieved better results irrespective of regimen. Such a conclusion is not surprising, since current chemotherapy, poised, as it must be, between hazardous overdosage and ineffective underdosage, must be managed by those with the greatest experience. Of course, in some circumstances treatment at a special centre may be contraindicated, and, as experience is disseminated, there will be more hospitals with the requisite fund of expertise. A.L.L. is in any case a diverse disease and many considerations must be balanced before the decision is taken as to how and where a child should be treated. Eventually, when there exists a relatively safe but curative treatment for most patients, a general policy of decentralisation could be recommended. But that is not yet the situation, and it would be tragic if the improved results now possible were to encourage the premature dissolution of the centres on which success still largely depends. Royal Marsden Hospital, H. E. M. KAY, Fulham Road, London SW3 6JJ. Secretary, M.R.C. Leukæmia Committee.
SiR,—In the currency of the medical oncologist or haematologist, lymphoblastic leukaemia ranks with diamonds. It does not surprise me that many practitioners wish to assemble patients with this condition. They provide an opportunity to test one’s skills and resources as few other haematological disorders, with the possibility of steering a patient out of hazard into cure. I think the claim by Dr McCarthy (May 17, p. 1128) that " treatment is moving towards semi-routine regimes " refers to the " protocol-bound " approach to therapy, essentially unimaginative and unamenable to adaptation. I agree with Professor Hardisty (May 31, p. 1235) that this is a disconcerting observation with echoes of complacency
SIR,-Mr Kirk and Professor Bennett (May 24, p. 1180) draw attention to the " gap between clinical practice and district management". This gap has been successfully closed in their community hospitals by a team consisting of a general practitioner, a senior nursing officer, and a local health service administrator. In the district general hospital a similar mechanism is needed and could perhaps be provided by an extension of the " information rooms " in service at Southampton. These rooms are situated beside the wards of a clinical specialty, undertake the management tasks for about one hundred beds, and organise the practices of four or five consultants. Secretarial and clerical services could be brought together in these rooms and daily control exercised by a meeting of the senior registrar, the nursing officer, and a higher clerical officer. This could be the first point in the information system with monthly reports going to the Cogwheel division and abstracts to the district medical committee and team. Conversely these committees would delegate short-term authority to the " information team " to interpret and act on the former’s instructions. The team and room would thereby become the daily executive arm, and make it possible to reconcile the contradictory needs of individualism in the medical and social care of the patient, and standardisation for administrative and financial gain. This of course goes against the present trend which is to centralise all administrative functions, with specified officers carrying out particular tasks for every clinical team. This centralisation has obvious administrative appeal but the individual officers cannot be expected to have insight into the total functioning of forty separate clinical teams. The secretaries will type the summaries and the clinic letters but know nothing of the admissions or of present problems in the wards. The admission officer knows little of the operating-list or of the ward policies. The ward sisters know the inpatients and the lists, but not the outpatients. This leaves the medical staff as the only general link and they might all be in theatre. This limitation of understanding militates strongly against the single hospital centre acting as the focal point for the daily reconciliation of possibly contradictory claims of medical effectiveness and administrative efficiency. The information rooms take more space and cost more money, but the investment makes a-priori sense in terms of a million-pound district specialty budget, as for instance in surgery, and the care of 5000 patients a year. At the very least a trial of the merits of the two systems would seem justified. Department of Community Medicine, St. Thomas’s Hospital Medical School, London SE1 7EH.
PETER SIMPSON.
COOPERATION BETWEEN DOCTOR AND NURSE
SIR,-We write from practical experience to support your leading article (April 12, p. 842) on the advantages of the provision of health care jointly by doctor and nurse. The main functions of the primary-care nurse as applied to a busy London N.H.S. general practice are, in our
opinion: (1) Standard nursing
duties (temperatures, most injections, testing, dressings, &c.). (2) Taking full routine medical history of new patients. (3) Taking history of presenting illness of children and infants. (4) Developmental screening of infants and pre-school
urine
children.
(5) Taking blood-pressure readings as a routine screening follow-up of hypertensive patients. of Assessment severity of overweight and supervision of (6)
examination and for
weight reduction. (7) Carrying out special investigations: venous blood sampling, electrocardiography, peak-flow-rate measurements, allergy testing, and urine dip-slide culturing of mid-stream specimens. (8) Ear syringing. (9) Home visiting (e.g., for house-bound patients, and to supervise dust-avoidance measures in cases of house-dust-mite allergy). The cooperation of doctor and nurse facilitates routine basic screening, health education, and first-line investigations, as well as attending to the patient’s immediate needs. 18 Anson
JEFFREY SEGALL
Road,
ELAINE LEE.
London NW2 3UU.
WHAT FUTURE FOR PERINATAL CARE?
SIR,—Your editorial is timely although half of
that
deaths
your estimate
nearly perinatal preventable by knowledge is optimistic. Superspecialism in neonatology is not new but inadequately developed and represented in the United Kingdom. In obstetrics, perinatal death and long-term morbidity are not yet clearly recognised as requiring full-time or nearly full-time clinical research effort. It is significant that in the United States, where perinatal medicine with endocrinology and oncology have specialty boards, it is in perinatal medicine that there is a real shortage of experts or of young doctors in training. Oncology and endocrinology are more defined and more recently popular. As you suggest, we must in obstetrics and paediatrics follow our American friends at least a good are
current
bit of the way. Department of Obstetrics and Gynæcology, Ninewells Hospital, Dundee DD1 9SY.
JAMES WALKER.
THE MELANCHOLY OF ANATOMY
SIR,-I have long been convinced that, if you scratch any member of the medical profession, you will discover a would-be expert on the teaching of anatomy, carrying a large blunt axe which he is anxious to grind. The letter from Dr Bull (June 7, p. 1290) provides further evidence for this notion. He is understandably pleased about the progress which has been made in the techniques of radiology, citing the fact that neuroradiologists have doubled the number of recognisable cerebral vessels. The relevance of this to the teaching of anatomy to undergraduates is not clear, unless Dr Bull is advocating that they should be taught more, rather than less, detail. He complains that anatomists are blind to radiology; in this department, which is not untypical, radiologists regularly lecture on the radiological aspects of the region which the students are dissecting, and appropriate radiographs are displayed in the dissecting-room and are discussed in tutorials. Anatomists do use radiology in their teaching and in their research when it is appropriate to do so. Dr Bull complains that anatomists are not trained to use radiology. It would be equally pointless for an anatomist to complain that radiologists are not trained to use electron microscopy, histochemistry, tissue culture, or autoradiography. I recall a discussion in the Board of Medicine here some years ago when the (then) professor of radiodiagnosis was urging us to teach gross anatomy by means of radiographs. The discussion was terminated when a member of the board
1421 out that " the substance ".
pointed
we
should
Department of Anatomy, University of Leeds, Leeds LS2 9NL.
not
confuse the shadow with
J. A. SHARP.
MASKED PRIMARY (OR TERTIARY) HYPERPARATHYROIDISM
SIR,-Having recently committed the therapeutic solecism of giving vitamin D to a patient from whom a large parathyroid adenoma was later removed, I was interested to read the paper by Professor Dent and his colleagues (May 24, p. 1161) and to find myself in such distinguished company. Now all can be told-and another case
of " masked
and alkaline
phosphatase
55
King-Armstrong units
per 100
ml.).
Plasma-bicarbonate remained low at 18 meq. per I. Although vitamin-D deficiency was not proven it seems very likely that this was present and masked coexistent primary hyperparathyroidism. The possibility of tertiary hyperparathyroidism secondary to Sjogren’s disease and hyperglobulinsemic renal tubular acidosis seems unlikely. The high-normal serum-calcium levels were in retrospect a pointer to the correct diagnosis. As Professor Dent and his colleagues suggest, a short course of vitamin D monitored by blood vitamin-D and calcium levels should confirm the presence of a parathyroid adenoma in these circumstances. Whittington Hospital, Archway Road, London N19.
B. I. HOFFBRAND.
primary (or tertiary) hyperparathyroid-
ism " reported. A 36-year-old vegetarian Kenyan Indian woman was found to be anaemic in November, 1973. Further inquiry revealed general ill health, vague thigh, shoulder, and calf pains, and loss of weight of about 6 kg. during the past year. She had also developed, more recently, nocturia and thirst. Since childhood she had had episodes of painful, bilateral parotid swelling after meals, and said that her four brothers were similarly afflicted. Apart from the anxmia, no abnormalities were found on physical examination. Blood-pressure 110/70 mm. Hg. Investigations.-Hb 9.0 g. per 100 ml., serum-iron 20 !-tg., total iron-binding capacity 405 g. per 100 ml., serum-B12 238 pg, per ml., folate 14-8 ng. per 100 ml. Sternal marrow : iron deficiency only. Serum calcium 10-2 mg. per 100 ml. (sp. gr. 1026), phosphorus 1-5 mg. per 100 ml., alkaline phosphatase 84 King-Armstrong units per 100 ml. (85% bone type), 24-hour urinary calcium 270 mg., phosphorus 450 mg., plasma sodium 139, potassium 4-3, bicarbonate 22, chloride 111 meq. per 1., urea 12 mg. per 100 ml. (repeat bicarbonates 15-20 meq. per 1.). Arterial pH 7-34, Pco. 36 mm. Hg, standard bicarbonate 19meq. per 1., base deficit 6 meq. per I. Lowest urinary pH with ammonium chloride test, 5-05. Maximum urinary osmolality after vasopressin, 606 mosmol per kg. Serum-creatinine 0-7 mg. per 100 ml. Creatinine clearance 83 ml. per min. Skeletal X-rays were considered within normal limits, but in retrospect probably show changes of hyperparathyroidism in hands and spine. Barium meal and follow-through, intravenous pyelogram, and bilateral parotid sialogram were normal. Stools contained no ova, cysts, or occult blood. Serum total-proteins 7-4, albumin 4-5 g. per 100 ml. Increase in gamma-globulin on strip. Rose-Waaler and antinuclear factor negative; gastric parietal cell antibodies positive; E.S.R. 8. No evidence of keratoconjunctivitis sicca on ophthalmological examination (Mr D. A. Langley). Dietary survey indicated deficiency of protein, iron, vitamin D, and vitamin C. Iliac crest biopsy showed poorly calcified fine trabeculae of woven bone in between stouter trabeculae of laminar structure with broad osteoid seams but centrally still well calcified and with no " moth-eaten " lesions. The appearances were considered consistent with a renal osteodystrophy perhaps complicated by dietary deficiency (Dr I. Magrath). A diagnosis of nutritional iron deficiency and osteomalacia with secondary hyperparathyroidism and renal tubular acidosis, with possible Sjogren’s disease, was made. The patient was discharged on ferrous sulphate and calcium-with-vitamin-D tablets, B.P.C. 3 a day. She left for a holiday in Kenya with instructions to have her serum-calcium measured. She was there found to be hypercalcaemic and the vitamin D was stopped. On her return in April, 1974, serum-calcium was 11-0 mg. per 100 ml. She was, however, eeling well, her weight had increased by 7 kg., and her anaamia was corrected. A hydrocortisone test in July, 1974, showed no suppression with serum-calcium levels of around 11 mg. Serum immunoreactive parathyroid hormone in November, 1974, was 3400 pg. per ml. (normal values for this assay < 200 pg. per ml.). In February, 1975, a large (3 x 1-8 x 1-7 cm.) chief-cell parathyroid adenoma was removed. Two other normal parathyroid glands were identified (Mr J. M. Davis). After operation she had prolonged tetany but on May 15, 1975, was well on no medication (serum calcium 87, phosphorus 3-5,
MEDICAL CARE OF CHILDHOOD LEUKÆMIA
SIR,-One may applaud Dr McCarthy’s intentions (May 17, p. 1128), and I appreciate that his article is an abbreviated form of his thesis, but the conclusions should not be allowed to pass without comment. " The survival of children given optimal regimens at local hospitals was equivalent to that of two of the three special centres. It is concluded that a regional policy for childhood leukaemia should be concerned to improve treatment regimens at local hospitals rather than an attempt to concentrate care at a few centres." That really will not do. For one thing, the figures, small as they are, still favour the two special centres against the better general hospital (7/10 survivors compared with 6/14), and it quite ignores the best results of all from the other special centre (16/17 survivors). An unprejudiced reader, on learning that " assessment of social, psychological, satisfaction or cost outcomes showed no difference between the groups " could only conclude that special centres should be preferred since they achieved better results irrespective of regimen. Such a conclusion is not surprising, since current chemotherapy, poised, as it must be, between hazardous overdosage and ineffective underdosage, must be managed by those with the greatest experience. Of course, in some circumstances treatment at a special centre may be contraindicated, and, as experience is disseminated, there will be more hospitals with the requisite fund of expertise. A.L.L. is in any case a diverse disease and many considerations must be balanced before the decision is taken as to how and where a child should be treated. Eventually, when there exists a relatively safe but curative treatment for most patients, a general policy of decentralisation could be recommended. But that is not yet the situation, and it would be tragic if the improved results now possible were to encourage the premature dissolution of the centres on which success still largely depends. Royal Marsden Hospital, H. E. M. KAY, Fulham Road, London SW3 6JJ. Secretary, M.R.C. Leukæmia Committee.
SiR,—In the currency of the medical oncologist or haematologist, lymphoblastic leukaemia ranks with diamonds. It does not surprise me that many practitioners wish to assemble patients with this condition. They provide an opportunity to test one’s skills and resources as few other haematological disorders, with the possibility of steering a patient out of hazard into cure. I think the claim by Dr McCarthy (May 17, p. 1128) that " treatment is moving towards semi-routine regimes " refers to the " protocol-bound " approach to therapy, essentially unimaginative and unamenable to adaptation. I agree with Professor Hardisty (May 31, p. 1235) that this is a disconcerting observation with echoes of complacency
