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COMBINED METFORMIN-CHLORPROPAMIDE THERAPY
37 about 1926. (5) Each age-specific death-rate will reach the edge of its plateau as men of this generation reach that age. Therefore, it is argued, no fall in the lung cancer death-rate is possible in the foreseeable future. But it is moving. Law Hospital, p T. ,y, W. LEES. Carluke, Lanarkshire.
Carluke,
OBESITY AND DIABETES SIR,-After all the efforts of the medical and scientific section of the British Diabetic Association to put the word " pre.diabetes " in its proper and very restricted place, one sighs to see it appear in your leading article (June 12). One sighs thrice, for it appears three times, and each time in a different sense; so that a gentle protest is allowable. On the first occasion there is reference to prediabetic controls (young women who have given birth to large babies, and of whom half also had a first-degree relative with diabetes). The objection is that there is no evidence that all these subjects will develop diabetes-there is no way of prophesying it with certainty in anyone-and the term potential diabetes " is preferable. On the second occasion a " prediabetic response is mentioned " with definitely impaired tolerance to glucose ". This is just diabetes. On the third occasion the word " prediabetic " is used in an almost acceptable sense in referring to the possibility that obesity is a consequence of the prediabetic state. In patients who develop diabetes the years before may properly be called prediabetic when looked at in retrospect, and this is the only use of the word prediabetes which means what it says. This is not just pedantry. If we are to communicate with those who share our interests we must use words in a sense that all of them will understand. JOHN MALINS. Birmingham, 15. "
"
COMBINED METFORMINCHLORPROPAMIDE THERAPY SIR,-The findings of Dr. Clarke and Dr. Duncan (June 12) must have been read with interest by many of your readers here in Dublin. Before the basically similar results of a study carried out in this hospital were published 1 they were presented at the Section of Medicine, Royal Academy of Medicine in Ireland, where they met with considerable criticism. Opponents of the combined therapy felt that, by including a diguanide in the treatment of diabetics not controlled by a sulphonylurea alone, " some patients would be put on a regimen of forced " oral treatment and thereby deprived of their exogenous insulin on which they depend in the long run. To deny or withdraw insulin from such patients, they thought, would carry the risk of producing acidosis without any advantages other than taking tablets instead of injections. In reply to the criticism, it was pointed out that, if a patient is considered suitable for oral treatment at all, then combined treatment does not carry any greater risks than treatment with a sulphonylurea alone. We found no evidence that toxicity was increased by combined therapy; and in fact, the adverse effects, especially the gastrointestinal, may be less than after single medication by virtue of the fact that smaller doses of each may be used. Moreover, the diguanide component, by improving the utilisation of available endogenous insulin, may protect the beta-cells from " burning out " completely and so prevent the development of severe from mild diabetes. Since then, two other important effects of the diguanides have been noted by a number of workers-namely, their effect in reducing weight, and their ability to increase the blood fibrinolytic activity in patients with occlusive vascular conditions. In view of these, one wonders if the time has not arrived when combination therapy should be considered as the first choice of treatment in all elderly diabetics, and not only in those who fail to respond properly to treatment with a sulphonylurea alone. Department of Medicine, Trinity College, and STEPHEN SZANTO. Meath Hospital, Dublin. 1. Szanto, S. Ir. J. med. Sci. January, 1964, p. 3.
INTEGRATION IN MENTAL HOSPITALS
SIR,-Recent newspaper publicity has exposed problems concerned with integration in some mental hospitals. Integration is an established adjunct to the effective implementation of the principles of the " therapeutic community ". In my opinion, however, its successful operation depends upon the following criteria: 1. The availability of sufficient trained nursing staff to supervise the project. 2. A good communications system in the mental hospital at all levels. The rapid introduction of integration may tend to undermine the authority of some nurses, particularly those who are personally insecure, and may be regarded as a threat by nursing staff who, through tradition, are accustomed to treating patients in segregated wards. Recently, at one hospital, after prolonged discussions I introduced an integration policy affecting several long-stay wards for meals, and social and recreational activities. The male patients, in particular, smartened themselves up in the presence of females, and many patients who for years had hardly spoken to members of their own sex began to take an active interest in each other and in their hospital. To my knowledge this venture did not result in any increased promiscuity and was regarded as highly successful. Integration is also valuable in admission units, occupational and industrial therapy departments, patients’ outings, and organised exchanges of patients between mental hospitals,! since it helps to reduce some of the differences between life inside and outside the mental hospital. It is also an established practice in some mental hospitals for female patients to work on male wards, and vice versa. It is important that the expressed opinions of those opposed to integration should not have the effect of setting the clocks back in our mental hospitals-thereby undoing much hard-won progress. It has been suggested that the Minister of Health should be approached to advise regional hospital boards " to call a halt to mixed mental wards pending a thorough investigation at national level". This is surely a retrograde move. It will first need to be proved that there is a real increase in promiscuity, taking " the pill ", or terminated pregnancies in mental hospitals which practise an active integration programme compared with those which do not. The incidence of sexual problems in the community in general should also be kept in perspective. Shelton Hospital, r C. BARKER. J. J. Shrewsbury, Shropshire. EXTRAMURAL CARE IN PSYCHIATRY SIR,-Dr. Hoenig and Miss Hamilton (June 19) discovered that some families who have a psychiatrically ill relative at home dislike being left on their own to cope with the problems which arise, and suggest that proper community care should include special support for such people. From our experience in the past year in running a monthly evening relatives’ club3 to try to give this support, we can confirm that only a very small minority of families need it, and that they are predominantly the families of schizophrenics. People with psychopathic or recurrently manic-depressive members, for instance, do not seem to need such support. We started our meetings at High Wycombe War Memorial Hospital, to discover what the need was, after the annual conference (1964) of the National Association for Mental Health had publicised relatives’ complaints of being abandoned by the Health Service. Posters were put up in clinics, advertisements were inserted in the local paper, and three groups were notified-relatives of all patients newly admitted from the area to St. John’s, relatives of all those admitted and discharged in the preceding twelve months, and relatives of about 90 other ex-patients or long-stay patients already known to the social work deoartment. Most of the response came 1. 2. 3.
Barker, J. C. Lancet, 1963, i, 1381. Sun, June 24, 1965. Crammer, J. L., Benger, K. M. Ment. Hlth, Lond. 1965, 24,
75.
Carluke,
OBESITY AND DIABETES SIR,-After all the efforts of the medical and scientific section of the British Diabetic Association to put the word " pre.diabetes " in its proper and very restricted place, one sighs to see it appear in your leading article (June 12). One sighs thrice, for it appears three times, and each time in a different sense; so that a gentle protest is allowable. On the first occasion there is reference to prediabetic controls (young women who have given birth to large babies, and of whom half also had a first-degree relative with diabetes). The objection is that there is no evidence that all these subjects will develop diabetes-there is no way of prophesying it with certainty in anyone-and the term potential diabetes " is preferable. On the second occasion a " prediabetic response is mentioned " with definitely impaired tolerance to glucose ". This is just diabetes. On the third occasion the word " prediabetic " is used in an almost acceptable sense in referring to the possibility that obesity is a consequence of the prediabetic state. In patients who develop diabetes the years before may properly be called prediabetic when looked at in retrospect, and this is the only use of the word prediabetes which means what it says. This is not just pedantry. If we are to communicate with those who share our interests we must use words in a sense that all of them will understand. JOHN MALINS. Birmingham, 15. "
"
COMBINED METFORMINCHLORPROPAMIDE THERAPY SIR,-The findings of Dr. Clarke and Dr. Duncan (June 12) must have been read with interest by many of your readers here in Dublin. Before the basically similar results of a study carried out in this hospital were published 1 they were presented at the Section of Medicine, Royal Academy of Medicine in Ireland, where they met with considerable criticism. Opponents of the combined therapy felt that, by including a diguanide in the treatment of diabetics not controlled by a sulphonylurea alone, " some patients would be put on a regimen of forced " oral treatment and thereby deprived of their exogenous insulin on which they depend in the long run. To deny or withdraw insulin from such patients, they thought, would carry the risk of producing acidosis without any advantages other than taking tablets instead of injections. In reply to the criticism, it was pointed out that, if a patient is considered suitable for oral treatment at all, then combined treatment does not carry any greater risks than treatment with a sulphonylurea alone. We found no evidence that toxicity was increased by combined therapy; and in fact, the adverse effects, especially the gastrointestinal, may be less than after single medication by virtue of the fact that smaller doses of each may be used. Moreover, the diguanide component, by improving the utilisation of available endogenous insulin, may protect the beta-cells from " burning out " completely and so prevent the development of severe from mild diabetes. Since then, two other important effects of the diguanides have been noted by a number of workers-namely, their effect in reducing weight, and their ability to increase the blood fibrinolytic activity in patients with occlusive vascular conditions. In view of these, one wonders if the time has not arrived when combination therapy should be considered as the first choice of treatment in all elderly diabetics, and not only in those who fail to respond properly to treatment with a sulphonylurea alone. Department of Medicine, Trinity College, and STEPHEN SZANTO. Meath Hospital, Dublin. 1. Szanto, S. Ir. J. med. Sci. January, 1964, p. 3.
INTEGRATION IN MENTAL HOSPITALS
SIR,-Recent newspaper publicity has exposed problems concerned with integration in some mental hospitals. Integration is an established adjunct to the effective implementation of the principles of the " therapeutic community ". In my opinion, however, its successful operation depends upon the following criteria: 1. The availability of sufficient trained nursing staff to supervise the project. 2. A good communications system in the mental hospital at all levels. The rapid introduction of integration may tend to undermine the authority of some nurses, particularly those who are personally insecure, and may be regarded as a threat by nursing staff who, through tradition, are accustomed to treating patients in segregated wards. Recently, at one hospital, after prolonged discussions I introduced an integration policy affecting several long-stay wards for meals, and social and recreational activities. The male patients, in particular, smartened themselves up in the presence of females, and many patients who for years had hardly spoken to members of their own sex began to take an active interest in each other and in their hospital. To my knowledge this venture did not result in any increased promiscuity and was regarded as highly successful. Integration is also valuable in admission units, occupational and industrial therapy departments, patients’ outings, and organised exchanges of patients between mental hospitals,! since it helps to reduce some of the differences between life inside and outside the mental hospital. It is also an established practice in some mental hospitals for female patients to work on male wards, and vice versa. It is important that the expressed opinions of those opposed to integration should not have the effect of setting the clocks back in our mental hospitals-thereby undoing much hard-won progress. It has been suggested that the Minister of Health should be approached to advise regional hospital boards " to call a halt to mixed mental wards pending a thorough investigation at national level". This is surely a retrograde move. It will first need to be proved that there is a real increase in promiscuity, taking " the pill ", or terminated pregnancies in mental hospitals which practise an active integration programme compared with those which do not. The incidence of sexual problems in the community in general should also be kept in perspective. Shelton Hospital, r C. BARKER. J. J. Shrewsbury, Shropshire. EXTRAMURAL CARE IN PSYCHIATRY SIR,-Dr. Hoenig and Miss Hamilton (June 19) discovered that some families who have a psychiatrically ill relative at home dislike being left on their own to cope with the problems which arise, and suggest that proper community care should include special support for such people. From our experience in the past year in running a monthly evening relatives’ club3 to try to give this support, we can confirm that only a very small minority of families need it, and that they are predominantly the families of schizophrenics. People with psychopathic or recurrently manic-depressive members, for instance, do not seem to need such support. We started our meetings at High Wycombe War Memorial Hospital, to discover what the need was, after the annual conference (1964) of the National Association for Mental Health had publicised relatives’ complaints of being abandoned by the Health Service. Posters were put up in clinics, advertisements were inserted in the local paper, and three groups were notified-relatives of all patients newly admitted from the area to St. John’s, relatives of all those admitted and discharged in the preceding twelve months, and relatives of about 90 other ex-patients or long-stay patients already known to the social work deoartment. Most of the response came 1. 2. 3.
Barker, J. C. Lancet, 1963, i, 1381. Sun, June 24, 1965. Crammer, J. L., Benger, K. M. Ment. Hlth, Lond. 1965, 24,
75.