- Email: [email protected]
EVALUATING GALLBLADDER LITHOTRIPSY
51 least six months-but that discourages dialysis patients from seeking work. The Government should review social security rules in rh:c arao
Renal Unit, Manchester Royal Infirmary, Manchester M13 9WL
J. P. STOUT V. F. HILLIER R. GOKAL
Winearls C, Oliver D. Quality of life of dialysis patients treated with r-HuEPO. J Intern Med (in press). 2. Spector DA, Davies PJ, Helderman H, Bell B, Utizer R. Thyroid function and 1. Auer J,
metabolic state in chronic renal failure. Ann Intern Med 1976; 85: 724-30. 3. Lim V, Fang V, Katz A. Thyroid dysfunction in chronic renal failure. J Clin Invest
1977; 60: 522-34. RA, Stead WW, Robinson RR. Physical activity and employment status of patients on maintenance dialysis. N Engl J Med 1981; 304: 309-13
4. Gutman
EVALUATING GALLBLADDER LITHOTRIPSY
SIR,-In the UK health authorities are considering acquiring lithotripters to treat gallstone disease or purchasing treatments for their patients on machines owned by other health authorities or by the private sector. Presumably it is intended that this new therapy will only be used for the 10% or so of patients with gallstone symptoms awaiting elective cholecystectomy, for whom it is claimed extracorporeal shock-wave lithotripsy (ESWL) is effective in the short term.1-3 The indications for ESWL for gallbladder stones were derived from several case series based on a highly selected group of patients. 1-3 The Department of Health has rightly taken the view that the introduction of ESWL for gallbladder stones in the National Health Service should be properly evaluated and is funding a randomised controlled clinical trial and economic analysis in Sheffield.4 Some of the important issues that a purchaser of a lithotripter for gallstones must address are: Are we certain the indications for the use of lithotripsy are agreed; what is the stone recurrence rate and the crossover rate to cholecystectomy; and which is the most cost-effective option? With the NHS white-paper there may be great pressure on self governing hospitals to acquire "glamorous high technology" to attract more patients, but with no regard to the answers to these questions. This possibility is very alarming since "high-tech" developments may have long-term side-effects just as new drugs do. We would never allow a new drug to be introduced without rigorous evaluation. Why should new therapeutic technology be treated differently? Medical Care Research Unit, Department of Community Medicine, University of Sheffield, Sheffield S10 2RX
University Department of Surgery, Royal Hallamshire Hospital, Sheffield
P. C. MILNER
J. E. BRAZIER J. P. NICHOLL B. Ross A. G. JOHNSON
M, Delius M, Saurbruch T, et al. Shock-wave lithotripsy of gallbladder the first 175 patients. N Engl J Med 1988; 318: 393-97. 2. Ell C, Kerzel W, Heyder N, Domschke W. Shock-wave lithotripsy of gallbladder stones. N Engl J Med 1988; 319: 371-12. 3 Hood KA, Keightley A, Dowling RH, Dick JA, Mallinson CN. Piezo-ceramic lithotripsy of gallbladder stones: initial experience in 38 patients. Lancet 1988; i: 1322-24. 4 Milner PC, Nicholl JP, Westlake L, et al. The evaluation of lithotripsy as a treatment for gallstones: a randomised controlled trial approach in England. J Lithotripsy Stone Dis (in press). 1. Sackmann stones:
INTERNATIONAL VERSUS DOMESTIC HEALTH: AN ANTIQUATED DISTINCTION?
SiR,—The traditional bases for differentiating domestic and international health have lost meaning because of changing epidemiology and demography. Four events have contributed to an unprecedented internationalisation of domestic health: (1) the re-emergence of a deadly infectious disease pandemic, HIV;1 (2) health effects anticipated from environmental exploitation and decays (3) a shift in immigration patterns such that developing world peoples comprise a majority of immigrants to Western nations (84% of 643 000 immigrants to the United States in 1988 were of Latin American or Asian origin);4 and (4) an emerging global economic interdependence independent of but heightened
by the facts that the United States is now a debtor nation and Japan leads absolute international health funding. The consequences of these trends are that the infrastructure of developed nations faces qualitatively new and intense pressures from developing world peoples. Furthermore the global village concept has never more aptly described the status of world health. There is an association between domestic and international public health research and practice that must be nurtured. An example of a mutual relation is global warming and parallel strategies include, for example, immunisation programmes. As the world is functionally shrinking with respect to health issues, awareness must increase that technical assistance benefits both donor and recipient nations. This necessitates decreasing emphasis on donor philanthropy as the basis for international health, while increasing emphasis on donor self-interest in preserving and promoting effective domestic public health. If the domestic public health of western nations is to be maintained, global interdependence-economic, environmental, and epidemiological-must become central to domestic policy. Medical practitioners have an obligation to assist policy formulators in transcending rhetoric. Greater research and publication should be encouraged on domestic/international health mutuality and parallelism. Curricula should emphasise the domestic/international health relation in schools of public health, medicine, and public policy. Exchange programmes will facilitate the emergence of practitioners competent in managing the new global realities of health. With respect to funding, health professionals should educate national and international leaders and policy makers, and especially the public of developed nations, about the essential self-interest of relegating to history the distinction between international and domestic health. G. A. GELLERT A. K. NEUMANN UCLA School of Public Health, Los Angeles, California 90024, USA R. S. GORDON 1. Samuels ME, Mann J, Koop CE. Containing the spread of HIV infection: a world health priority. Public Health Rep 1988; 103: 221-23. 2. Longstreth JD, ed. Ultraviolet radiation and melanoma with a special focus on assessing the risks of stratospheric ozone depletion. United States Environmental Protection Agency 400/1-87/001D. Washington, DC: Government Printing Office, 1987. 3. Smith J, Tirpak D, eds. The potential effects of global climate change on the United States. EPA 1988, Draft report to Congress prepared by the Office of Policy, Planning and Evaluation, Office of Research and Development. Washington, DC: United States Environmental Protection Agency, 1988. 4. Statistical yearbook of the Immigration and Naturalisation Service. Washington, DC: Immigration and Naturalisation Service, United States Department of Justice, 1988.
BERIBERI SECONDARY TO TOOTH DECAY
SIR,-Few forms of heart failure are curable. One that is is wet beriberi. A 42-year-old woman presented with a 3-week history of worsening dyspnoea, leg oedema, and increasing abdominal girth. Her medical history was significant only for neglected dental caries. She took no medication; she did not drink alcohol and she was a non-smoker. She had had amenorrhoea for 3 years and had not noticed blood loss from any source. Examination revealed anasarca, severe anaemia, and gross dental caries with haemorrhagic gingivitis; blood pressure 120/70 mm Hg, central venous pressure raised by 8 cm water, and heart rate 100/min. She had cardiomegaly and a gallop rhythm, and signs of pulmonary oedema and pleural effusions were present. No neuropathy was found. There was severe iron-deficiency anaemia with a haemoglobin of 2-3 g/dl. Chest X-ray confirmed cardiomegaly, pulmonary oedema, and pleural and pericardial effusions, and electrocardiography revealed sinus tachycardia. Blood transfusion and diuretics did not correct the disorder. Oesophagogastroduodenoscopy, duodenal biopsy, sigmoidoscopy, faecal fat collection, and renal and thyroid function tests were normal. Liver enzymes were slightly raised and liver biopsy suggested "resolving hepatitis" without Mallory’s hyaline. Tests for hepatitis B infection were negative. Erythrocyte transketolase stimulation by thiamine was diagnostic of beriberi at 77% (normal less than 15%). Diuretics were stopped
Renal Unit, Manchester Royal Infirmary, Manchester M13 9WL
J. P. STOUT V. F. HILLIER R. GOKAL
Winearls C, Oliver D. Quality of life of dialysis patients treated with r-HuEPO. J Intern Med (in press). 2. Spector DA, Davies PJ, Helderman H, Bell B, Utizer R. Thyroid function and 1. Auer J,
metabolic state in chronic renal failure. Ann Intern Med 1976; 85: 724-30. 3. Lim V, Fang V, Katz A. Thyroid dysfunction in chronic renal failure. J Clin Invest
1977; 60: 522-34. RA, Stead WW, Robinson RR. Physical activity and employment status of patients on maintenance dialysis. N Engl J Med 1981; 304: 309-13
4. Gutman
EVALUATING GALLBLADDER LITHOTRIPSY
SIR,-In the UK health authorities are considering acquiring lithotripters to treat gallstone disease or purchasing treatments for their patients on machines owned by other health authorities or by the private sector. Presumably it is intended that this new therapy will only be used for the 10% or so of patients with gallstone symptoms awaiting elective cholecystectomy, for whom it is claimed extracorporeal shock-wave lithotripsy (ESWL) is effective in the short term.1-3 The indications for ESWL for gallbladder stones were derived from several case series based on a highly selected group of patients. 1-3 The Department of Health has rightly taken the view that the introduction of ESWL for gallbladder stones in the National Health Service should be properly evaluated and is funding a randomised controlled clinical trial and economic analysis in Sheffield.4 Some of the important issues that a purchaser of a lithotripter for gallstones must address are: Are we certain the indications for the use of lithotripsy are agreed; what is the stone recurrence rate and the crossover rate to cholecystectomy; and which is the most cost-effective option? With the NHS white-paper there may be great pressure on self governing hospitals to acquire "glamorous high technology" to attract more patients, but with no regard to the answers to these questions. This possibility is very alarming since "high-tech" developments may have long-term side-effects just as new drugs do. We would never allow a new drug to be introduced without rigorous evaluation. Why should new therapeutic technology be treated differently? Medical Care Research Unit, Department of Community Medicine, University of Sheffield, Sheffield S10 2RX
University Department of Surgery, Royal Hallamshire Hospital, Sheffield
P. C. MILNER
J. E. BRAZIER J. P. NICHOLL B. Ross A. G. JOHNSON
M, Delius M, Saurbruch T, et al. Shock-wave lithotripsy of gallbladder the first 175 patients. N Engl J Med 1988; 318: 393-97. 2. Ell C, Kerzel W, Heyder N, Domschke W. Shock-wave lithotripsy of gallbladder stones. N Engl J Med 1988; 319: 371-12. 3 Hood KA, Keightley A, Dowling RH, Dick JA, Mallinson CN. Piezo-ceramic lithotripsy of gallbladder stones: initial experience in 38 patients. Lancet 1988; i: 1322-24. 4 Milner PC, Nicholl JP, Westlake L, et al. The evaluation of lithotripsy as a treatment for gallstones: a randomised controlled trial approach in England. J Lithotripsy Stone Dis (in press). 1. Sackmann stones:
INTERNATIONAL VERSUS DOMESTIC HEALTH: AN ANTIQUATED DISTINCTION?
SiR,—The traditional bases for differentiating domestic and international health have lost meaning because of changing epidemiology and demography. Four events have contributed to an unprecedented internationalisation of domestic health: (1) the re-emergence of a deadly infectious disease pandemic, HIV;1 (2) health effects anticipated from environmental exploitation and decays (3) a shift in immigration patterns such that developing world peoples comprise a majority of immigrants to Western nations (84% of 643 000 immigrants to the United States in 1988 were of Latin American or Asian origin);4 and (4) an emerging global economic interdependence independent of but heightened
by the facts that the United States is now a debtor nation and Japan leads absolute international health funding. The consequences of these trends are that the infrastructure of developed nations faces qualitatively new and intense pressures from developing world peoples. Furthermore the global village concept has never more aptly described the status of world health. There is an association between domestic and international public health research and practice that must be nurtured. An example of a mutual relation is global warming and parallel strategies include, for example, immunisation programmes. As the world is functionally shrinking with respect to health issues, awareness must increase that technical assistance benefits both donor and recipient nations. This necessitates decreasing emphasis on donor philanthropy as the basis for international health, while increasing emphasis on donor self-interest in preserving and promoting effective domestic public health. If the domestic public health of western nations is to be maintained, global interdependence-economic, environmental, and epidemiological-must become central to domestic policy. Medical practitioners have an obligation to assist policy formulators in transcending rhetoric. Greater research and publication should be encouraged on domestic/international health mutuality and parallelism. Curricula should emphasise the domestic/international health relation in schools of public health, medicine, and public policy. Exchange programmes will facilitate the emergence of practitioners competent in managing the new global realities of health. With respect to funding, health professionals should educate national and international leaders and policy makers, and especially the public of developed nations, about the essential self-interest of relegating to history the distinction between international and domestic health. G. A. GELLERT A. K. NEUMANN UCLA School of Public Health, Los Angeles, California 90024, USA R. S. GORDON 1. Samuels ME, Mann J, Koop CE. Containing the spread of HIV infection: a world health priority. Public Health Rep 1988; 103: 221-23. 2. Longstreth JD, ed. Ultraviolet radiation and melanoma with a special focus on assessing the risks of stratospheric ozone depletion. United States Environmental Protection Agency 400/1-87/001D. Washington, DC: Government Printing Office, 1987. 3. Smith J, Tirpak D, eds. The potential effects of global climate change on the United States. EPA 1988, Draft report to Congress prepared by the Office of Policy, Planning and Evaluation, Office of Research and Development. Washington, DC: United States Environmental Protection Agency, 1988. 4. Statistical yearbook of the Immigration and Naturalisation Service. Washington, DC: Immigration and Naturalisation Service, United States Department of Justice, 1988.
BERIBERI SECONDARY TO TOOTH DECAY
SIR,-Few forms of heart failure are curable. One that is is wet beriberi. A 42-year-old woman presented with a 3-week history of worsening dyspnoea, leg oedema, and increasing abdominal girth. Her medical history was significant only for neglected dental caries. She took no medication; she did not drink alcohol and she was a non-smoker. She had had amenorrhoea for 3 years and had not noticed blood loss from any source. Examination revealed anasarca, severe anaemia, and gross dental caries with haemorrhagic gingivitis; blood pressure 120/70 mm Hg, central venous pressure raised by 8 cm water, and heart rate 100/min. She had cardiomegaly and a gallop rhythm, and signs of pulmonary oedema and pleural effusions were present. No neuropathy was found. There was severe iron-deficiency anaemia with a haemoglobin of 2-3 g/dl. Chest X-ray confirmed cardiomegaly, pulmonary oedema, and pleural and pericardial effusions, and electrocardiography revealed sinus tachycardia. Blood transfusion and diuretics did not correct the disorder. Oesophagogastroduodenoscopy, duodenal biopsy, sigmoidoscopy, faecal fat collection, and renal and thyroid function tests were normal. Liver enzymes were slightly raised and liver biopsy suggested "resolving hepatitis" without Mallory’s hyaline. Tests for hepatitis B infection were negative. Erythrocyte transketolase stimulation by thiamine was diagnostic of beriberi at 77% (normal less than 15%). Diuretics were stopped