- Email: [email protected]
Controlling tuberculosis
gradient (serum albumin concentration minus ascitic fluid albumin concentration) is influenced by only one variableportal pressure-and better categorises ascites than does ascitic total protein concentration.; A patient with a high gradient (more than 11g/L) has portal hypertension, usually due to cirrhosis or heart failure. The higher the gradient, the higher the portal pressure. A patient with a low gradient (less than 11 g/L) does not have portal hypertension and most often has peritoneal carcinomatosis or tuberculosis. Most of the patients reported by Freers et al had right ventricular a involvement and presumably degree of portal if in part caused by Even the ascites was hypertension. inflammation mixed a high serum(ie, ascites), peritoneal ascites albumin gradient would be expected. A more pertinent question is why some patients with heart failure, particularly those with tricuspid regurgitation and with constrictive pericarditis, often have prominent ascites with little peripheral oedema. We suggest the pronounced right heart pulsations in these patients are preferentially transmitted to the hepatic vein, which enters the inferior vena cava below the right atrium, resulting in liver and ascites. congestion *Cornelius C Cronin, Miriam
training, a tiered system of referral is also important. Many health facilities need renovation, equipment, and supplies if they are to function as effective referral points. Maternal care activities should be monitored continuously by audit. For this purpose it is recommended that maternal and perinatal mortality committees be with basic
established at the district level motherhood.
*Gijs Walraven, Jos
van
as
a
step towards safer
Roosmalen
*Medical Research Council Laboratories, Banjul, Gambia; and Leiden Hospital, Department of Obstetrics, 2300 RC Leiden, Netherlands
1 2
3 4
5
University
Panter KR, Hannah ME. Umbilical cord prolapse: so far so good? Lancet 1996; 347: 74. Walraven GEL, Mkanje RJB, van Roosmalen J, Van Dongen PWJ, Dolmans WMV. Perinatal mortality in home births in rural Tanzania. Eur J Obstet Reprod Biol 1995; 58: 131-34. Van Roosmalen J, van der Does CD. Caesarean birth rates worldwide. Assessments of determinants. Trop Geogr Med 1995; 47: 19-22. Barret JM. Funic reduction for the management of umbilical cord prolapse. Am J Obstet Gynecol 1991: 654-57. World Health Organization. New estimates of maternal mortality. Wkly Epidemiol Rec 1991; 66: 345-48.
Duggan
Department of Medicine, Cork University Hospital, Wilton, Cork, Ireland
Male 1 Freers J,
2
Mayanja-Kizzo H, Rutakingirwa M, Gerwing E. Endomyocardial fibrosis: why is there striking ascites with little or no peripheral oedema? Lancet 1996; 347: 197. Runyon BA. Cardiac ascites: a characterization. J Clin Gastroenterol 1988, 10: 410-12.
3 Hoefs JC. Serum protein concentration and portal pressure determine the ascitic fluid protein concentration in patients with chronic liver disease. J Lab Clin Med 1983; 102: 260-73.
Umbilical cord
prolapse in rural Africa
SiR-Panter and Hannah (Jan 13, p 74)’ assert that no new have evolved since the 1950s for umbilical cord prolapse. We agree. However, the increased use in industrialised countries of elective and intrapartum caesarean section for the non-cephalic or unengaged is not and feasible, may also be inappropriate, presentations in many parts of rural Africa. In this region, most women still deliver at home; the numbers with high-risk pregnancies who deliver in hospital are low, and transfer facilities from home to hospital are often inadequate when they are most needed.Furthermore, maternal mortality after caesarean section in African hospitals has been reported to be 1-8% (range 0’65-5%);3 this compares unfavourably with the estimated rate of less than 0-1% in the industrialised countries. For these reasons we advocate consideration of alternatives to caesarean section. When there is full dilation of the cervical os, forceps or breech extraction can be considered. When cervical dilation in a multiparous woman has reached 6 cm or more, emergency vacuum extraction can save the life of the baby without endangering the mother. Funic reduction for the management of a proplapsed umbilical cord has been successful in some cases.4 We mention that elevation of the presenting part can be achieved by filling the bladder, and this allows more time to initiate proper treatment. This technique can be used outside hospital before referral. The present crisis in safe motherhood in rural Africa, where maternal mortality is not decreasing,’ shows that there is a need to address several priorities: improvement in the quality of institutional care in combination with appropriate basic training, continuing education, and supervision of selected traditional birth attendants and village health workers. Besides a motivated village midwife treatments
reproductive hazards and occupation
SiR-Thonneau and colleagues (Jan 20, p 204)’ note that pregnancy is significantly delayed when the man is a driver or is occupationally exposed to heat. I have noted that reproductive hazards associated with male occupations may be usefully indexed by low sex ratios (proportions male)2 in their children. Significantly low offspring sex ratios have been reported for men who are drivers3 and men occupationally exposed to heat (eg, carbon setters4 and divers5). Perhaps the delayed conceptions and low sex ratios are hormonally mediated (eg, by low testosterone or high gonadotropin levels). Either way, a low offspring sex ratio may prove to be a useful alternative to sperm counts, conception waits, or homone assays as an indicator of male reproductive hazards. William H James Galton Laboratory, University College London, London NW1 2HE, UK
1 2 3 4 5
Thonneau P, Ducot B, Bujan L, Mieusset R, Spira A. Heat exposure as a hazard to male fertility. Lancet 1996; 347: 204-05. James WH. Occupations associated with low offspring sex ratios. Am J Ind Med 1994; 25: 607-08. Dickinson H, Parker L. Do alcohol and lead change the sex ratio? J Theor Biol 1994; 169: 313. Milham S. Unusual sex ratio of births to carbon setter fathers. Am J Ind Med 1993; 23: 829-31. Lyster WR. Altered sex ratio in children of divers. Lancet 1982; ii: 152.
Controlling tuberculosis SiR-Reichman is indignant about inadequate WHO attention to tuberculosis (Jan 20, p 171),’ but the following points are worthy of consideration. In 1995, WHO had a deficit of US$177 million in membership dues and the USA was$104 million in arrears.2 Second, despite annual expenditure of more than$3000 per person on health care in the USA (ten times greater than the total per capita income of half the world’s population) about 40 million US citizens have no, or inadequate, health insurance. Further, health statistics for the USA reveal that it lags well behind many industrial nations of similar or lesser wealth,3 which raises questions about the US commitment to the "ethical imperative to cure disease and 773
save lives" that Reichman cites so glibly. Inadequate US national concern for the health of its own citizens hardly sets an example for other nations. More could be done for tuberculosis in the world through attention to the power of moral example rather than moral exhortation. Third, tuberculosis is a disease that is critically influenced by social and economic circumstances (especially in poor countries) that deeply implicate many wealthy industrialised nations.4 Fourth, a purely biomedical approach to prevention and cure to tuberculosis is far from adequate. Last, managed care, which Reichman seems to support, is more concerned with profits than health, and those who criticise it stand to lose their jobs.5
Medicine in China SIR-Fazel (Dec 23/30, p 1687)’ reviews the practice of medicine in China. As the Chinese saying goes, one picture is better than a thousand words. So I thought your readers might like to see how tongue appearances indeed offer clues to the underlying diseases according to Chinese traditional medicine (figure, upper).2
S R Benatar *Department of Medicine, University of Cape Town and Groote Schuur Hospital, Observatory 7925, South Africa; and Groote Schuur Hospital, Cape, South Africa
2
Reichman L. How to ensure the continued resurgence of tuberculosis. Lancet 1996; 347: 175-77. McGregor A. Chronic cash shortage hits WHO. Lancet 1995; 347:
3 4
Sagan LA. The health of nations. New York: Basic Books, 1987. Benatar SR. Prospects for global health: lessons from tuberculosis.
5
Thorax 1995; 50: 487-89. Woolhandler S, Himmelstein DU. Extreme risk-the new corporate proposition for physicians. N Engl J Med 1995; 333: 1706-08.
1
187.
Author’s
reply
SIR-I was unaware that responsible scientific or academic discourse requires acknowledgment of one’s government’s failings. Such acknowledgment notwithstanding, especially with the improvements in both the US and South African government’s achievements, I agree that tuberculosis is indeed "a disease that is critically influenced by social and economic circumstances", but as opposed to most other human ills has a well defined means of prevention and cure that is highly cost-effective. Granted, social and economic circumstances are deeply implicated, but any country’s first line of defence must be itself, its own self-interest and concern. A purely biomedical approach to prevention and cure of tuberculosis may well be "far from adequate", but effective tuberculosis control programmes do reduce disease incidence much more quickly2 than improvement of the macro issues facing global human progress. In addition they are at least well characterised and attainable by current stateof-the-art as opposed to other strategies that have been suggested by Benatar.3 I am quite surprised that Benatar thinks I support managed care. On the contrary, so far (at least under the strategies being considered), public health programmes, especially tuberculosis control, may be incompatible with managed care and may suffer even greater neglect and decimation than we have previously considered.4 This is another reason why a well-funded highly visible tuberculosis programme at WHO will be critical to maintain previous advances. Lee B Reichman Departments of Medicine, Preventive Medicine, and Community Health, New Jersey Medical School, Newark, NJ 07107, USA
Figure: Tongue appearances in different cardiovascular diseases (upper); poster showing how appendicitis may be managed by the modern western method or the traditional Chinese method integrated with the western (lower) Upper figure. Top: left, normal coated tongue of a cigarette smoker with nicotine staining; middle, normal fissured tongue (scrotal tongue); nght, transverse fissuring of tongue in Down’s syndrome. Bottom: left, combined horizontal, vertical, and diagonal fissuring of the tongue m a patient with cardiac arrhythmias; middle, geographic tongue in patient with coronary artery disese and cerebral artery spasm; right, chicken heart tongue in a patient with coronary artery disease (from ref 2). Lower figure. In the background is another poster detailing the pros and cons of both approaches. I would also like to offer some evidence to support Fazel’s report that, unbelievable as it might sound, the Chinese do make their own choices about which type of treatment they will receive. The photograph (figure, lower), which I took on one of my trips to China, shows Chinese people viewing a poster explaining how appendicitis might be treated by either the modern Western method (column A) or the traditional Chinese method integrated with the western way
(column B). 1 2
3 4
World Bank. World Development Report 1993: investing in health. Oxford: Oxford University Press, 1993. Styblo K, Salomao MA. National tuberculosis control programs. In: Reichman LB, Hersfield ES, eds. Tuberculosis: a comprehensive international approach, ch 26. New York: Marcel Dekker, 1993: 576-600. Benatar SR. Prospects for global health: lessons from tuberculosis. Thorax 1995; 50: 487-89. Reichman LB. The U-shaped curve of concern. Am Rev Respir Dis 1991; 144: 741-43.
774
Tsung O Cheng Division of
Cardiology, Department Washington, DC 20037, USA
1 2
of
Medicine, George Washington University,
Fazel M. Now show me your tongue: a taste of medicine in China. Lancet 1995; 346: 1687-88. Cheng TO. The international textbook of cardiology. New York/Tokyo: Pergamon Press, 1987: 27-28.
training, a tiered system of referral is also important. Many health facilities need renovation, equipment, and supplies if they are to function as effective referral points. Maternal care activities should be monitored continuously by audit. For this purpose it is recommended that maternal and perinatal mortality committees be with basic
established at the district level motherhood.
*Gijs Walraven, Jos
van
as
a
step towards safer
Roosmalen
*Medical Research Council Laboratories, Banjul, Gambia; and Leiden Hospital, Department of Obstetrics, 2300 RC Leiden, Netherlands
1 2
3 4
5
University
Panter KR, Hannah ME. Umbilical cord prolapse: so far so good? Lancet 1996; 347: 74. Walraven GEL, Mkanje RJB, van Roosmalen J, Van Dongen PWJ, Dolmans WMV. Perinatal mortality in home births in rural Tanzania. Eur J Obstet Reprod Biol 1995; 58: 131-34. Van Roosmalen J, van der Does CD. Caesarean birth rates worldwide. Assessments of determinants. Trop Geogr Med 1995; 47: 19-22. Barret JM. Funic reduction for the management of umbilical cord prolapse. Am J Obstet Gynecol 1991: 654-57. World Health Organization. New estimates of maternal mortality. Wkly Epidemiol Rec 1991; 66: 345-48.
Duggan
Department of Medicine, Cork University Hospital, Wilton, Cork, Ireland
Male 1 Freers J,
2
Mayanja-Kizzo H, Rutakingirwa M, Gerwing E. Endomyocardial fibrosis: why is there striking ascites with little or no peripheral oedema? Lancet 1996; 347: 197. Runyon BA. Cardiac ascites: a characterization. J Clin Gastroenterol 1988, 10: 410-12.
3 Hoefs JC. Serum protein concentration and portal pressure determine the ascitic fluid protein concentration in patients with chronic liver disease. J Lab Clin Med 1983; 102: 260-73.
Umbilical cord
prolapse in rural Africa
SiR-Panter and Hannah (Jan 13, p 74)’ assert that no new have evolved since the 1950s for umbilical cord prolapse. We agree. However, the increased use in industrialised countries of elective and intrapartum caesarean section for the non-cephalic or unengaged is not and feasible, may also be inappropriate, presentations in many parts of rural Africa. In this region, most women still deliver at home; the numbers with high-risk pregnancies who deliver in hospital are low, and transfer facilities from home to hospital are often inadequate when they are most needed.Furthermore, maternal mortality after caesarean section in African hospitals has been reported to be 1-8% (range 0’65-5%);3 this compares unfavourably with the estimated rate of less than 0-1% in the industrialised countries. For these reasons we advocate consideration of alternatives to caesarean section. When there is full dilation of the cervical os, forceps or breech extraction can be considered. When cervical dilation in a multiparous woman has reached 6 cm or more, emergency vacuum extraction can save the life of the baby without endangering the mother. Funic reduction for the management of a proplapsed umbilical cord has been successful in some cases.4 We mention that elevation of the presenting part can be achieved by filling the bladder, and this allows more time to initiate proper treatment. This technique can be used outside hospital before referral. The present crisis in safe motherhood in rural Africa, where maternal mortality is not decreasing,’ shows that there is a need to address several priorities: improvement in the quality of institutional care in combination with appropriate basic training, continuing education, and supervision of selected traditional birth attendants and village health workers. Besides a motivated village midwife treatments
reproductive hazards and occupation
SiR-Thonneau and colleagues (Jan 20, p 204)’ note that pregnancy is significantly delayed when the man is a driver or is occupationally exposed to heat. I have noted that reproductive hazards associated with male occupations may be usefully indexed by low sex ratios (proportions male)2 in their children. Significantly low offspring sex ratios have been reported for men who are drivers3 and men occupationally exposed to heat (eg, carbon setters4 and divers5). Perhaps the delayed conceptions and low sex ratios are hormonally mediated (eg, by low testosterone or high gonadotropin levels). Either way, a low offspring sex ratio may prove to be a useful alternative to sperm counts, conception waits, or homone assays as an indicator of male reproductive hazards. William H James Galton Laboratory, University College London, London NW1 2HE, UK
1 2 3 4 5
Thonneau P, Ducot B, Bujan L, Mieusset R, Spira A. Heat exposure as a hazard to male fertility. Lancet 1996; 347: 204-05. James WH. Occupations associated with low offspring sex ratios. Am J Ind Med 1994; 25: 607-08. Dickinson H, Parker L. Do alcohol and lead change the sex ratio? J Theor Biol 1994; 169: 313. Milham S. Unusual sex ratio of births to carbon setter fathers. Am J Ind Med 1993; 23: 829-31. Lyster WR. Altered sex ratio in children of divers. Lancet 1982; ii: 152.
Controlling tuberculosis SiR-Reichman is indignant about inadequate WHO attention to tuberculosis (Jan 20, p 171),’ but the following points are worthy of consideration. In 1995, WHO had a deficit of US$177 million in membership dues and the USA was$104 million in arrears.2 Second, despite annual expenditure of more than$3000 per person on health care in the USA (ten times greater than the total per capita income of half the world’s population) about 40 million US citizens have no, or inadequate, health insurance. Further, health statistics for the USA reveal that it lags well behind many industrial nations of similar or lesser wealth,3 which raises questions about the US commitment to the "ethical imperative to cure disease and 773
save lives" that Reichman cites so glibly. Inadequate US national concern for the health of its own citizens hardly sets an example for other nations. More could be done for tuberculosis in the world through attention to the power of moral example rather than moral exhortation. Third, tuberculosis is a disease that is critically influenced by social and economic circumstances (especially in poor countries) that deeply implicate many wealthy industrialised nations.4 Fourth, a purely biomedical approach to prevention and cure to tuberculosis is far from adequate. Last, managed care, which Reichman seems to support, is more concerned with profits than health, and those who criticise it stand to lose their jobs.5
Medicine in China SIR-Fazel (Dec 23/30, p 1687)’ reviews the practice of medicine in China. As the Chinese saying goes, one picture is better than a thousand words. So I thought your readers might like to see how tongue appearances indeed offer clues to the underlying diseases according to Chinese traditional medicine (figure, upper).2
S R Benatar *Department of Medicine, University of Cape Town and Groote Schuur Hospital, Observatory 7925, South Africa; and Groote Schuur Hospital, Cape, South Africa
2
Reichman L. How to ensure the continued resurgence of tuberculosis. Lancet 1996; 347: 175-77. McGregor A. Chronic cash shortage hits WHO. Lancet 1995; 347:
3 4
Sagan LA. The health of nations. New York: Basic Books, 1987. Benatar SR. Prospects for global health: lessons from tuberculosis.
5
Thorax 1995; 50: 487-89. Woolhandler S, Himmelstein DU. Extreme risk-the new corporate proposition for physicians. N Engl J Med 1995; 333: 1706-08.
1
187.
Author’s
reply
SIR-I was unaware that responsible scientific or academic discourse requires acknowledgment of one’s government’s failings. Such acknowledgment notwithstanding, especially with the improvements in both the US and South African government’s achievements, I agree that tuberculosis is indeed "a disease that is critically influenced by social and economic circumstances", but as opposed to most other human ills has a well defined means of prevention and cure that is highly cost-effective. Granted, social and economic circumstances are deeply implicated, but any country’s first line of defence must be itself, its own self-interest and concern. A purely biomedical approach to prevention and cure of tuberculosis may well be "far from adequate", but effective tuberculosis control programmes do reduce disease incidence much more quickly2 than improvement of the macro issues facing global human progress. In addition they are at least well characterised and attainable by current stateof-the-art as opposed to other strategies that have been suggested by Benatar.3 I am quite surprised that Benatar thinks I support managed care. On the contrary, so far (at least under the strategies being considered), public health programmes, especially tuberculosis control, may be incompatible with managed care and may suffer even greater neglect and decimation than we have previously considered.4 This is another reason why a well-funded highly visible tuberculosis programme at WHO will be critical to maintain previous advances. Lee B Reichman Departments of Medicine, Preventive Medicine, and Community Health, New Jersey Medical School, Newark, NJ 07107, USA
Figure: Tongue appearances in different cardiovascular diseases (upper); poster showing how appendicitis may be managed by the modern western method or the traditional Chinese method integrated with the western (lower) Upper figure. Top: left, normal coated tongue of a cigarette smoker with nicotine staining; middle, normal fissured tongue (scrotal tongue); nght, transverse fissuring of tongue in Down’s syndrome. Bottom: left, combined horizontal, vertical, and diagonal fissuring of the tongue m a patient with cardiac arrhythmias; middle, geographic tongue in patient with coronary artery disese and cerebral artery spasm; right, chicken heart tongue in a patient with coronary artery disease (from ref 2). Lower figure. In the background is another poster detailing the pros and cons of both approaches. I would also like to offer some evidence to support Fazel’s report that, unbelievable as it might sound, the Chinese do make their own choices about which type of treatment they will receive. The photograph (figure, lower), which I took on one of my trips to China, shows Chinese people viewing a poster explaining how appendicitis might be treated by either the modern Western method (column A) or the traditional Chinese method integrated with the western way
(column B). 1 2
3 4
World Bank. World Development Report 1993: investing in health. Oxford: Oxford University Press, 1993. Styblo K, Salomao MA. National tuberculosis control programs. In: Reichman LB, Hersfield ES, eds. Tuberculosis: a comprehensive international approach, ch 26. New York: Marcel Dekker, 1993: 576-600. Benatar SR. Prospects for global health: lessons from tuberculosis. Thorax 1995; 50: 487-89. Reichman LB. The U-shaped curve of concern. Am Rev Respir Dis 1991; 144: 741-43.
774
Tsung O Cheng Division of
Cardiology, Department Washington, DC 20037, USA
1 2
of
Medicine, George Washington University,
Fazel M. Now show me your tongue: a taste of medicine in China. Lancet 1995; 346: 1687-88. Cheng TO. The international textbook of cardiology. New York/Tokyo: Pergamon Press, 1987: 27-28.