1615
Such issues, in the context of the provision of care for children with problems that were potentially "preventable", have already been raised in North America, and have been related to cases of "wrongful life", and to health insurance provided by employers.’ Do we want to see this happen in Britain too? If society answers Collins’ question by charging the cost of refusing blood transfusion to Jehovah’s Witnesses themselves, will the provision of nationalised health care for children with genetic disease be similarly restricted? Will National Health Service (NHS) care be denied to those whose parents are labelled as irresponsible because they have declined to take part in prenatal diagnosis or screening, or because they have declined to terminate a pregnancy at high risk of some disorder? Will budget-holding general practitioners seek to remove from their lists those families that refuse antenatal screening? The reasons for declining to participate in such programmes, of course, may vary-but these reasons are
HIV infection in Victoria, and a social justice payment was added for those people whose cases in law were weakest. Group settlement in late 1991, despite grossly disparate payments for equally infected people, has resolved much of the anger and divisiveness that was destroying our patients and our centre. The enormous relief, consequent upon settlement, which is shared by patients and their carers, allows patients to plan for quality, not merely in financial terms, in their shortened futures. The gloomy days of HIV disease remain but the distress of litigation no longer affects the immune system.
quite irrelevant if a "medicine of the bottom line" is all that the NHS will seek to provide. The restriction of access to health care in such circumstances could doubtless be justified as the promotion of autonomy and responsibility; appeals to autonomy in this sense (of self-reliance, rather than self-determination) are used to justify cuts in public services by those inclined for political reasons in that direction.2 In addition to these questions of principle, there is also a practical question to be addressed. Do Jehovah’s Witnesses really cost the NHS more, on average, than other citizens? Or do they make less use of it, perhaps dying sooner after trauma, or just preferring to avoid contact with contemporary medicine for minor ailments ? If so, they may actually be saving NHS money. If they, or some other identifiable group, in fact consume fewer NHS resources than the average, should they then pay less tax than the rest of the
SjR,—For the newly qualified junior hospital doctor the stresses and strains of final examinations pale into insignificance when compared with the prospect of the first day of August, this being the start, in the UK at least, of "house jobs". Much folklore and handed-down anecdotal tales abound about this, possibly the most stressful and eventful month of the houseman’s year. The psychological and emotional impact on the new graduate is well documented/,2 but what of the organic signs? We sent a two-part questionnaire about diet and weight to all (102) doctors who graduated in 1991 from the University of Leicester. Part A was completed within the first week of August and part B in the first week of September. 61 forms were returned for part A and 48 for part B. Data for analysis were thus available for 31 women and 17 men (age 22-30, mean 23 years). No subject was actively dieting during the period under consideration. About two-thirds (30) lost weight during their first four weeks as a houseman; 10 gained weight; and 8 remained the same weight. 19 women and 11 men lost an average of 2-6 kg (range 0’4-6-4). Of these, 28 thought their diet had been adversely affected by their job and 2 thought not. 17 had found their hospital canteen unacceptable whereas 13 thought it was acceptable or good. Common reasons given for weight loss were lack of time for eating and increased energy expenditure. 8 women and 2 men gained an average of 1 -7 kg (04-1). 7 had found their diet to be adversely affected and 3 had not; 6 found the hospital canteen unacceptable; and 4 thought it was acceptable or good. 4 women admitted to a partiality for chocolates, which were readily available on the ward and were therefore consumed more liberally than usual. Of the 4 men and 4 women whose weight remained stable, although all thought their diet had been adversely affected by their job, all, surprisingly, found the food in their hospital canteen acceptable. The year spent as a houseman is the subject of two witty novels3,4 which are read avidly by medical students. The year is not all roses, however, and many find the hours long and arduous. Chronic tiredness, lack of support, and a feeling of being uncared for, among others, contribute to stress. The stress and pace of the job also leads to a change in diet, as shown in our series where 43 of the 48 (90%) thought that their diet was adversely affected and 62% did lose weight. That the weight loss was almost certainly occupational is probably not in doubt. Does this then commend house jobs as a way to diet? In the short term, perhaps yes; in the long term, thankfully
population? We believe that health care should be provided for all, irrespective of race or religion, and with full respect for any constraints imposed by the patient on the grounds of their religious, moral, or cultural beliefs or customs. To make any other decision would be a violation of human rights, of medical ethics, and of the obligation of our secular society to respect the various sets of values of all its citizens. Institute of Medical Genetics, University of Wales College of Medicine, Cardiff CF4 4XN, UK
ANGUS CLARKE CARINA WALLGREN-PETTERSSON HELEN E. HUGHES
Billings PR, Kohn MA, de Cuevas M, et al. Discrimination as consequence of genetic testing. Am J Hum Genet 1992; 50: 476-82. 2. Chadwick R. What counts as success in genetic counselling? Med Ethics (in press). J 1.
Compensation for medically acquired AIDS SiR,—Iwould expand Mark Ragg’s (Feb 15, p 419) comments about compensation for medically acquired AIDS in Victoria, Australia. Claims made since 1985 by haemophilia patients, infected with HIV, against State and Federal Governments, as producers and administrators of contaminated plasma concentrates, were almost completely disregarded. The Federal Government had set up a "token" trust in 1990 with staged minimum payments. Patients sought further legal retribution, having been inflamed by Government advice that this was their only recourse. The haemophilia community was deeply divided in taking such action not only between HIV infected and uninfected factions but also within the infected group. Many were deeply embarassed about suing their haemophilia treatment centres in three-way suits against hospital, Red Cross Transfusion Service, and Commonwealth Serum Laboratories. A landmark court case was brought in Victoria, the only state to have a jury for civil cases, in 1990. It was won by the plaintiff against a haemophilia treatment centre only. This case was noteworthy not
only for the verdict but also for the notoriously high legal costs disbursed from state-funded legal aid and other public sources. A formula, based on legal likelihood of successful case prosecution, was crafted for out-of-court settlements in South Australia in 1991. This model was applied to all known cases of transfusion-related
Haemophilia Treatment Centre, Alfred Hospital, Melbourne, Victoria 3181, Australia
Acute
weight reduction
ALISON STREET
in junior doctors
not.
Department of Surgery, University of Manchester, Hope Hospital, Salford M6 8HD, UK
N. WILLIAMS G. K. ROSE
DI, Gruzelier JH. Adverse changes in mood and cognitive performance of house officers after night duty. Br Med J 1989; 298: 21-22. 2. Dudley HAF. Stress in junior doctors. Br Med J 1990; 301: 75-76. 3. Colin Douglas. The Houseman’s Tale. London: Canongate Publishing, 1975. 4. Samuel Shem. The house of God. NSW: Transworld Publishers, 1985. 1. Orton
Safety guidelines for use of nitric oxide SiR,—There is interest in inhaled nitric oxide (NO) as a pulmonary vasodilator which, unlike intravenous pulmonary vasodilators, does not affect the systemic circulation.l-3 One suggestion is that inhaled NO may reduce intrapulmonary shunting
1616
1.
Pepke-Zaba J, Higenbottam TW, Dinh-Xuan A, et al. Inhaled nitric oxide as a cause of selective pulmonary vasodilation in pulmonary hypertension. Lancet 1991; 338:
1173. 2. Frostell C, Fratacci M-D, Wain
JC, Jones R, Zapol WM. Inhaled nitric oxide: a selective pulmonary vasodilator reversing hypoxic pulmonary vasoconstriction. Circulation 1991: 83 (6): 2038-47. 3. Fratacci MD, Frostell C, Chen TY, et al. Inhaled nitric oxide: a selective pulmonary vasodilator of heparin-protamine vasoconstriction in sheep. Anesthesiology 1991; 75 (16): 900-99.
4. Falke K, Rossaint R, Pison V, et al. Inhaled nitric oxide selectively reduces pulmonary hypertension in severe ARDS and improves gas exchange as well as right heart ejection fraction: a case report. Am Rev Resp Dis 1991; 143 (suppl): A248. 5. Centers for Disease Control. Recommendations for occupational safety and health standard. MMWR 1988; 37 (suppl): 21. 6. Baulch DL, Drysdale DD. Evaluated kinetic data for high temperature reactions. London: Butterworths, 1973.
Acute-phase response in patients given rhIL-3 after chemotherapy SIR,-Dr Vreugdenhil and colleagues (May 2, p 1118) draw Time (min) to and O2,
yield 5
ppm
N02 with different
mixtures of NO
in patients with adult respiratory distress syndrome (ARDS).4 Nonetheless the therapeutic use of NO has to be considered in the light of the toxicity of higher oxides of nitrogen. Although methaemoglobin levels remain within safe limits,’-’ attention should be drawn to the rapid oxidation of NO to nitrogen dioxide (N02) in the presence of oxygen. N02 could be transformed to nitric and nitrous acids, causing severe pulmonary oedema, acid pneumonitis, and death.2 Unless further toxicity studies reveal new data, recommendations for occupational safety and health standards that put the upper limit for N02 inhalation at 5 parts per million (ppm)5 should be respected. The rate of conversion of NO can be calculated from the formula:
attention to the broader effects of haemopoietic growth factors other than their known ability to stimulate haemopoiesis. They present data on enhanced production of interleukin-6 (IL-6) several hours after intravenous recombinant human (rh) granulocyte-
macrophage colony-stimulating factor (ecogramostim, GM-CSF) after chemotherapy. Vreugdenhil et al postulate that this effect of GM-CSF on IL-6 release could induce an acute-phase response that might have beneficial effects on host defence against infectious complications. This acute-phase response is seen with another growth factor, interleukin-3 (rhIL-3), when given after chemotherapy.
- d(NO)/dt=2k(NO(0,) Since the O2 concentration will be little changed, it can be assumed to be constant. Integration of this formula gives the following:
l/(NOB-l/(NO)i = 2k(02)t where (NO)i is the NO concentration initially and (NO)t is that at time t, and k (rate constant) is 1-93 x 10s cm6 mol-2s-1 at 3000 K.6 Assuming that a change in NO concentration is completely due to oxidation to N0, the above equation can be used to calculate the time to reach 5 ppm N02 at any concentration of NO in 0. We have calculated the time to yield 5 ppm N02 from NO concentrations of 20,40,80, and 120 ppm in O2 concentrations of 20-100% (figure). The implications are that one should be very careful when NO concentrations greater than 80 ppm are administered. The delivery systems for the use of NO in ventilated patients should be designed in such a way that contact times of NO with O2 are as short as
possible. in bags to be used in should be administered within the spontaneously breathing patients appropriate time limits to avoid unacceptably high inhalational N02 levels. Fresh soda-lime can be used to absorb N02 that may be generated, but little is known of its clinical efficacy. Recent data suggest that 18 ppm NO might be effective in ARDS.4 We suggest further studies to investigate whether 10-20 ppm NO mixtures are useful in clinical practice, because this could significantly reduce the toxicity: the time to reach 5 ppm N02 from 20 ppm NO in 100% oxygen is 12 min and in air is more than 1 h. NO and N02 concentrations should be measured when patients are receiving NO. NO concentrations should be kept as low as possible, contact times with O2 should be short, and the inspiratory O2 fraction should not be higher than clinically indicated.
Mixtures of NO in
air/02,collected
Department of Anaesthesia, Papworth Hospital
Cambridgeshire CB3 8RE,
UK
LUC FOUBERT BRUCE FLEMING RAY LATIMER MAX JONAS AMO ODURO
Hinchingbrooke Hospital, Huntingdon
COLIN BORLAND
Department of Respiratory Physiology, Papworth Hospital
TIM HIGENBOTTAM
UIIIG
Effect of first subcutaneous rhlL-3 dose (8/1g/kg. n = 3:16 M/kg, n = 3) on IL-6 (lower) and acute-phase proteins (SAA and CRP)
(upper). Baseline values
are
set at
100%; values are median percentages.
Such issues, in the context of the provision of care for children with problems that were potentially "preventable", have already been raised in North America, and have been related to cases of "wrongful life", and to health insurance provided by employers.’ Do we want to see this happen in Britain too? If society answers Collins’ question by charging the cost of refusing blood transfusion to Jehovah’s Witnesses themselves, will the provision of nationalised health care for children with genetic disease be similarly restricted? Will National Health Service (NHS) care be denied to those whose parents are labelled as irresponsible because they have declined to take part in prenatal diagnosis or screening, or because they have declined to terminate a pregnancy at high risk of some disorder? Will budget-holding general practitioners seek to remove from their lists those families that refuse antenatal screening? The reasons for declining to participate in such programmes, of course, may vary-but these reasons are
HIV infection in Victoria, and a social justice payment was added for those people whose cases in law were weakest. Group settlement in late 1991, despite grossly disparate payments for equally infected people, has resolved much of the anger and divisiveness that was destroying our patients and our centre. The enormous relief, consequent upon settlement, which is shared by patients and their carers, allows patients to plan for quality, not merely in financial terms, in their shortened futures. The gloomy days of HIV disease remain but the distress of litigation no longer affects the immune system.
quite irrelevant if a "medicine of the bottom line" is all that the NHS will seek to provide. The restriction of access to health care in such circumstances could doubtless be justified as the promotion of autonomy and responsibility; appeals to autonomy in this sense (of self-reliance, rather than self-determination) are used to justify cuts in public services by those inclined for political reasons in that direction.2 In addition to these questions of principle, there is also a practical question to be addressed. Do Jehovah’s Witnesses really cost the NHS more, on average, than other citizens? Or do they make less use of it, perhaps dying sooner after trauma, or just preferring to avoid contact with contemporary medicine for minor ailments ? If so, they may actually be saving NHS money. If they, or some other identifiable group, in fact consume fewer NHS resources than the average, should they then pay less tax than the rest of the
SjR,—For the newly qualified junior hospital doctor the stresses and strains of final examinations pale into insignificance when compared with the prospect of the first day of August, this being the start, in the UK at least, of "house jobs". Much folklore and handed-down anecdotal tales abound about this, possibly the most stressful and eventful month of the houseman’s year. The psychological and emotional impact on the new graduate is well documented/,2 but what of the organic signs? We sent a two-part questionnaire about diet and weight to all (102) doctors who graduated in 1991 from the University of Leicester. Part A was completed within the first week of August and part B in the first week of September. 61 forms were returned for part A and 48 for part B. Data for analysis were thus available for 31 women and 17 men (age 22-30, mean 23 years). No subject was actively dieting during the period under consideration. About two-thirds (30) lost weight during their first four weeks as a houseman; 10 gained weight; and 8 remained the same weight. 19 women and 11 men lost an average of 2-6 kg (range 0’4-6-4). Of these, 28 thought their diet had been adversely affected by their job and 2 thought not. 17 had found their hospital canteen unacceptable whereas 13 thought it was acceptable or good. Common reasons given for weight loss were lack of time for eating and increased energy expenditure. 8 women and 2 men gained an average of 1 -7 kg (04-1). 7 had found their diet to be adversely affected and 3 had not; 6 found the hospital canteen unacceptable; and 4 thought it was acceptable or good. 4 women admitted to a partiality for chocolates, which were readily available on the ward and were therefore consumed more liberally than usual. Of the 4 men and 4 women whose weight remained stable, although all thought their diet had been adversely affected by their job, all, surprisingly, found the food in their hospital canteen acceptable. The year spent as a houseman is the subject of two witty novels3,4 which are read avidly by medical students. The year is not all roses, however, and many find the hours long and arduous. Chronic tiredness, lack of support, and a feeling of being uncared for, among others, contribute to stress. The stress and pace of the job also leads to a change in diet, as shown in our series where 43 of the 48 (90%) thought that their diet was adversely affected and 62% did lose weight. That the weight loss was almost certainly occupational is probably not in doubt. Does this then commend house jobs as a way to diet? In the short term, perhaps yes; in the long term, thankfully
population? We believe that health care should be provided for all, irrespective of race or religion, and with full respect for any constraints imposed by the patient on the grounds of their religious, moral, or cultural beliefs or customs. To make any other decision would be a violation of human rights, of medical ethics, and of the obligation of our secular society to respect the various sets of values of all its citizens. Institute of Medical Genetics, University of Wales College of Medicine, Cardiff CF4 4XN, UK
ANGUS CLARKE CARINA WALLGREN-PETTERSSON HELEN E. HUGHES
Billings PR, Kohn MA, de Cuevas M, et al. Discrimination as consequence of genetic testing. Am J Hum Genet 1992; 50: 476-82. 2. Chadwick R. What counts as success in genetic counselling? Med Ethics (in press). J 1.
Compensation for medically acquired AIDS SiR,—Iwould expand Mark Ragg’s (Feb 15, p 419) comments about compensation for medically acquired AIDS in Victoria, Australia. Claims made since 1985 by haemophilia patients, infected with HIV, against State and Federal Governments, as producers and administrators of contaminated plasma concentrates, were almost completely disregarded. The Federal Government had set up a "token" trust in 1990 with staged minimum payments. Patients sought further legal retribution, having been inflamed by Government advice that this was their only recourse. The haemophilia community was deeply divided in taking such action not only between HIV infected and uninfected factions but also within the infected group. Many were deeply embarassed about suing their haemophilia treatment centres in three-way suits against hospital, Red Cross Transfusion Service, and Commonwealth Serum Laboratories. A landmark court case was brought in Victoria, the only state to have a jury for civil cases, in 1990. It was won by the plaintiff against a haemophilia treatment centre only. This case was noteworthy not
only for the verdict but also for the notoriously high legal costs disbursed from state-funded legal aid and other public sources. A formula, based on legal likelihood of successful case prosecution, was crafted for out-of-court settlements in South Australia in 1991. This model was applied to all known cases of transfusion-related
Haemophilia Treatment Centre, Alfred Hospital, Melbourne, Victoria 3181, Australia
Acute
weight reduction
ALISON STREET
in junior doctors
not.
Department of Surgery, University of Manchester, Hope Hospital, Salford M6 8HD, UK
N. WILLIAMS G. K. ROSE
DI, Gruzelier JH. Adverse changes in mood and cognitive performance of house officers after night duty. Br Med J 1989; 298: 21-22. 2. Dudley HAF. Stress in junior doctors. Br Med J 1990; 301: 75-76. 3. Colin Douglas. The Houseman’s Tale. London: Canongate Publishing, 1975. 4. Samuel Shem. The house of God. NSW: Transworld Publishers, 1985. 1. Orton
Safety guidelines for use of nitric oxide SiR,—There is interest in inhaled nitric oxide (NO) as a pulmonary vasodilator which, unlike intravenous pulmonary vasodilators, does not affect the systemic circulation.l-3 One suggestion is that inhaled NO may reduce intrapulmonary shunting
1616
1.
Pepke-Zaba J, Higenbottam TW, Dinh-Xuan A, et al. Inhaled nitric oxide as a cause of selective pulmonary vasodilation in pulmonary hypertension. Lancet 1991; 338:
1173. 2. Frostell C, Fratacci M-D, Wain
JC, Jones R, Zapol WM. Inhaled nitric oxide: a selective pulmonary vasodilator reversing hypoxic pulmonary vasoconstriction. Circulation 1991: 83 (6): 2038-47. 3. Fratacci MD, Frostell C, Chen TY, et al. Inhaled nitric oxide: a selective pulmonary vasodilator of heparin-protamine vasoconstriction in sheep. Anesthesiology 1991; 75 (16): 900-99.
4. Falke K, Rossaint R, Pison V, et al. Inhaled nitric oxide selectively reduces pulmonary hypertension in severe ARDS and improves gas exchange as well as right heart ejection fraction: a case report. Am Rev Resp Dis 1991; 143 (suppl): A248. 5. Centers for Disease Control. Recommendations for occupational safety and health standard. MMWR 1988; 37 (suppl): 21. 6. Baulch DL, Drysdale DD. Evaluated kinetic data for high temperature reactions. London: Butterworths, 1973.
Acute-phase response in patients given rhIL-3 after chemotherapy SIR,-Dr Vreugdenhil and colleagues (May 2, p 1118) draw Time (min) to and O2,
yield 5
ppm
N02 with different
mixtures of NO
in patients with adult respiratory distress syndrome (ARDS).4 Nonetheless the therapeutic use of NO has to be considered in the light of the toxicity of higher oxides of nitrogen. Although methaemoglobin levels remain within safe limits,’-’ attention should be drawn to the rapid oxidation of NO to nitrogen dioxide (N02) in the presence of oxygen. N02 could be transformed to nitric and nitrous acids, causing severe pulmonary oedema, acid pneumonitis, and death.2 Unless further toxicity studies reveal new data, recommendations for occupational safety and health standards that put the upper limit for N02 inhalation at 5 parts per million (ppm)5 should be respected. The rate of conversion of NO can be calculated from the formula:
attention to the broader effects of haemopoietic growth factors other than their known ability to stimulate haemopoiesis. They present data on enhanced production of interleukin-6 (IL-6) several hours after intravenous recombinant human (rh) granulocyte-
macrophage colony-stimulating factor (ecogramostim, GM-CSF) after chemotherapy. Vreugdenhil et al postulate that this effect of GM-CSF on IL-6 release could induce an acute-phase response that might have beneficial effects on host defence against infectious complications. This acute-phase response is seen with another growth factor, interleukin-3 (rhIL-3), when given after chemotherapy.
- d(NO)/dt=2k(NO(0,) Since the O2 concentration will be little changed, it can be assumed to be constant. Integration of this formula gives the following:
l/(NOB-l/(NO)i = 2k(02)t where (NO)i is the NO concentration initially and (NO)t is that at time t, and k (rate constant) is 1-93 x 10s cm6 mol-2s-1 at 3000 K.6 Assuming that a change in NO concentration is completely due to oxidation to N0, the above equation can be used to calculate the time to reach 5 ppm N02 at any concentration of NO in 0. We have calculated the time to yield 5 ppm N02 from NO concentrations of 20,40,80, and 120 ppm in O2 concentrations of 20-100% (figure). The implications are that one should be very careful when NO concentrations greater than 80 ppm are administered. The delivery systems for the use of NO in ventilated patients should be designed in such a way that contact times of NO with O2 are as short as
possible. in bags to be used in should be administered within the spontaneously breathing patients appropriate time limits to avoid unacceptably high inhalational N02 levels. Fresh soda-lime can be used to absorb N02 that may be generated, but little is known of its clinical efficacy. Recent data suggest that 18 ppm NO might be effective in ARDS.4 We suggest further studies to investigate whether 10-20 ppm NO mixtures are useful in clinical practice, because this could significantly reduce the toxicity: the time to reach 5 ppm N02 from 20 ppm NO in 100% oxygen is 12 min and in air is more than 1 h. NO and N02 concentrations should be measured when patients are receiving NO. NO concentrations should be kept as low as possible, contact times with O2 should be short, and the inspiratory O2 fraction should not be higher than clinically indicated.
Mixtures of NO in
air/02,collected
Department of Anaesthesia, Papworth Hospital
Cambridgeshire CB3 8RE,
UK
LUC FOUBERT BRUCE FLEMING RAY LATIMER MAX JONAS AMO ODURO
Hinchingbrooke Hospital, Huntingdon
COLIN BORLAND
Department of Respiratory Physiology, Papworth Hospital
TIM HIGENBOTTAM
UIIIG
Effect of first subcutaneous rhlL-3 dose (8/1g/kg. n = 3:16 M/kg, n = 3) on IL-6 (lower) and acute-phase proteins (SAA and CRP)
(upper). Baseline values
are
set at
100%; values are median percentages.
