- Email: [email protected]
A question of balance
298
insurance programmes leaves gaps in coverage: in France only 250 000 people are without health insurance, in Germany more than 1 million. Will these uninsured citizens, if they seek care outside their country, be asked for immediate payment? Will such payments be based on the fee schedule operative in their own country, or on that of the country in which they receive services? On what basis will insured EC citizens receive services? Will the country of origin pay, and if so at what rate? And so on. The proposed integration also has implications for doctors. For instance, some countries strictly delimit the kind of practice in which physicians may engage, depending on their training and
experience. The EC is embarking on a difficult course towards what may become a United States of Europe. If the integration of its health services succeeds, the EC might show the other United States how to shake loose the entrepreneurial fetters and establish the national health programme that has been needed here for a hundred years. Yale University School of Medicine, 590 Ellsworth Avenue, New Haven, CT 06511, USA
GEORGE A.
SILVER,
Emeritus Professor of Public Health
1. Glaser WA. Health insurance in practice: international variations in financing, benefits, and problems. San Francisco: Jossey-Bass, 1991.
Noticeboard A question of balance The British Agrochemicals Association (BAA) has reversed its controversial decision to dissociate itself from a newly published British Medical Association (BMA) guide to pesticides.1 When a draft of the report first appeared in October, 1990, the BAA commented that it contained "too many factual errors to be acceptable". The BAA’s representative on the working party, Dr John Bonsall, resigned over concern that its conclusion "could raise unnecessary alarm". Despite the BAA’s U-turn, the same concerns were again expressed by Dr Andrew Cockburn of Schering Agrochemicals at a symposium to launch the book. He stated that the final conclusions of the report were "unbalanced" and "alarmist". He remarked that only "bad news sells" and that it was highly questionable who would benefit from chasing the largely illusory risks associated with pesticide use. This surprising attack on the BMA’s motives for producing its guide drew a cool response from independent observers, who noted that in some areas the report did not go far enough in its recommendations. The BMA guide identifies five key areas for change: a reduction in pesticide use and the risks associated with that use; increased access to information about the efficacy and toxicity of pesticides; diversification of pest control measures; review and improvement of regulatory standards; and education of all those involved in the manufacture and application of pesticides. The importance of these recommendations was highlighted last week with the European Court’s decision that Britain had failed to bring its drinking water up to European Community standards. The green-card pilot scheme, run jointly between pesticide incident monitoring units in the West Midlands and Trent regional health authorities, is now fully under way. Several hundred reports of adverse reactions to pesticides have already been submitted. The number of confirmed cases (proven by chemical analysis as well as by an unambiguous clinical history) are likely to be small, since patients often present to their doctors several months after the incident, when toxicological proof is difficult to obtain. The need for a national green-card system will not be decided until 1993, when the pilot scheme ends. Green cards can be obtained from Miss Patricia Casey, Pesticides Officer, Pesticides Monitoring Unit, Dudley Road Hospital, Birmingham B 18 4BR, UK. 1. British Medical Association. The BMA
London: BMA, 1992.
guide to pesticides, chemicals, Pp 215. £16.95. ISBN 0-340549246.
and health.
Tales of the
unexpected
Transgenic mice, now as dear to the heart of a many a geneticist as the humble fruit fly once was, are useful models for studying human genetic diseases. But the unexpected results of a study of inappropriate plasminogen activator expression by the liver’ introduce a note of uncertainty into the interpretation of such experiments: the stability of trans gene expression is, it seems, by no means assured. Plasminogen activators catalyse the conversion of plasminogen to plasmin, which degrades fibrin clots. Though useful in the treatment of thrombotic disorders, including myocardial infarction, they have the disadvantage of causing spontaneous bleeding. To investigate the effects of high plasma plasminogen activator concentrations, Heckel et al established a line of transgenic mice carrying the urokinase-type plasminogen activator (uPA) gene fused to the albumin enhancer/promoter coding sequence.’ All the newborn transgenic mice had high plasma levels of uPA, hypofibrinogenaemia, and unclottable blood. Half of them had spontaneous intestinal and intra-abdominal bleeding and died within four days of birth. The survivors, however, unexpectedly showed a gradual reduction in plasma uPA activity and restoration of clotting function. Microscopical examination of fixed liver from mice 3-5 weeks old showed red areas containing normal hepatocytes, and white areas containing cells in various stages of degeneration. But the normal tissue gradually expanded at the expense of the abnormal and by age 6-8 weeks had completely replaced it. uPA, which is cytotoxic for hepatocytes, was absent from normal cells and present in large amounts in abnormal ones.2 Heckel et al traced the loss of uPA to a rearrangement of the transgene DNA, and they concluded that cells carrying this rearrangement survived, proliferated, and eventually repopulated the entire liverThat even the smallest red foci were composed of mature hepatocytes suggests that stem cells were not involved in the observed regeneration and may be unnecessary for regeneration after other forms of liver damage. 1.
Heckel JL, Sandgren EP, Degen JL, Palmiter RD, Brinster RL. Neonatal bleeding in transgenic mice expressing urokinase-type plasminogen activator. Cell 1990; 62:
2.
Sandgren EP, Palmiter RD, Heckel JL, Daugherty CC, Brinster RL, Degen JL Complete hepatic regeneration after somatic deletion of an albumin-plasminogen
447-56.
activator
transgene. Cell 1991; 66: 245-56
Activities of European
Pharmacopoeia
organisation To accelerate European agreement on standards in medicinal testing, the European Pharmacopoeia organisation in Strasbourg has been allocated new laboratories and a 100% budget increase to bring the 1992 funding to £ 38 million. On Jan 13 the organisation began transferring to new premises costing 53 million and offering about 5000 sq m of laboratory and support facilities. The move from a 17th-century building at the Quai Jacoutot to a suburban industrial complex at Meinau also involves the transfer of the Pharmacopoeia collection of 450 reference substances. During 1991 nearly 13 000 samples were supplied to the pharmaceutical industry world wide. Operating under the wing of the Council of Europe and founded in 1964, the Pharmacopoeia has since played an increasingly important part in defining common criteria and control standards for pharmaceutical substances. It now has 19 member countries, whose national standards covering 750 active or auxiliary substances have been superseded by European monographs binding in these countries and routinely adopted in the British Commonwealth and in former colonies of France, Spain, and Belgium. 350 experts working in specialist groups are preparing 300 new monographs, while continually updating existing texts, on substances ranging from simple inorganic materials to the most
biological products. Pharmacopoeia is now aiming for 1500 monographs. covering the main existing pharmaceutical substances. Meanwhile the organisation is involved in moves towards world wde harmonisation through contacts with officials in the US and Japan
recent
The
insurance programmes leaves gaps in coverage: in France only 250 000 people are without health insurance, in Germany more than 1 million. Will these uninsured citizens, if they seek care outside their country, be asked for immediate payment? Will such payments be based on the fee schedule operative in their own country, or on that of the country in which they receive services? On what basis will insured EC citizens receive services? Will the country of origin pay, and if so at what rate? And so on. The proposed integration also has implications for doctors. For instance, some countries strictly delimit the kind of practice in which physicians may engage, depending on their training and
experience. The EC is embarking on a difficult course towards what may become a United States of Europe. If the integration of its health services succeeds, the EC might show the other United States how to shake loose the entrepreneurial fetters and establish the national health programme that has been needed here for a hundred years. Yale University School of Medicine, 590 Ellsworth Avenue, New Haven, CT 06511, USA
GEORGE A.
SILVER,
Emeritus Professor of Public Health
1. Glaser WA. Health insurance in practice: international variations in financing, benefits, and problems. San Francisco: Jossey-Bass, 1991.
Noticeboard A question of balance The British Agrochemicals Association (BAA) has reversed its controversial decision to dissociate itself from a newly published British Medical Association (BMA) guide to pesticides.1 When a draft of the report first appeared in October, 1990, the BAA commented that it contained "too many factual errors to be acceptable". The BAA’s representative on the working party, Dr John Bonsall, resigned over concern that its conclusion "could raise unnecessary alarm". Despite the BAA’s U-turn, the same concerns were again expressed by Dr Andrew Cockburn of Schering Agrochemicals at a symposium to launch the book. He stated that the final conclusions of the report were "unbalanced" and "alarmist". He remarked that only "bad news sells" and that it was highly questionable who would benefit from chasing the largely illusory risks associated with pesticide use. This surprising attack on the BMA’s motives for producing its guide drew a cool response from independent observers, who noted that in some areas the report did not go far enough in its recommendations. The BMA guide identifies five key areas for change: a reduction in pesticide use and the risks associated with that use; increased access to information about the efficacy and toxicity of pesticides; diversification of pest control measures; review and improvement of regulatory standards; and education of all those involved in the manufacture and application of pesticides. The importance of these recommendations was highlighted last week with the European Court’s decision that Britain had failed to bring its drinking water up to European Community standards. The green-card pilot scheme, run jointly between pesticide incident monitoring units in the West Midlands and Trent regional health authorities, is now fully under way. Several hundred reports of adverse reactions to pesticides have already been submitted. The number of confirmed cases (proven by chemical analysis as well as by an unambiguous clinical history) are likely to be small, since patients often present to their doctors several months after the incident, when toxicological proof is difficult to obtain. The need for a national green-card system will not be decided until 1993, when the pilot scheme ends. Green cards can be obtained from Miss Patricia Casey, Pesticides Officer, Pesticides Monitoring Unit, Dudley Road Hospital, Birmingham B 18 4BR, UK. 1. British Medical Association. The BMA
London: BMA, 1992.
guide to pesticides, chemicals, Pp 215. £16.95. ISBN 0-340549246.
and health.
Tales of the
unexpected
Transgenic mice, now as dear to the heart of a many a geneticist as the humble fruit fly once was, are useful models for studying human genetic diseases. But the unexpected results of a study of inappropriate plasminogen activator expression by the liver’ introduce a note of uncertainty into the interpretation of such experiments: the stability of trans gene expression is, it seems, by no means assured. Plasminogen activators catalyse the conversion of plasminogen to plasmin, which degrades fibrin clots. Though useful in the treatment of thrombotic disorders, including myocardial infarction, they have the disadvantage of causing spontaneous bleeding. To investigate the effects of high plasma plasminogen activator concentrations, Heckel et al established a line of transgenic mice carrying the urokinase-type plasminogen activator (uPA) gene fused to the albumin enhancer/promoter coding sequence.’ All the newborn transgenic mice had high plasma levels of uPA, hypofibrinogenaemia, and unclottable blood. Half of them had spontaneous intestinal and intra-abdominal bleeding and died within four days of birth. The survivors, however, unexpectedly showed a gradual reduction in plasma uPA activity and restoration of clotting function. Microscopical examination of fixed liver from mice 3-5 weeks old showed red areas containing normal hepatocytes, and white areas containing cells in various stages of degeneration. But the normal tissue gradually expanded at the expense of the abnormal and by age 6-8 weeks had completely replaced it. uPA, which is cytotoxic for hepatocytes, was absent from normal cells and present in large amounts in abnormal ones.2 Heckel et al traced the loss of uPA to a rearrangement of the transgene DNA, and they concluded that cells carrying this rearrangement survived, proliferated, and eventually repopulated the entire liverThat even the smallest red foci were composed of mature hepatocytes suggests that stem cells were not involved in the observed regeneration and may be unnecessary for regeneration after other forms of liver damage. 1.
Heckel JL, Sandgren EP, Degen JL, Palmiter RD, Brinster RL. Neonatal bleeding in transgenic mice expressing urokinase-type plasminogen activator. Cell 1990; 62:
2.
Sandgren EP, Palmiter RD, Heckel JL, Daugherty CC, Brinster RL, Degen JL Complete hepatic regeneration after somatic deletion of an albumin-plasminogen
447-56.
activator
transgene. Cell 1991; 66: 245-56
Activities of European
Pharmacopoeia
organisation To accelerate European agreement on standards in medicinal testing, the European Pharmacopoeia organisation in Strasbourg has been allocated new laboratories and a 100% budget increase to bring the 1992 funding to £ 38 million. On Jan 13 the organisation began transferring to new premises costing 53 million and offering about 5000 sq m of laboratory and support facilities. The move from a 17th-century building at the Quai Jacoutot to a suburban industrial complex at Meinau also involves the transfer of the Pharmacopoeia collection of 450 reference substances. During 1991 nearly 13 000 samples were supplied to the pharmaceutical industry world wide. Operating under the wing of the Council of Europe and founded in 1964, the Pharmacopoeia has since played an increasingly important part in defining common criteria and control standards for pharmaceutical substances. It now has 19 member countries, whose national standards covering 750 active or auxiliary substances have been superseded by European monographs binding in these countries and routinely adopted in the British Commonwealth and in former colonies of France, Spain, and Belgium. 350 experts working in specialist groups are preparing 300 new monographs, while continually updating existing texts, on substances ranging from simple inorganic materials to the most
biological products. Pharmacopoeia is now aiming for 1500 monographs. covering the main existing pharmaceutical substances. Meanwhile the organisation is involved in moves towards world wde harmonisation through contacts with officials in the US and Japan
recent
The