- Email: [email protected]
CARDIAC REHABILITATION
355
acid output. MCCONNELL and others 20 have shown that dietary vegetable fibres vary in their ability to adsorb water and thus influence bowel function. Bran, mango, carrot, apple, brussels sprouts, and oranges seem to be better hydrophilic laxatives than bananas, cauliflower, potato, and turnip. Another constituent of plant fibre, pectin, protects laboratory animals against atherosclerosis 21 and lowers plasmacholesterol in man.22 Mean cholesterol levels fell significantly when volunteers took pectin and guar, but again there was no effect when wheat fibre was added to the diet. 23 These experiments took place over only two weeks. Clearly the interrelation between fibre and lipid metabolism is complex, and more specific characterisation of vegetable dietary fibre and its constituents is necessary. CARDIAC REHABILITATION A REVERSAL of attitudes to the treatment and longterm effects of heart-disease has taken many middleaged doctors by surprise. Sir Thomas Lewis,24 on whose precepts much of modern cardiology was founded, set the minimum bed-rest time for the treatment of coronary occlusion at 6-8 weeks and added that " during the whole of this period the patient is to be guarded by day and night nursing and helped in every way to avoid voluntary movement or effort". Price 25 wrote in 1942 of the need for " three months’ rest, physical and mental, followed by a similar period of partial rest ... in severe cases even longer ... the patient should be impressed with the importance of living not only within the limits of his diminished cardiac strength but even keeping something in reserve, during the rest of his life ". Levine broke the spell. 2As far back as 1937 he started his armchair method of nursing in myocardial infarction. And although slow to adopt shorter periods of bed rest, most British cardiologists are now down to 4-10 days according to the severity of the infarct. 27 This more liberal approach extends to convalescence: numerous reports 28-30 suggest that shorter convalescence and return to work in 6-8 weeks is not only possible but also advisable. Some physicians go further, by encouraging quite strenuous exercise.31 It is hardly surprising that both patients and doctors are seeking guidelines, and such are now provided by a joint working-party of the Royal College of Physicians and the British Cardiac Society.32 It covers all forms McConnell, A. A., Eastwood, M. A., Mitchell, W. D. J. Sci. Fd Agric. 1974, 25, 1457. 21. Erschoff, B. H. Exp. Med. Surg. 1963, 21, 108. 22. Keys, A., Grande, F., Anderson, J. T. Proc. Soc. exp. Biol. Med. 1961, 106, 555. 23. Jenkins, D. J. A., Leeds, A. R., Newton, C., Cummings, J. H. Lancet, 1974, i, 116. 24. Lewis, T. Diseases of the Heart. London, 1943. 25. Price, F. W. A Textbook of the Practice of Medicine. London, 1942. 26. Levine, S. A. J. Am. med. Ass. 1944, 126, 80. 27. Lancet, 1971, ii, 1359. 28. Groden, B. M. Scott. med. J. 1967, 12, 297. 29. Mulcahy, R., Hickey, H. J. Ir. med. Ass. 1971, 64, 541. 30. Wenger, N. K., Hellerstein, H. K., Blackburn, H., Castranova, S. J. J. Am. med. Ass. 1973, 224, 511. 31. Sanne, H. Acta med. scand. 1973, suppl. 551. 32. Cardiac Rehabilitation 1975: report of a joint working party of the Royal College of Physicians and the British Cardiac Society. Obtainable from the R.C.P. (St. Andrew’s Place, London NW1) £1 post free.
20.
of cardiac illness, but the emphasis is on ischaemic heart-disease. There are no claims that morbidity or mortality are reduced by the new approach to convalescence after myocardial infarction or by the secondary preventive measures now being widely adopted. Research in this area is difficult. Nevertheless, early rehabilitation almost certainly is worth while in cases of mild infarction-a group with good prognosis in terms both of return to work and of quality of life. Remedial rehabilitation can be started quickly in such patients, whereas those more seriously affected need an individual approach including careful appraisal of physical, psychological, and social factors. (Though the patient and the nation may benefit from shorter hospital stays and quicker convalescence, an effective rehabilitation programme adds to, rather than subtracts from, the time a doctor spends on these patients.) The present approach is necessarily multifactorial; and we need to know what is worth doing and what is not. Take smoking. There is some evidence 33,344 that stopping smoking benefits post-infarct patients, and much time and energy may be spent helping patients to stop. Often a patient stops smoking at once after the acute episode, and this should be encouraged. But in more addicted cases how long should the physician persevere with antismoking efforts? Or at what point does one settle for reduced consumption rather than total abstinence? Dieting is another category of negative advice little beloved by patients, though British cardiologists have never felt as strongly as their North American colleagues about diet in ischsemic heart-disease—except of course in
obese, hyperlipidæmic, or diabetic patients. The most interesting and perhaps most
contro-
versial side of the rehabilitation programme concerns exercise-in several centres supervised exercise programmes have been started, and some workers regard them as a positive preventive measure. There is, of course, evidence that ischæmic heart-disease is less common in active workers than in sedentary workers,35 but whether this principle applies after the event is another matter. Granted the case for exercise, what kind of exercise, and how should it be supervised? (In Britain at least, the average patient does not take kindly to callisthenics.) At this stage, and until experience gathers, a cautious approach seems best. Not all patients should be advised to exercise; and the degree of exercise should be carefully selected. Certain forms of exertion such as weight-lifting and car-pushing, which chiefly involve a single group of muscles, can be positively harmful.36 Probably the best scheme is graduated walking, which is practical and not without interest, although even here the patient must be cautioned about the adverse effects of cold, windy days and heavy meals. For those who
prefer 33. 34. 35. 36. 37. 38.
indoor
exercises, graduated
courses
exist, 37,88
Mulcahy, R., Hickey, H., McKenzie, G., Graham, I. Br. Heart J. 1975, 37, 158. Wilhelmsson, C., Vedin, J. A., Elmfeldt, D., Tibblin, G., Wilhelmsen, L. Lancet, 1975, i, 415. Morris, J. N., Heady, J. A., Raffle, P. A. B., Roberts, C. G., Parks, J. W. ibid. 1953, ii, 1111. Ewing, D. J., Kerr, F., Irving, J. B., Muir, A. L. ibid. 1975, i, 1113. Physical Fitness. Harmondsworth, 1964. Nye, E. R., Wood, P. G. Exercise and the Coronary Patient. London, 1971.
356 and ideally these should be worked through in supervised classes. What emerges is that most patients can exercise much more than was formerly thought possible or advisable, and they can therefore live a fuller and Much remains to be learned more enjoyable life. about rehabilitation, an aspect of medical care not less important than diagnosis or therapy. The patient needs advice which is both well-founded and practical; and in cardiac rehabilitation the R.C.P./B.C.S. report sets new standards. MASS SCREENING FOR CRETINISM
NEONATAL feeding difficulties confront the pædiatrician daily. Common causes include birth shock, infection, and jaundice; but, along with constipation and respiratory troubles, feeding difficulties may be the presenting clinical feature of hypothyroidism. The classic cretinous facies is seen in only a quarter of cases diagnosed before three months, the proportion increasing with increasing delay in replacement
therapy.1 Cretinism is a rare cause of mental retardation but treatable one. It can be easily missed until later in the first year of life, and early replacement therapy In a Great Ormond is unfortunately essential. Street series,l 14 out of 19 children diagnosed and treated before three months of age had I.Q.s over 90, whereas only about a third of those treated later reached this level. These findings are borne out by Klein and his co-workers.2 Eayrs3 has shown that thyroxine is essential for brain maturation in prenatal and early postnatal life and only small amounts of thyroxine cross the human placental barrier. In the neonate there is acute release of thyroidstimulating hormone (T.s.H.) during the first hours of life, causing an increase in all indices of thyroid function.4 Serum protein-bound iodine, butamolextractable thyroxine, 131I-triiodothyronine uptake in erythrocytes or resin (T3 tests), dialysable thyroxine, and 131I uptake in the thyroid gland should all be raised-i.e., the normal infant is hyperthyroid. Rogowski and co-workers5 report that the rise in dialysable thyroxine parallels the rise in total thyroxine; therefore the increase in plasma-thyroxine is not caused by an increase in thyroxine-binding proteins, 6 as has been suggested. Until lately only small series of infants have been studied, because of the quantity of blood needed for macromethod testing of thyroid function. But now micromethods permit testing of large numbers. The series of Dussault et al.,’ in Canada, is the largest so a
far. 47 000 newborns have been studied by a cheap, reliable micromethod using the T4 test, which has revealed an incidence of hypothyroidism of 1 in 7000. In a smaller series from the U.S.A., Klein and others8 used a T.S.H. screening procedure and found an incid1. Raiti, S., Newns, G. H. Archs Dis. Childh. 1971, 46, 692. Klein, A. H., Meltzer, S., Kenny, F. M. J. Pediat. 1972, 81, 912. Eayrs, J. T. Br. med. Bull. 1960, 16, 122. Utiger, R. D., Wilber, J. F., Cornbathy, M., Harm, J. P., Mack, R. E. J. clin. Invest. 1968, 47, 97. 5. Rogowski, P., Siersboek-Nielsen, K., Hansen, J. M. Acta pœdiat. scand. 1974, 63, 201. 6. Chadd, M. A., Gray, O. P., Davies, D. F. Archs Dis. Childh. 1970, 45, 374. 2. 3. 4.
7.
8.
Dussault, J. H., Coulombe, P., Laberge, C., Letatle, J., Guyda, M., Khoury, K. Pediatrics, 1975, 86, 670. Klein, A. H., Agustin, A. V., Foley, T. P. Lancet, 1974, ii, 77.
of 1 in 8500, which they compare with the incidof phenylketonuria in the United States-1 in 14 300. These figures present a serious case for routine
ence
ence
screening. CANCER BY COUNTY MAps of cancer distribution are a fascinating source of clues-and of false trails-in the search for aetiological factors. In the U.S.A. the variations from State to State are striking, and now the magnification has been stepped up with a county-by-county survey.2 The basic data were derived by the epidemiology branch of the National Cancer Institute from all the death certificates of the 48 contiguous States in which cancer was listed as the cause of death. The average annual age-adjusted mortality-rates for the period 1950-69 were calculated for individual counties or State economic areas using the total U.S. population of 1960 as standard, and the maps were produced by a special automated cartography system. They deal with cancer in U.S. Whites, since for non-Whites basic data on cancer mortality and populations at risk were too scanty. For cancers of salivary glands and pancreas, of the nasal system, of the nervous system, and of connective tissue no geographic patterns are discernible. Rates for ovary, testis, and bladder in females are high in the rural north and low in the rural south. Males in the North-East and in some urban Great Lakes centres prone to cancers of gastrointestinal tract, œsophagus, larynx, and bladder, while the rates in southern
are
generally low. The northdistinguished by high rates for lymphomas (in females), multiple myeloma, leukaemia, and cancers of stomach, kidney, and prostate, while southern females are susceptible to cancers of eye, bone, lip, mouth, throat, oesophagus, and cervix uteri: they share with the southern male high rates and central males central States are
are
for melanoma and other skin cancers. Liver cancer is irregularly distributed, with high rates along the Gulf Coast from Texas to Louisiana and in parts of
Appalachia. Some of the factors behind these irregularities emerge when individual counties are compared. Thus stomach cancer seems to be influenced by ethnic factors: the high mortality in certain north-central areas corresponds to immigration from parts of Europe with high stomach-cancer rates; but why should colon cancer be frequent in both sexes in S.E. Nebraska, and why is lung cancer so frequent in some rural and port areas of the south ? Industrial exposure must surely be responsible for the monstrous bladder-cancer rates in New Jersey, especially in Salem county, where a quarter of the workforce is in chemical or allied industries. Almost all these maps show areas of high and low occurrence of some or other cancer, and if one of the functions of maps is direction-finding then this atlas is full of pointers. 1. 2.
Burbank, F. Patterns of Cancer Mortality in the United States 1950-1967. Natn. Cancer Inst. Monogr. no. 33, 1971. Mason, T. J., McKay, F. W., Hoover, R., Blot, W. J., Fraumeni, J. F. Atlas of Cancer Mortality for U.S. Counties 1950-1969. Department of Health, Education and Welfare publication no. (NIH) 75.480. National Institutes of Health, Washington, D.C., 1975.
acid output. MCCONNELL and others 20 have shown that dietary vegetable fibres vary in their ability to adsorb water and thus influence bowel function. Bran, mango, carrot, apple, brussels sprouts, and oranges seem to be better hydrophilic laxatives than bananas, cauliflower, potato, and turnip. Another constituent of plant fibre, pectin, protects laboratory animals against atherosclerosis 21 and lowers plasmacholesterol in man.22 Mean cholesterol levels fell significantly when volunteers took pectin and guar, but again there was no effect when wheat fibre was added to the diet. 23 These experiments took place over only two weeks. Clearly the interrelation between fibre and lipid metabolism is complex, and more specific characterisation of vegetable dietary fibre and its constituents is necessary. CARDIAC REHABILITATION A REVERSAL of attitudes to the treatment and longterm effects of heart-disease has taken many middleaged doctors by surprise. Sir Thomas Lewis,24 on whose precepts much of modern cardiology was founded, set the minimum bed-rest time for the treatment of coronary occlusion at 6-8 weeks and added that " during the whole of this period the patient is to be guarded by day and night nursing and helped in every way to avoid voluntary movement or effort". Price 25 wrote in 1942 of the need for " three months’ rest, physical and mental, followed by a similar period of partial rest ... in severe cases even longer ... the patient should be impressed with the importance of living not only within the limits of his diminished cardiac strength but even keeping something in reserve, during the rest of his life ". Levine broke the spell. 2As far back as 1937 he started his armchair method of nursing in myocardial infarction. And although slow to adopt shorter periods of bed rest, most British cardiologists are now down to 4-10 days according to the severity of the infarct. 27 This more liberal approach extends to convalescence: numerous reports 28-30 suggest that shorter convalescence and return to work in 6-8 weeks is not only possible but also advisable. Some physicians go further, by encouraging quite strenuous exercise.31 It is hardly surprising that both patients and doctors are seeking guidelines, and such are now provided by a joint working-party of the Royal College of Physicians and the British Cardiac Society.32 It covers all forms McConnell, A. A., Eastwood, M. A., Mitchell, W. D. J. Sci. Fd Agric. 1974, 25, 1457. 21. Erschoff, B. H. Exp. Med. Surg. 1963, 21, 108. 22. Keys, A., Grande, F., Anderson, J. T. Proc. Soc. exp. Biol. Med. 1961, 106, 555. 23. Jenkins, D. J. A., Leeds, A. R., Newton, C., Cummings, J. H. Lancet, 1974, i, 116. 24. Lewis, T. Diseases of the Heart. London, 1943. 25. Price, F. W. A Textbook of the Practice of Medicine. London, 1942. 26. Levine, S. A. J. Am. med. Ass. 1944, 126, 80. 27. Lancet, 1971, ii, 1359. 28. Groden, B. M. Scott. med. J. 1967, 12, 297. 29. Mulcahy, R., Hickey, H. J. Ir. med. Ass. 1971, 64, 541. 30. Wenger, N. K., Hellerstein, H. K., Blackburn, H., Castranova, S. J. J. Am. med. Ass. 1973, 224, 511. 31. Sanne, H. Acta med. scand. 1973, suppl. 551. 32. Cardiac Rehabilitation 1975: report of a joint working party of the Royal College of Physicians and the British Cardiac Society. Obtainable from the R.C.P. (St. Andrew’s Place, London NW1) £1 post free.
20.
of cardiac illness, but the emphasis is on ischaemic heart-disease. There are no claims that morbidity or mortality are reduced by the new approach to convalescence after myocardial infarction or by the secondary preventive measures now being widely adopted. Research in this area is difficult. Nevertheless, early rehabilitation almost certainly is worth while in cases of mild infarction-a group with good prognosis in terms both of return to work and of quality of life. Remedial rehabilitation can be started quickly in such patients, whereas those more seriously affected need an individual approach including careful appraisal of physical, psychological, and social factors. (Though the patient and the nation may benefit from shorter hospital stays and quicker convalescence, an effective rehabilitation programme adds to, rather than subtracts from, the time a doctor spends on these patients.) The present approach is necessarily multifactorial; and we need to know what is worth doing and what is not. Take smoking. There is some evidence 33,344 that stopping smoking benefits post-infarct patients, and much time and energy may be spent helping patients to stop. Often a patient stops smoking at once after the acute episode, and this should be encouraged. But in more addicted cases how long should the physician persevere with antismoking efforts? Or at what point does one settle for reduced consumption rather than total abstinence? Dieting is another category of negative advice little beloved by patients, though British cardiologists have never felt as strongly as their North American colleagues about diet in ischsemic heart-disease—except of course in
obese, hyperlipidæmic, or diabetic patients. The most interesting and perhaps most
contro-
versial side of the rehabilitation programme concerns exercise-in several centres supervised exercise programmes have been started, and some workers regard them as a positive preventive measure. There is, of course, evidence that ischæmic heart-disease is less common in active workers than in sedentary workers,35 but whether this principle applies after the event is another matter. Granted the case for exercise, what kind of exercise, and how should it be supervised? (In Britain at least, the average patient does not take kindly to callisthenics.) At this stage, and until experience gathers, a cautious approach seems best. Not all patients should be advised to exercise; and the degree of exercise should be carefully selected. Certain forms of exertion such as weight-lifting and car-pushing, which chiefly involve a single group of muscles, can be positively harmful.36 Probably the best scheme is graduated walking, which is practical and not without interest, although even here the patient must be cautioned about the adverse effects of cold, windy days and heavy meals. For those who
prefer 33. 34. 35. 36. 37. 38.
indoor
exercises, graduated
courses
exist, 37,88
Mulcahy, R., Hickey, H., McKenzie, G., Graham, I. Br. Heart J. 1975, 37, 158. Wilhelmsson, C., Vedin, J. A., Elmfeldt, D., Tibblin, G., Wilhelmsen, L. Lancet, 1975, i, 415. Morris, J. N., Heady, J. A., Raffle, P. A. B., Roberts, C. G., Parks, J. W. ibid. 1953, ii, 1111. Ewing, D. J., Kerr, F., Irving, J. B., Muir, A. L. ibid. 1975, i, 1113. Physical Fitness. Harmondsworth, 1964. Nye, E. R., Wood, P. G. Exercise and the Coronary Patient. London, 1971.
356 and ideally these should be worked through in supervised classes. What emerges is that most patients can exercise much more than was formerly thought possible or advisable, and they can therefore live a fuller and Much remains to be learned more enjoyable life. about rehabilitation, an aspect of medical care not less important than diagnosis or therapy. The patient needs advice which is both well-founded and practical; and in cardiac rehabilitation the R.C.P./B.C.S. report sets new standards. MASS SCREENING FOR CRETINISM
NEONATAL feeding difficulties confront the pædiatrician daily. Common causes include birth shock, infection, and jaundice; but, along with constipation and respiratory troubles, feeding difficulties may be the presenting clinical feature of hypothyroidism. The classic cretinous facies is seen in only a quarter of cases diagnosed before three months, the proportion increasing with increasing delay in replacement
therapy.1 Cretinism is a rare cause of mental retardation but treatable one. It can be easily missed until later in the first year of life, and early replacement therapy In a Great Ormond is unfortunately essential. Street series,l 14 out of 19 children diagnosed and treated before three months of age had I.Q.s over 90, whereas only about a third of those treated later reached this level. These findings are borne out by Klein and his co-workers.2 Eayrs3 has shown that thyroxine is essential for brain maturation in prenatal and early postnatal life and only small amounts of thyroxine cross the human placental barrier. In the neonate there is acute release of thyroidstimulating hormone (T.s.H.) during the first hours of life, causing an increase in all indices of thyroid function.4 Serum protein-bound iodine, butamolextractable thyroxine, 131I-triiodothyronine uptake in erythrocytes or resin (T3 tests), dialysable thyroxine, and 131I uptake in the thyroid gland should all be raised-i.e., the normal infant is hyperthyroid. Rogowski and co-workers5 report that the rise in dialysable thyroxine parallels the rise in total thyroxine; therefore the increase in plasma-thyroxine is not caused by an increase in thyroxine-binding proteins, 6 as has been suggested. Until lately only small series of infants have been studied, because of the quantity of blood needed for macromethod testing of thyroid function. But now micromethods permit testing of large numbers. The series of Dussault et al.,’ in Canada, is the largest so a
far. 47 000 newborns have been studied by a cheap, reliable micromethod using the T4 test, which has revealed an incidence of hypothyroidism of 1 in 7000. In a smaller series from the U.S.A., Klein and others8 used a T.S.H. screening procedure and found an incid1. Raiti, S., Newns, G. H. Archs Dis. Childh. 1971, 46, 692. Klein, A. H., Meltzer, S., Kenny, F. M. J. Pediat. 1972, 81, 912. Eayrs, J. T. Br. med. Bull. 1960, 16, 122. Utiger, R. D., Wilber, J. F., Cornbathy, M., Harm, J. P., Mack, R. E. J. clin. Invest. 1968, 47, 97. 5. Rogowski, P., Siersboek-Nielsen, K., Hansen, J. M. Acta pœdiat. scand. 1974, 63, 201. 6. Chadd, M. A., Gray, O. P., Davies, D. F. Archs Dis. Childh. 1970, 45, 374. 2. 3. 4.
7.
8.
Dussault, J. H., Coulombe, P., Laberge, C., Letatle, J., Guyda, M., Khoury, K. Pediatrics, 1975, 86, 670. Klein, A. H., Agustin, A. V., Foley, T. P. Lancet, 1974, ii, 77.
of 1 in 8500, which they compare with the incidof phenylketonuria in the United States-1 in 14 300. These figures present a serious case for routine
ence
ence
screening. CANCER BY COUNTY MAps of cancer distribution are a fascinating source of clues-and of false trails-in the search for aetiological factors. In the U.S.A. the variations from State to State are striking, and now the magnification has been stepped up with a county-by-county survey.2 The basic data were derived by the epidemiology branch of the National Cancer Institute from all the death certificates of the 48 contiguous States in which cancer was listed as the cause of death. The average annual age-adjusted mortality-rates for the period 1950-69 were calculated for individual counties or State economic areas using the total U.S. population of 1960 as standard, and the maps were produced by a special automated cartography system. They deal with cancer in U.S. Whites, since for non-Whites basic data on cancer mortality and populations at risk were too scanty. For cancers of salivary glands and pancreas, of the nasal system, of the nervous system, and of connective tissue no geographic patterns are discernible. Rates for ovary, testis, and bladder in females are high in the rural north and low in the rural south. Males in the North-East and in some urban Great Lakes centres prone to cancers of gastrointestinal tract, œsophagus, larynx, and bladder, while the rates in southern
are
generally low. The northdistinguished by high rates for lymphomas (in females), multiple myeloma, leukaemia, and cancers of stomach, kidney, and prostate, while southern females are susceptible to cancers of eye, bone, lip, mouth, throat, oesophagus, and cervix uteri: they share with the southern male high rates and central males central States are
are
for melanoma and other skin cancers. Liver cancer is irregularly distributed, with high rates along the Gulf Coast from Texas to Louisiana and in parts of
Appalachia. Some of the factors behind these irregularities emerge when individual counties are compared. Thus stomach cancer seems to be influenced by ethnic factors: the high mortality in certain north-central areas corresponds to immigration from parts of Europe with high stomach-cancer rates; but why should colon cancer be frequent in both sexes in S.E. Nebraska, and why is lung cancer so frequent in some rural and port areas of the south ? Industrial exposure must surely be responsible for the monstrous bladder-cancer rates in New Jersey, especially in Salem county, where a quarter of the workforce is in chemical or allied industries. Almost all these maps show areas of high and low occurrence of some or other cancer, and if one of the functions of maps is direction-finding then this atlas is full of pointers. 1. 2.
Burbank, F. Patterns of Cancer Mortality in the United States 1950-1967. Natn. Cancer Inst. Monogr. no. 33, 1971. Mason, T. J., McKay, F. W., Hoover, R., Blot, W. J., Fraumeni, J. F. Atlas of Cancer Mortality for U.S. Counties 1950-1969. Department of Health, Education and Welfare publication no. (NIH) 75.480. National Institutes of Health, Washington, D.C., 1975.