- Email: [email protected]
A MEDICAL SCHOOL IN HULL
186
conclusions are that Zagreb antivenom is indicated at all ages when life is endangered by shock. In addition, it should be considered in adult patients seen within two hours of the bite and already showing swelling extending up the bitten limb, with the object of reducing morbidity from local effects. Adults take longer than children to recover, two-thirds taking three or more weeks and a quarter taking one to nine months." During these months aches and intermittent swelling of the bitten limb may be disabling. Lessening the time for full recovery is more important for adults than it is for children. What are the dangers of antivenom therapy? Reactions of one kind or another are common, up to 48%,13 but immediate hypotensive reactions are much less common, about 3%. Zagreb antivenom is highly refined, making immediate reactions uncommon; for immediate antivenom reactions Reid" reports that adrenaline was invariably successful, provided it was promptly injected.
excess
ueciuie
iti
first six months
venniaLury capaciLy
uuserveu
III
Lite
sustained. These findings are not unexpected, but 23 of the group also had neural symptoms which have not previously been reported with isocyanates. 5 had immediate symptoms-euphoria, ataxia, and loss of consciousness. These and 9 others complained of headache, difficulty in concentration, poor memory, and confusion during the next three weeks. After four years, 13 men still complained of poor memory, personality change, irritability, and depression, and some of these symptoms were confirmed by psychowas not
metric testing. Normal industrial exposure is unlikely to be high enough to produce these symptoms, but the fact that they can occur after heavy exposure will be noted by those caring for isocyanate workers. The incident also draws attention to the need for special instruction of firemen about the hazards of fires in factories making and using substances with toxic products of combustion. Breathing apparatus seems to be the only safeguard against hazardous substances in the smoke.
ISOCYANATES IN THE FIRE ISOCYANATES are widely used in the synthesis of polyurethane, and their hazards have been known for at least twenty years. Polyurethane foam is one of the end-products, and the paint industry has been devising quick-drying polyurethane paints which depend on the presence of an isocyanate hardener or activator in the mix made for spraying. Toluene di-isocyanate (T.D.I.) is the most widely used of these compounds, but diphenyl methane di-isocyanate (M.D.I.), naphthalene di-iso-
(N.D.I.), and hexamethylene di-isocyanate also employed. Exposed workers may become sensitised and develop asthma-like symptoms which
cyanate
(H.D.I.)
are
re-exposure even to small amounts, and this sensitisation is commonest with T.D.I. and H.D.I., the more volatile members of the group. There is also an irritant effect on mucous membranes and skin. More rarely there may be irreversible lung damage, probably due to alveolitis, which shows itself in a permanent reduction in ventilatory capacity. In industry, the hazards are now generally recognised, the threshold limit value being 0-02 p.p.m. (For a potential sensitising agent there is no such thing as a safe limit, but this is a reasonably practicable level.) However, a further addition to recorded experience comes in two reports14 15 concerning a group of firemen who received a single severe exposure while dealing with recur on
fire in
polyurethane-foam factory, during which in large quantities from storage tanks. 35 firemen were exposed and most of them had symptoms at the time or in the ensuing three weeks. 15 complained of gastrointestinal symptoms, which were transient; but 31 had respiratory symptoms-initially, irritation of mucous membranes and subsequently tightness of the chest, cough, and breathlessness. These tended to improve ; but of 31 who were seen again after six months, 14 had persistent symptoms and said they were more susceptible to respiratory infections. Almost four years later, 20 men still had respiratory symptoms, but the a
T.D.I.
a
BILATERAL NEPHRECTOMY BEFORE TRANSPLANTATION
SOME transplant surgeons routinely remove both kidneys from patients on the waiting-list for renal transplantation. Now groups from Glasgow and Portland, Oregon, recommend a more conservative approach. In Glasgow’ 53 patients underwent bilateral nephrectomy, usually as a separate procedure from the transplantation.5 patients died as a result of the operation, and complications included hypotension, infection, and clotting of external shunts or arteriovenous fistulas. In the Portland series2 there were no operative deaths, but analysis of the results of subsequent transplantation revealed a significant advantage in terms of rejection and a possible one in terms of patient survival for the 49 patients without pre-transplant nephrectomy compared with the 27 who had had both kidneys removed. The rationale for nephrectomy is the avoidance of graft-hazarding urinary-tract infection: in Portland no patient with their old kidneys in place had graft-threatening sepsis, and in the Glasgow series 9 of the 17 nephrectomised pyelonephritic patients had one or more urinary infections. Some indications for bilateral nephrectomy remain, but the procedure is likely to become less of a routine in the light of these two reports.
spilled
13 Campbell, C. H Med. J. Aust. 1967, ii, 106. 14. Axford, A. T., McKerrow, C. B., Parry Jones, A., Le ind. Med. 1976, 33, 65. 15. Le Quesne, P. M., Axford, A. T., McKerrow, C. B.,
p.72
Quesne,
P. M.
A MEDICAL SCHOOL IN HULL
ANYONE advocating a scheme involving even modest Government expenditure today must be unbalanced, ridiculously optimistic, or convinced that his case is so strong that even penurious Britain cannot ignore it. The University of Hull clearly believes that its proposal for an early start on a medical school falls in the last category. The first formal case for a medical faculty in Hull was made in evidence to the Todd Commission in 1966,
Br. J. 1
Parry Jones,
A. ibid.
Calman, K C., Bell, P R. F., Bnggs, J. D., Hamilton, D N. H., Macpherson, S. G., Paton, A. M. Br J.Surg. 1976, 63, 512. 2. Bennett, W. M. J. Am. med. Ass. 1976, 235, 1703.
187
resulting in a lukewarm mention in its report. Undeterred, the university established a Medical School Foundation Committee which presented a strong document to the University Grants Committee2 in 1971, and updated it in 1973.3 Apart from the continuing enthusiasm of university and medical profession in Hull for a medical school, what has prompted a further lengthy submission4 at this economically inauspicious time? Men of Hull clearly retain a certain Yorkshire bluntness, even though they are now segregated into their own county of Humberside. They forthrightly declare their belief that the Department of Health will not reach its target of a 4100 annual medical student intake in 1979, and anyway doubt whether that number would provide an adequate number of doctors for the country, in the light of renegotiated contracts and reduced immigration. Their second argument (which has hitherto been the strongest) is based on geography. Kingston upon Hull is the centre of an eastern void deprived of any medical school. Its nearest neighbours, Leeds and Newcastle, have their own densely populated regions, and few of their alumni find their way to Humberside. This isolation of Hull has not been entirely disadvantageous, for it has stimulated the doctors who practise there to develop a comprehensive service which now functions with complete independence of other medical centres, but the propensity of doctors to settle near their alma mater makes recruitment to the area more difficult. The third aspect of the revitalised case is that all parts of the Humberside Health Area, with its population of over a million, will enjoy good (if not free) road communication by 1979 when the longest single-spari bridge in the world will link the two banks of the Humber. It was the lack of this bridge and the access it would give the medical school to the people and hospitals of Grimsby and Scunthorpe which particularly deterred the Todd Commission in 1968, but now the objection is disappearing. Those three points, however cogent, do not explain the University’s pressure at a time of financial stringency. This is clarified by the substance of its new document4 which sets out a plan to capitalise on existing university and hospital facilities in order to accommodate an intake of about 50 students a year as early as 1979. A detailed account is given of existing hospital facilities throughout the area, with comments on their ability to accommodate students. The university has spare capacity because of generous building in the 1960s and the national trend towards fewer applications for sciencefaculty places. The document-which here and there seems starry-eyed-argues that, unlike the three new medical schools of the past decade, which have demanded massive building programmes, this one could at least begin with little new construction. The case for early opening of a Hull Medical School thus appeals to the Government’s pocket as well as to its commitment to regional egalitarianism. If enthusiasm could win the day, Hull would have its medical school this decade.
on Medical Education (Cmnd. 3569). H.M. Stationery Office, 1968. 2 A Medical School for Hull. University of Hull, 1971. 3 A Medical School for Hull Three New Factors. University of Hull, 1973. 4 Statement by the University on the Admission of Students to a Medical Course, University of Hull, 1976.
1 Royal Commission
DAY-CARE UNITS FOR DIABETICS IN young and middle-aged people with diabetes we should now aim to achieve blood-glucose levels close to those in non-diabetics.1 These are the patients at greatest risk of acquiring microvascular disease. Many such patients are still very poorly controlled, and there is a strong association between early age of onset and poor control. Studied in their own homes, diabetics often reveal ignorance of the basic rules of management. These findings raise the question, are hospital clinics best-placed to help the diabetic achieve good control ?
diabetic clinics vary, but usually their size is make rapport between physician and patient impossible. Almost certainly, an interested general practitioner can cater equally well for most of his diabetic patients;4indeed, much of the work now being done by doctors can be successfully delegated to nurses. The nurse with experience in diabetes has a vital role in teaching the patient and in organising psychosocial support. Komaroff et a1.6 go further: they taught physician assistants to take a history and do a basic physical examination, and they reported a 20% saving in physician time which they devoted to diabetics who needed their special skills.
Hospital
such
as to
For patients who are poorly controlled and for patients who seek better standards of control, the diabetic day-care unit has much to offer. Unlike hospital admission, the day-care unit enables patients to be seen in a setting close to everyday life. It is certainly less disruptive of activities such as school and work. Noviks, King, and Spaulding’ have shown that these units can improve diabetic control and that they are also a suitable place to start insulin treatment-saving much time and money.8 Diabetic control is hard to define, but they devised a points system to quantitate control based on blood-glucose, urine glucose, episodes of diabetic acidosis or hypoglycaemia, symptoms associated with hyperglycaemia, and control of weight. Guided by these scores, diabetics are encouraged to take on more responsibility for their own management.9 The day-care unit also offers a system of continued support, which is probably just as important as instruction.2 The emphasis is on details of management, and the staff are concerned about the diabetic as an individual with his own particular problems. Advice is also freely available by telephone. Some will say that too much attention to good control will make patients obsessional, but it would be equally wrong to imply that diabetics can lead a completely normal life without cares. The success achieved by highly motivated young diabetics during pregnancy is an object lesson when we try to raise standards of diabetic control in other groups.
1. Cahill, G. F, Etzwiler, D. D., Freinkel, N. New Engl. J Med 1976, 294, 1004. 2. Williams, T. F., Martin, D A., Hogan, M D., Watkins, J D., Ellis, E. V. Am. J. publ Hlth, 1967, 57, 441. 3. Watkins, J. D., Williams, T F., Martin, D. A., Hogan, M. D., Anderson, E. ibid p. 452 4. Malins, J.M, Stuart, J M. Br. med J1971, iv, 161 5. Thorn, P. A., Russell, R. G. ibid 1973, ii, 534. 6. Komaroff, A L., Flatley, M., Browne, C., Sherman, H, Fineberg, S. E., Knopp, R. H Diabetes, 1976, 25, 297. 7. Noviks, L., King, B., Spaulding, W. B. Can. med Ass. J. 1976, 114, 777. 8. Spaulding, R. H , Spaulding. W. B ibid p. 780. 9. Spaulding, W. B. ibid 1971, 105, 1078.
conclusions are that Zagreb antivenom is indicated at all ages when life is endangered by shock. In addition, it should be considered in adult patients seen within two hours of the bite and already showing swelling extending up the bitten limb, with the object of reducing morbidity from local effects. Adults take longer than children to recover, two-thirds taking three or more weeks and a quarter taking one to nine months." During these months aches and intermittent swelling of the bitten limb may be disabling. Lessening the time for full recovery is more important for adults than it is for children. What are the dangers of antivenom therapy? Reactions of one kind or another are common, up to 48%,13 but immediate hypotensive reactions are much less common, about 3%. Zagreb antivenom is highly refined, making immediate reactions uncommon; for immediate antivenom reactions Reid" reports that adrenaline was invariably successful, provided it was promptly injected.
excess
ueciuie
iti
first six months
venniaLury capaciLy
uuserveu
III
Lite
sustained. These findings are not unexpected, but 23 of the group also had neural symptoms which have not previously been reported with isocyanates. 5 had immediate symptoms-euphoria, ataxia, and loss of consciousness. These and 9 others complained of headache, difficulty in concentration, poor memory, and confusion during the next three weeks. After four years, 13 men still complained of poor memory, personality change, irritability, and depression, and some of these symptoms were confirmed by psychowas not
metric testing. Normal industrial exposure is unlikely to be high enough to produce these symptoms, but the fact that they can occur after heavy exposure will be noted by those caring for isocyanate workers. The incident also draws attention to the need for special instruction of firemen about the hazards of fires in factories making and using substances with toxic products of combustion. Breathing apparatus seems to be the only safeguard against hazardous substances in the smoke.
ISOCYANATES IN THE FIRE ISOCYANATES are widely used in the synthesis of polyurethane, and their hazards have been known for at least twenty years. Polyurethane foam is one of the end-products, and the paint industry has been devising quick-drying polyurethane paints which depend on the presence of an isocyanate hardener or activator in the mix made for spraying. Toluene di-isocyanate (T.D.I.) is the most widely used of these compounds, but diphenyl methane di-isocyanate (M.D.I.), naphthalene di-iso-
(N.D.I.), and hexamethylene di-isocyanate also employed. Exposed workers may become sensitised and develop asthma-like symptoms which
cyanate
(H.D.I.)
are
re-exposure even to small amounts, and this sensitisation is commonest with T.D.I. and H.D.I., the more volatile members of the group. There is also an irritant effect on mucous membranes and skin. More rarely there may be irreversible lung damage, probably due to alveolitis, which shows itself in a permanent reduction in ventilatory capacity. In industry, the hazards are now generally recognised, the threshold limit value being 0-02 p.p.m. (For a potential sensitising agent there is no such thing as a safe limit, but this is a reasonably practicable level.) However, a further addition to recorded experience comes in two reports14 15 concerning a group of firemen who received a single severe exposure while dealing with recur on
fire in
polyurethane-foam factory, during which in large quantities from storage tanks. 35 firemen were exposed and most of them had symptoms at the time or in the ensuing three weeks. 15 complained of gastrointestinal symptoms, which were transient; but 31 had respiratory symptoms-initially, irritation of mucous membranes and subsequently tightness of the chest, cough, and breathlessness. These tended to improve ; but of 31 who were seen again after six months, 14 had persistent symptoms and said they were more susceptible to respiratory infections. Almost four years later, 20 men still had respiratory symptoms, but the a
T.D.I.
a
BILATERAL NEPHRECTOMY BEFORE TRANSPLANTATION
SOME transplant surgeons routinely remove both kidneys from patients on the waiting-list for renal transplantation. Now groups from Glasgow and Portland, Oregon, recommend a more conservative approach. In Glasgow’ 53 patients underwent bilateral nephrectomy, usually as a separate procedure from the transplantation.5 patients died as a result of the operation, and complications included hypotension, infection, and clotting of external shunts or arteriovenous fistulas. In the Portland series2 there were no operative deaths, but analysis of the results of subsequent transplantation revealed a significant advantage in terms of rejection and a possible one in terms of patient survival for the 49 patients without pre-transplant nephrectomy compared with the 27 who had had both kidneys removed. The rationale for nephrectomy is the avoidance of graft-hazarding urinary-tract infection: in Portland no patient with their old kidneys in place had graft-threatening sepsis, and in the Glasgow series 9 of the 17 nephrectomised pyelonephritic patients had one or more urinary infections. Some indications for bilateral nephrectomy remain, but the procedure is likely to become less of a routine in the light of these two reports.
spilled
13 Campbell, C. H Med. J. Aust. 1967, ii, 106. 14. Axford, A. T., McKerrow, C. B., Parry Jones, A., Le ind. Med. 1976, 33, 65. 15. Le Quesne, P. M., Axford, A. T., McKerrow, C. B.,
p.72
Quesne,
P. M.
A MEDICAL SCHOOL IN HULL
ANYONE advocating a scheme involving even modest Government expenditure today must be unbalanced, ridiculously optimistic, or convinced that his case is so strong that even penurious Britain cannot ignore it. The University of Hull clearly believes that its proposal for an early start on a medical school falls in the last category. The first formal case for a medical faculty in Hull was made in evidence to the Todd Commission in 1966,
Br. J. 1
Parry Jones,
A. ibid.
Calman, K C., Bell, P R. F., Bnggs, J. D., Hamilton, D N. H., Macpherson, S. G., Paton, A. M. Br J.Surg. 1976, 63, 512. 2. Bennett, W. M. J. Am. med. Ass. 1976, 235, 1703.
187
resulting in a lukewarm mention in its report. Undeterred, the university established a Medical School Foundation Committee which presented a strong document to the University Grants Committee2 in 1971, and updated it in 1973.3 Apart from the continuing enthusiasm of university and medical profession in Hull for a medical school, what has prompted a further lengthy submission4 at this economically inauspicious time? Men of Hull clearly retain a certain Yorkshire bluntness, even though they are now segregated into their own county of Humberside. They forthrightly declare their belief that the Department of Health will not reach its target of a 4100 annual medical student intake in 1979, and anyway doubt whether that number would provide an adequate number of doctors for the country, in the light of renegotiated contracts and reduced immigration. Their second argument (which has hitherto been the strongest) is based on geography. Kingston upon Hull is the centre of an eastern void deprived of any medical school. Its nearest neighbours, Leeds and Newcastle, have their own densely populated regions, and few of their alumni find their way to Humberside. This isolation of Hull has not been entirely disadvantageous, for it has stimulated the doctors who practise there to develop a comprehensive service which now functions with complete independence of other medical centres, but the propensity of doctors to settle near their alma mater makes recruitment to the area more difficult. The third aspect of the revitalised case is that all parts of the Humberside Health Area, with its population of over a million, will enjoy good (if not free) road communication by 1979 when the longest single-spari bridge in the world will link the two banks of the Humber. It was the lack of this bridge and the access it would give the medical school to the people and hospitals of Grimsby and Scunthorpe which particularly deterred the Todd Commission in 1968, but now the objection is disappearing. Those three points, however cogent, do not explain the University’s pressure at a time of financial stringency. This is clarified by the substance of its new document4 which sets out a plan to capitalise on existing university and hospital facilities in order to accommodate an intake of about 50 students a year as early as 1979. A detailed account is given of existing hospital facilities throughout the area, with comments on their ability to accommodate students. The university has spare capacity because of generous building in the 1960s and the national trend towards fewer applications for sciencefaculty places. The document-which here and there seems starry-eyed-argues that, unlike the three new medical schools of the past decade, which have demanded massive building programmes, this one could at least begin with little new construction. The case for early opening of a Hull Medical School thus appeals to the Government’s pocket as well as to its commitment to regional egalitarianism. If enthusiasm could win the day, Hull would have its medical school this decade.
on Medical Education (Cmnd. 3569). H.M. Stationery Office, 1968. 2 A Medical School for Hull. University of Hull, 1971. 3 A Medical School for Hull Three New Factors. University of Hull, 1973. 4 Statement by the University on the Admission of Students to a Medical Course, University of Hull, 1976.
1 Royal Commission
DAY-CARE UNITS FOR DIABETICS IN young and middle-aged people with diabetes we should now aim to achieve blood-glucose levels close to those in non-diabetics.1 These are the patients at greatest risk of acquiring microvascular disease. Many such patients are still very poorly controlled, and there is a strong association between early age of onset and poor control. Studied in their own homes, diabetics often reveal ignorance of the basic rules of management. These findings raise the question, are hospital clinics best-placed to help the diabetic achieve good control ?
diabetic clinics vary, but usually their size is make rapport between physician and patient impossible. Almost certainly, an interested general practitioner can cater equally well for most of his diabetic patients;4indeed, much of the work now being done by doctors can be successfully delegated to nurses. The nurse with experience in diabetes has a vital role in teaching the patient and in organising psychosocial support. Komaroff et a1.6 go further: they taught physician assistants to take a history and do a basic physical examination, and they reported a 20% saving in physician time which they devoted to diabetics who needed their special skills.
Hospital
such
as to
For patients who are poorly controlled and for patients who seek better standards of control, the diabetic day-care unit has much to offer. Unlike hospital admission, the day-care unit enables patients to be seen in a setting close to everyday life. It is certainly less disruptive of activities such as school and work. Noviks, King, and Spaulding’ have shown that these units can improve diabetic control and that they are also a suitable place to start insulin treatment-saving much time and money.8 Diabetic control is hard to define, but they devised a points system to quantitate control based on blood-glucose, urine glucose, episodes of diabetic acidosis or hypoglycaemia, symptoms associated with hyperglycaemia, and control of weight. Guided by these scores, diabetics are encouraged to take on more responsibility for their own management.9 The day-care unit also offers a system of continued support, which is probably just as important as instruction.2 The emphasis is on details of management, and the staff are concerned about the diabetic as an individual with his own particular problems. Advice is also freely available by telephone. Some will say that too much attention to good control will make patients obsessional, but it would be equally wrong to imply that diabetics can lead a completely normal life without cares. The success achieved by highly motivated young diabetics during pregnancy is an object lesson when we try to raise standards of diabetic control in other groups.
1. Cahill, G. F, Etzwiler, D. D., Freinkel, N. New Engl. J Med 1976, 294, 1004. 2. Williams, T. F., Martin, D A., Hogan, M D., Watkins, J D., Ellis, E. V. Am. J. publ Hlth, 1967, 57, 441. 3. Watkins, J. D., Williams, T F., Martin, D. A., Hogan, M. D., Anderson, E. ibid p. 452 4. Malins, J.M, Stuart, J M. Br. med J1971, iv, 161 5. Thorn, P. A., Russell, R. G. ibid 1973, ii, 534. 6. Komaroff, A L., Flatley, M., Browne, C., Sherman, H, Fineberg, S. E., Knopp, R. H Diabetes, 1976, 25, 297. 7. Noviks, L., King, B., Spaulding, W. B. Can. med Ass. J. 1976, 114, 777. 8. Spaulding, R. H , Spaulding. W. B ibid p. 780. 9. Spaulding, W. B. ibid 1971, 105, 1078.