- Email: [email protected]
COMPUTERS OR NURSES?
1321
consideration by the professions and by the health and local authorities.I The King’s Fund has recently funded a research study of the needs of the elderly in the community in Exeter, in which the social and health services will examine their joint role in detecting these needs, and the pooling of their information at the health centre. It is hoped that this exercise might represent a blue-print for others to follow. On the whole, those social workers who have been attached to a health centre have not been overwhelmed.’ It appears that this is the direction in which we should be heading.
cooperative
Social Services Department, 77 George Street, Oxford.
Geriatric Department, Royal Devon and Exeter Hospital, Exeter EX1 2ED.
PRIMROSE HALLIBURTON.
W. B. WRIGHT.
COMPUTERS OR NURSES? SiR,—Your editorial (Oct. 12, p. 877) prompts us to add some remarks in the light of our experiences in the cardiothoracic department at Wythenshawe. It is, indeed, self-evident that the computer was grossly oversold as the panacea for too many ills, and not only in medicine. However, your leader focuses on the computer mainly for on-line monitoring; our system uses the person who conventionally records the information (nurse, laboratory technician, doctor) to insert this into the system via a very simple-to-use intercom set linked to the data system. The system then produces far better (and more meaningful) graphical charts than a nurse can. It is interesting that none of our users has requested any on-line data acquisition (except in theatres), yet nearly every visitor asks why we do not have this facility. You supply many of the answers in your article. Our nurses can record the patient’s vital signs at the bedside faster using the data system than on conventional charts, although the longer time to record drugs and free text notes counterbalances this. Provisional estimates show that our system costs between E5 and E8 per patientday as opposed to the$50 to$200 quoted8 for clinical systems in the United States, although some costs are even higher9 and often do not include technician costs. Adding on-line data acquisition, which has been tested and proven, would not increase our costs significantly. The computer must only be considered an aid to the nurse, not a competitor-no-one is suggesting that a ventilator makes the anaesthetist redundant ! Our experience at Wythenshawe shows that computer-assisted recording of patient information can be a valuable aid to all staff in a critical-care area. Finally, may we reject most forcibly your suggestion that " medical computing should eventually be removed from the computer experts and placed where it rightly belongswith the doctors and nurses ". One of the reasons that the history of medical computing is littered with failures is that medical men have too often tried to develop systems on their own initiative and not left the computer experts to solve their own technical problems. It’s every man to his own trade, and progress will only be made if the two disciplines work hand-in-hand. J. M. ASHCROFT, Wythenshawe Hospital, Manchester M23 9LT. 7.
Nursing Officer. J. L. BERRY, Technical Coordinator, Computer Project.
E. M., Neil, J. E. Social Work in General Practice. National Institute for Social Work Training. 1972. 8. Abstracts of 1st World Congress on Intensive Care (edited by I. McA. Ledingham). Intensive Care Society, 1974. 9. Evaluation of Computer-based Patient Monitoring Systems. Arthur D. Little Inc., Cambridge, Massachusetts, 1973.
Goldberg,
HYPOSPLENISM IN ULCERATIVE COLITIS Six,-Dr Ryan and his colleagues (Aug. 10, p. 318) and Dr Goodyear and Dr Forster (Sept. 14, p. 658) reported the occurrence of hyposplenism in ulcerative colitis. Their diagnosis of hyposplenism was based either on necropsy findings or on the appearance of Howell-Jolly bodies in the peripheral-blood smear and decreased clearance of heatdamaged red cells. Thrombocytosis has often been observed in ulcerative colitis. 1-4 Since splenectomy invariably leads to a high platelet-count, the thrombocytosis in ulcerative colitis might be taken as further evidence of hyposplenism. Hyposplenism was also described in patients with adult coeliac disease 5,6 and with dermatitis herpetiformis.7 Since autoimmune mechanisms seem to operate in the pathogenesis of both these disorders and ulcerative colitis, I should like to suggest that similar autoimmune processes are also responsible for the hyposplenism in these diseases. Indeed most autoimmune diseases are characterised by pathological changes in the lymphoreticular system, and thrombocytosis has often been observed in these diseases.4 In view of these data the following hypothesis is suggested : immunologically mediated autoaggressive mechanisms cause functional hyposplenism in patients with autoimmune diseases; this hyposplenism can be associated either with splenic enlargement, as in systemic lupus erythematosus, or with splenic atrophy, as in ulcerative colitis; and it may lead to the thrombocytosis in these disnrders-
Department of Medicine B, Beilinson Medical Center, Petach-Tikva, Israel.
Y. LEVO.
POLYETHYLENE GLYCOL ON AGAR-GEL
ELECTROPHORESIS SiR,—It could be inferred from the letter of Dr Mangla and his colleagues (Nov. 9, p. 1145) that the cathodallymoving proteolytic band, demonstrated by us on agar-gel electrophoresis of extracts of gastric carcinomas, is an artefact arising from the use of carbowax in concentrating eluted fractions of the extracts. Dr Mangla and his colleagues seem to have missed our further paper 8 in which we resolved the cathodal band into four components and isolated each of them chromatographically. We then define the pH-activity curves of each proteinase, and were able to ascertain which peptide bonds of the Bchain of oxidised insulin were hydrolysed by the two most went on to
cathodally-moving
enzymes.
We would make three further points. First, our proteinases never moved as far towards the cathode as does the band which Mangla et al. ascribe to polyethylene glycol, and which we never saw in over 100 electrophoretograms. Secondly, the uppermost electrophoretic strip of their figure, despite their claim to the contrary, seems to us to show clearly a cathodally-moving band, quite close to the origin, in exactly the same place as we found our own unresolved band, and remote from the band which they ascribe to polyethylene glycol. Thirdly, we are puzzled by the appearance of polyethylene glycol in their electrophoretogram, for the compound should not enter the Morowitz, D. A., Allen, L. W., Kirsner, J. B. Ann. intern. Med. 1968, 68, 1013. 2. Levin, J., Conley, C. L. Archs intern. Med. 1964, 114, 497. 3. Farmer, R. G., Scudamore, H. H., Bayrd, E. D. Am. J. Gastroent. 1963, 40, 601. 4. Bean, R. H. D. Bibl. Hæmat. 1965, 23, 43. 5. Marsh, G. W., Stewart, J. S. Br. J. Hæmat. 1970, 19, 445. 6. McCarthy, C. F., Fraser, I. D., Evans, K. T., Read, A. E. Gut, 1966, 7, 140. 7. Pettit, J. E., Hoffbrand, A. V., Seah, P. P., Fry, L. Br. med. J. 1972, ii, 438. 8. Etherington, D. J., Taylor, W. H. Clin. Sci. 1972, 42, 79. 1.
consideration by the professions and by the health and local authorities.I The King’s Fund has recently funded a research study of the needs of the elderly in the community in Exeter, in which the social and health services will examine their joint role in detecting these needs, and the pooling of their information at the health centre. It is hoped that this exercise might represent a blue-print for others to follow. On the whole, those social workers who have been attached to a health centre have not been overwhelmed.’ It appears that this is the direction in which we should be heading.
cooperative
Social Services Department, 77 George Street, Oxford.
Geriatric Department, Royal Devon and Exeter Hospital, Exeter EX1 2ED.
PRIMROSE HALLIBURTON.
W. B. WRIGHT.
COMPUTERS OR NURSES? SiR,—Your editorial (Oct. 12, p. 877) prompts us to add some remarks in the light of our experiences in the cardiothoracic department at Wythenshawe. It is, indeed, self-evident that the computer was grossly oversold as the panacea for too many ills, and not only in medicine. However, your leader focuses on the computer mainly for on-line monitoring; our system uses the person who conventionally records the information (nurse, laboratory technician, doctor) to insert this into the system via a very simple-to-use intercom set linked to the data system. The system then produces far better (and more meaningful) graphical charts than a nurse can. It is interesting that none of our users has requested any on-line data acquisition (except in theatres), yet nearly every visitor asks why we do not have this facility. You supply many of the answers in your article. Our nurses can record the patient’s vital signs at the bedside faster using the data system than on conventional charts, although the longer time to record drugs and free text notes counterbalances this. Provisional estimates show that our system costs between E5 and E8 per patientday as opposed to the$50 to$200 quoted8 for clinical systems in the United States, although some costs are even higher9 and often do not include technician costs. Adding on-line data acquisition, which has been tested and proven, would not increase our costs significantly. The computer must only be considered an aid to the nurse, not a competitor-no-one is suggesting that a ventilator makes the anaesthetist redundant ! Our experience at Wythenshawe shows that computer-assisted recording of patient information can be a valuable aid to all staff in a critical-care area. Finally, may we reject most forcibly your suggestion that " medical computing should eventually be removed from the computer experts and placed where it rightly belongswith the doctors and nurses ". One of the reasons that the history of medical computing is littered with failures is that medical men have too often tried to develop systems on their own initiative and not left the computer experts to solve their own technical problems. It’s every man to his own trade, and progress will only be made if the two disciplines work hand-in-hand. J. M. ASHCROFT, Wythenshawe Hospital, Manchester M23 9LT. 7.
Nursing Officer. J. L. BERRY, Technical Coordinator, Computer Project.
E. M., Neil, J. E. Social Work in General Practice. National Institute for Social Work Training. 1972. 8. Abstracts of 1st World Congress on Intensive Care (edited by I. McA. Ledingham). Intensive Care Society, 1974. 9. Evaluation of Computer-based Patient Monitoring Systems. Arthur D. Little Inc., Cambridge, Massachusetts, 1973.
Goldberg,
HYPOSPLENISM IN ULCERATIVE COLITIS Six,-Dr Ryan and his colleagues (Aug. 10, p. 318) and Dr Goodyear and Dr Forster (Sept. 14, p. 658) reported the occurrence of hyposplenism in ulcerative colitis. Their diagnosis of hyposplenism was based either on necropsy findings or on the appearance of Howell-Jolly bodies in the peripheral-blood smear and decreased clearance of heatdamaged red cells. Thrombocytosis has often been observed in ulcerative colitis. 1-4 Since splenectomy invariably leads to a high platelet-count, the thrombocytosis in ulcerative colitis might be taken as further evidence of hyposplenism. Hyposplenism was also described in patients with adult coeliac disease 5,6 and with dermatitis herpetiformis.7 Since autoimmune mechanisms seem to operate in the pathogenesis of both these disorders and ulcerative colitis, I should like to suggest that similar autoimmune processes are also responsible for the hyposplenism in these diseases. Indeed most autoimmune diseases are characterised by pathological changes in the lymphoreticular system, and thrombocytosis has often been observed in these diseases.4 In view of these data the following hypothesis is suggested : immunologically mediated autoaggressive mechanisms cause functional hyposplenism in patients with autoimmune diseases; this hyposplenism can be associated either with splenic enlargement, as in systemic lupus erythematosus, or with splenic atrophy, as in ulcerative colitis; and it may lead to the thrombocytosis in these disnrders-
Department of Medicine B, Beilinson Medical Center, Petach-Tikva, Israel.
Y. LEVO.
POLYETHYLENE GLYCOL ON AGAR-GEL
ELECTROPHORESIS SiR,—It could be inferred from the letter of Dr Mangla and his colleagues (Nov. 9, p. 1145) that the cathodallymoving proteolytic band, demonstrated by us on agar-gel electrophoresis of extracts of gastric carcinomas, is an artefact arising from the use of carbowax in concentrating eluted fractions of the extracts. Dr Mangla and his colleagues seem to have missed our further paper 8 in which we resolved the cathodal band into four components and isolated each of them chromatographically. We then define the pH-activity curves of each proteinase, and were able to ascertain which peptide bonds of the Bchain of oxidised insulin were hydrolysed by the two most went on to
cathodally-moving
enzymes.
We would make three further points. First, our proteinases never moved as far towards the cathode as does the band which Mangla et al. ascribe to polyethylene glycol, and which we never saw in over 100 electrophoretograms. Secondly, the uppermost electrophoretic strip of their figure, despite their claim to the contrary, seems to us to show clearly a cathodally-moving band, quite close to the origin, in exactly the same place as we found our own unresolved band, and remote from the band which they ascribe to polyethylene glycol. Thirdly, we are puzzled by the appearance of polyethylene glycol in their electrophoretogram, for the compound should not enter the Morowitz, D. A., Allen, L. W., Kirsner, J. B. Ann. intern. Med. 1968, 68, 1013. 2. Levin, J., Conley, C. L. Archs intern. Med. 1964, 114, 497. 3. Farmer, R. G., Scudamore, H. H., Bayrd, E. D. Am. J. Gastroent. 1963, 40, 601. 4. Bean, R. H. D. Bibl. Hæmat. 1965, 23, 43. 5. Marsh, G. W., Stewart, J. S. Br. J. Hæmat. 1970, 19, 445. 6. McCarthy, C. F., Fraser, I. D., Evans, K. T., Read, A. E. Gut, 1966, 7, 140. 7. Pettit, J. E., Hoffbrand, A. V., Seah, P. P., Fry, L. Br. med. J. 1972, ii, 438. 8. Etherington, D. J., Taylor, W. H. Clin. Sci. 1972, 42, 79. 1.