- Email: [email protected]
FIBRINOLYTIC ACTIVITY AND TREATMENT OF DIABETES
1342 We wish to thank Dr J. W. Farquhar for permission clinical details of this case.
to
publish
J. M. ANDERSON Royal Hospital for Sick Children, Edinburgh EH9 1LF.
G. A. MACHIN I. MCKINLAY D. THISTLETHWAITE.
keratin of the sole of the foot immediately over each embedded spine, followed by salicylic-acid paste for 24-48 hours, enabled all the spines to be expelled easily through the soggy skin by vigorous, and not too painful, squeezing. But clearly those more deeply embedded will require the measures you recommend. Southward, Mount Park
Road,
Harrow, Middlesex.
W. S. KILLPACK.
FIBRINOLYTIC ACTIVITY AND TREATMENT OF DIABETES
SIR,-Dr Farid and others (April 6, p. 631) reported that diabetic
patients on sulphonylurea had a lower fibrinolytic activity than other diabetics, but this was later questioned by Dr Bogie and Mrs Peers of Hoechst Pharmaceuticals (May 18, p. 1000). At the third congress of the International Society on Thrombosis and Hsemostasis in August, 1972, we reported findings corroborating Dr Farid’s. We have now studied spontaneous fibrinolytic activity in 221 diabetics, including 21 receiving only sulphonylurea, by testing redissolved euglobulin precipitate on fibrin plates. Compared to an age and sex matched control group more (153 subjects) there were significantly (P<0’01) mm. diabetics who had a low activity (<15’0 sq. lysis), although the mean activity in the diabetics was 30-5 (±S.E. 2-4) and in the controls 34-4 (±3-3) sq. mm. In the sulphonylurea-treated group of 21 patients, however, the mean activity was only 14-6 ±4-0, significantly lower than in the remaining diabetics (p < 0-02) (9 women with a mean of 18-0 and 12 men with a mean of 12-0). Patients treated by dietary measures only or on insulin had a mean fibrinolytic activity close to that of the controls. as did those receiving such treatment combined with phenformin. The fibrinolytic activity tends to be much lower in obesity, but when obese patients (actual/ideal weight 120%) were excluded, the mean activity of those on sulphonylurea was still lower than in any of the other groups of diabetics. Since this decrease in fibrinolytic activity might help to explain the biochemical basis for the high frequency of cardiovascular deaths in diabetes treated with sulphonylurea in the U.G.D.P. reports, we studied the plasminogen-activator content of the vessel walls of such diabetics with a modification1 of the Todd histochemical method2 and examined biopsy specimens of superficial veins of the dorsum of the hand. We found that the activator content was normal whether the patients were receiving sulphonylurea or not. The endothelial cells are thus not deprived of their activator content, but for some reason the release of the activator to the blood is decreased. The patients on sulphonylurea did not differ significantly from the others in respect of inhibitors of plasminogen activation (urokinase inhibitors), mean a2-macroglobulin
level, plasma cholesterol, triglycerides, or fibrinogen. We feel that further investigation of the influence of
sulphonylurea
on
the
fibrinolytic activity in diabetes is responsible for the
desirable to elucidate the mechanism low activity in long-term treatment. Department of Internal Medicine, and Coagulation Laboratory, Malmö General Hospital, Malmö, Sweden.
INJURY
L.-O. ALMÉR I. M. NILSSON.
FROM SPINES OF SEA URCHINS
SIR,-With reference to your editorial of June 1 (p. 1091), record of recent personal injury may be of interest. A Mediterranean holiday seemed threatened until the following treatment was evolved: removal of the thick a
INEQUALITY AND THE HEALTH SERVICE SIR,-Professor Townsend (June 15, p. 1188) criticises hierarchic models of organisation as if they necessarily imply the " superior power and status of some kind of elite and an exclusivity of knowledge ". But we should not discard the baby with the bathwater: we still need the concept of hierarchy. I suggest that the dislike of hierarchies expressed by some social scientists (and others) stems from our common failure to take seriously enough the distinction between the executive function and the information-collecting function, both of which are needed by complex adaptive systems such as human organisations and communities. The mammalian central nervous system (which is also a complex adaptive system) demonstrates that the evolutionary process "
has found this functional distinction to be so essential that it has become embodied in structure-in the physical separation of the sensory and motor pathways. In social interactions, of course, an individual is not structurally limited to one or other of these functions, but has the " " capacity to play both a motor role " and a sensory role ": he can do a job, and he can communicate his experience (his perceptions, opinions, and attitudes). When we are dealing with social organisations of large size and complexity (the critical size probably numbers about 500 people), we need two conceptually distinct hierarchies. One is centrifugal in operation, concerned with the performance of the organisation’s primary tasks. It is usually recognised as the " executive system ". The other operates centripetally, and is concerned with the collection and processing of information derived from internal and external sources from all members of the organisation, irrespective of their executive status. This is less widely recognised but has been described in an industrial setting as the " representative system ".1The biological analogy of the c.N.s. suggests how structurally dissimilar these two systems may be (e.g., the motor pathways contain two neurones between cortex and periphery; the sensory pathways at least three)-yet both are hierarchic. Many of the ills of our current organisations (in the N.H.S. and elsewhere) and our forebodings about their future arise from our failure to develop a sophisticated social analogue for the " sensory system ". Executive systems which look lovely on paper often fail in practice because they do not have access to adequately processed information from their environment and their customers and front-line workers. In the reorganised N.H.S., community health councils (c.H.c.s) are clearly intended to be the basic informationcollecting and processing bodies. They are entirely distinct from the executive bodies (area health authorities and district management teams), and their reports are to be published and made widely available to the public if they wish. It seems unreasonable to criticise their constitution as Professor Townsend does, for not according them executive powers. No-one knows how effective they will be, but to give them executive responsibility would be the surest way to muzzle them. Professor Townsend describes them as below " the management structure. I prefer to "
1. 2.
Pandolfi, M., Nilsson, I. M., Robertson, B., Isacson, S. Lancet, 1967, ii, 127. Todd, A. S. Nature, 1958, 181, 495.
1.
Brown, W. Exploration in Management.
1960.
to
publish
J. M. ANDERSON Royal Hospital for Sick Children, Edinburgh EH9 1LF.
G. A. MACHIN I. MCKINLAY D. THISTLETHWAITE.
keratin of the sole of the foot immediately over each embedded spine, followed by salicylic-acid paste for 24-48 hours, enabled all the spines to be expelled easily through the soggy skin by vigorous, and not too painful, squeezing. But clearly those more deeply embedded will require the measures you recommend. Southward, Mount Park
Road,
Harrow, Middlesex.
W. S. KILLPACK.
FIBRINOLYTIC ACTIVITY AND TREATMENT OF DIABETES
SIR,-Dr Farid and others (April 6, p. 631) reported that diabetic
patients on sulphonylurea had a lower fibrinolytic activity than other diabetics, but this was later questioned by Dr Bogie and Mrs Peers of Hoechst Pharmaceuticals (May 18, p. 1000). At the third congress of the International Society on Thrombosis and Hsemostasis in August, 1972, we reported findings corroborating Dr Farid’s. We have now studied spontaneous fibrinolytic activity in 221 diabetics, including 21 receiving only sulphonylurea, by testing redissolved euglobulin precipitate on fibrin plates. Compared to an age and sex matched control group more (153 subjects) there were significantly (P<0’01) mm. diabetics who had a low activity (<15’0 sq. lysis), although the mean activity in the diabetics was 30-5 (±S.E. 2-4) and in the controls 34-4 (±3-3) sq. mm. In the sulphonylurea-treated group of 21 patients, however, the mean activity was only 14-6 ±4-0, significantly lower than in the remaining diabetics (p < 0-02) (9 women with a mean of 18-0 and 12 men with a mean of 12-0). Patients treated by dietary measures only or on insulin had a mean fibrinolytic activity close to that of the controls. as did those receiving such treatment combined with phenformin. The fibrinolytic activity tends to be much lower in obesity, but when obese patients (actual/ideal weight 120%) were excluded, the mean activity of those on sulphonylurea was still lower than in any of the other groups of diabetics. Since this decrease in fibrinolytic activity might help to explain the biochemical basis for the high frequency of cardiovascular deaths in diabetes treated with sulphonylurea in the U.G.D.P. reports, we studied the plasminogen-activator content of the vessel walls of such diabetics with a modification1 of the Todd histochemical method2 and examined biopsy specimens of superficial veins of the dorsum of the hand. We found that the activator content was normal whether the patients were receiving sulphonylurea or not. The endothelial cells are thus not deprived of their activator content, but for some reason the release of the activator to the blood is decreased. The patients on sulphonylurea did not differ significantly from the others in respect of inhibitors of plasminogen activation (urokinase inhibitors), mean a2-macroglobulin
level, plasma cholesterol, triglycerides, or fibrinogen. We feel that further investigation of the influence of
sulphonylurea
on
the
fibrinolytic activity in diabetes is responsible for the
desirable to elucidate the mechanism low activity in long-term treatment. Department of Internal Medicine, and Coagulation Laboratory, Malmö General Hospital, Malmö, Sweden.
INJURY
L.-O. ALMÉR I. M. NILSSON.
FROM SPINES OF SEA URCHINS
SIR,-With reference to your editorial of June 1 (p. 1091), record of recent personal injury may be of interest. A Mediterranean holiday seemed threatened until the following treatment was evolved: removal of the thick a
INEQUALITY AND THE HEALTH SERVICE SIR,-Professor Townsend (June 15, p. 1188) criticises hierarchic models of organisation as if they necessarily imply the " superior power and status of some kind of elite and an exclusivity of knowledge ". But we should not discard the baby with the bathwater: we still need the concept of hierarchy. I suggest that the dislike of hierarchies expressed by some social scientists (and others) stems from our common failure to take seriously enough the distinction between the executive function and the information-collecting function, both of which are needed by complex adaptive systems such as human organisations and communities. The mammalian central nervous system (which is also a complex adaptive system) demonstrates that the evolutionary process "
has found this functional distinction to be so essential that it has become embodied in structure-in the physical separation of the sensory and motor pathways. In social interactions, of course, an individual is not structurally limited to one or other of these functions, but has the " " capacity to play both a motor role " and a sensory role ": he can do a job, and he can communicate his experience (his perceptions, opinions, and attitudes). When we are dealing with social organisations of large size and complexity (the critical size probably numbers about 500 people), we need two conceptually distinct hierarchies. One is centrifugal in operation, concerned with the performance of the organisation’s primary tasks. It is usually recognised as the " executive system ". The other operates centripetally, and is concerned with the collection and processing of information derived from internal and external sources from all members of the organisation, irrespective of their executive status. This is less widely recognised but has been described in an industrial setting as the " representative system ".1The biological analogy of the c.N.s. suggests how structurally dissimilar these two systems may be (e.g., the motor pathways contain two neurones between cortex and periphery; the sensory pathways at least three)-yet both are hierarchic. Many of the ills of our current organisations (in the N.H.S. and elsewhere) and our forebodings about their future arise from our failure to develop a sophisticated social analogue for the " sensory system ". Executive systems which look lovely on paper often fail in practice because they do not have access to adequately processed information from their environment and their customers and front-line workers. In the reorganised N.H.S., community health councils (c.H.c.s) are clearly intended to be the basic informationcollecting and processing bodies. They are entirely distinct from the executive bodies (area health authorities and district management teams), and their reports are to be published and made widely available to the public if they wish. It seems unreasonable to criticise their constitution as Professor Townsend does, for not according them executive powers. No-one knows how effective they will be, but to give them executive responsibility would be the surest way to muzzle them. Professor Townsend describes them as below " the management structure. I prefer to "
1. 2.
Pandolfi, M., Nilsson, I. M., Robertson, B., Isacson, S. Lancet, 1967, ii, 127. Todd, A. S. Nature, 1958, 181, 495.
1.
Brown, W. Exploration in Management.
1960.