- Email: [email protected]
Future of postgraduate medical education
1246
change in codon 23 of the rhodopsin gene in 12% of their patients with autosomal dominant retinitis pigmentosa,’ have now identified three more mutations in the same gene (which is located on the long arm of chromosome 3).2 Each mutation was found exclusively in patients with autosomal dominant retinitis pigmentosa, and the three mutations together account for 6% of the cases in Dryja’s series. All three mutations correspond to a change in a single aminoacid residue in the rhodopsin molecule. Two are C-T transitions involving separate nucleotides of codon 347, which normally specifies proline but in the mutants specifies, respectively, leucine and serine. The third mutation is a C-G transition in codon 58, which in the abnormal form specifies arginine (instead of
threonine). Whether other mutations in the rhodopsin gene will surface in patients with autosomal dominant retinitis pigmentosa remains to be seen. How or indeed whether mutations in a gene thought to be expressed exclusively in rods leads eventually to widespread degeneration of cone receptors is unclear. Dryja TP, McGee TL, Reichel E, et al. A point mutation of the rhodopsin gene m one form of retinitis pigmentosa. Nature 1990; 343: 364-66 2. Dryja TP, McGee TL, Hahn LB, et al. Mutations within the rhodopsin gene in patients with autosomal dominant retinitis pigmentosa. N Engl J Med 1990; 323: 1.
1302-07.
Future of
postgraduate medical education
The Department of Health is expected to issue a policy document on the delivery of postgraduate and continuing medical education on January 7. Some of the new arrangements were announced by Mr Kenneth Clarke, when he was Secretary of State for Health, at a lecture in York in July (see Lancet Sept 29, p 780). In formulating its policy the Department had considered a report produced by the Standing Committee on Postgraduate Medical Education; SCOPME has now published this report.l Its main recommendations-that there be defined budgets for postgraduate medical education and that these be held by the regional postgraduate dean-have been accepted by the Department. Whether and to what degree its other recommendations will be taken up remain to be seen-eg, the contractual arrangements for the continuing medical education of doctors of all grades, in directly managed NHS hospitals and in those run by NHS trusts. 1.
Standing Committee on Postgraduate Medical Education. A new infrastructure for postgraduate medical training and continuing education. London: SCOPME. November, 1990. Pp 14.
Where does the money
go?
This year the world will spend 1500 billion dollars on health care. Yet too many people are beyond the reach of modem medicine and dissatisfied with their medical services. In the USA, for instance, 70% of hospital costs are spent on 7% of the population, much of it in the few months before death. The USA, because of its technology orientation, spends more on health care than any other industrialised nation—11-2% of gross domestic product (GDP). Last month, at an international conference on the Economics of Health Care: Challenges for the Nineties, held in Princeton, New Jersey, Richard Larnm, a former Governor of Colorado, called US health care expenditure "a black hole that threatens to suck in the entire budget". In the USSR, by contrast, the 3% of GDP allocated to health care is barely enough to make even basic medical services work. Infant mortality in the Soviet Union is 3-7 times higher than in Sweden and the prevalence of tuberculosis 4-8 times higher than in the west. However, under the Health Finance Reform Bill now before the Supreme Soviet, medical care will be paid for out of a payroll tax, with federal support to areas of particular need. The USSR, like the USA, has an excess of doctors-indeed the Soviet Union has the highest ratio of doctors to population of any country in the world. Nevertheless, 45% of hospitals have no central water
supply.
Even in a country affluent enough to afford choice in health care explicit decision to pay for one procedure is an implicit decision not to opt for another. And so the USA, obsessed with high technology, will spend$158 000 on intensive care of a premature infant abandoned by its cocaine-addicted mother, while 600 000 women go without antenatal care. In one week the California legislature voted both to pay for organ transplants and to drop thousands of indigent people from the medical insurance system. The crisis in US medicine seems to derive as much from mismanagement of fmances as from poor planning of services. For every physician there are four bureaucrats. There are 800 medical insurance firms competing for business, many from small employers, with the result that up to 40% of insurance costs go on administration and marketing. The US spends$80 billion a year on processing health fmance payments. This is twice the cost of all pharmaceuticals and enough to cover the uninsured population in the country. Contrary to common perception, drug costs in the USA have been steadily falling as a percentage of total health care expenditure and now account for only 7% of that total. Treatment costs tend to be expensive when only palliative therapy is available (eg, for AIDS today). As medical knowledge advances and aetiology is defined, true cost-effective technology emerges (eg, poliovaccine, fluoride in dentistry). Contemporary research permits molecular modelling and synthesis on a scale never before imagined. an
Health risks of oil mist The wheels of industry are oiled in many ways. The estimated world consumption of petroleum products in 1988 was over 3 billion tonnes. Apart from fuel, oil is the raw material for products ranging from plastics to lubricants. The health risks from oil mist formed during the production and use of oil-based products were discussed at a conference at the Institute of Petroleum, London, on Oct 18. Oil mist can be generated by evaporation, condensation, or mechanical dispersion. The metal working, mining, printing, and textile industries were noted as particular sources of oil mist, and the conference tended to concentrate on oil mist from cutting fluids used for cooling and lubrication during metal working. The skin and respiratory system are particularly vulnerable to damage by oil mist. Dermatitis is more likely to be allergic than irritant, because irritants in oil mist seldom accumulate in concentrations sufficient to cause harm. Allergens present in cutting fluids include formaldehyde, mercaptobenzothiazole, and chromium. Dermatitis from cutting fluids tends to persist-Dr R. J. G. Rycroft (St Thomas’ Hospital, London) found that 70% of clinic patients with cutting-fluid dermatitis (mainly from direct contact, but from oil mist also) still had symptoms 2 years after contact had ceased. Rycroft suggested that the best way to prevent allergic dermatitis was to prevent sensitisation, and that suppliers of cutting fluids should notify factory medical departments of their constituents. There is little evidence that exposure to oil mist can lead to lipoid pneumonia, bronchitis, or pulmonary fibrosis, and most studies show no excess of respiratory tumours in workers exposed to oil mist. However, inhalation of oil mist is now well recognised as a cause of occupational asthma. Asthma may develop soon after initial exposure or at any time during long-term exposure. A patient who does not recover within 2 years is likely to persist in an asthmatic state. The provoking factor within oil appears to vary from patient to
patient.
In the UK the occupational exposure standard (OES) for oil mist is 5 mgjm3; this standard applies to inhalation only. At this concentration factory conditions are unpleasant, so it is seldom reached without complaint from the workforce. Dr Nigel Long (Health and Safety Executive, Birmingham) noted that, on the rare
occasions it has been measured, oil-mist concentration seldom exceeded the OES, even in factories that took no precautions against exposure to oil mist. The OES was originally set for exposure to neat mineral oils; perhaps standards should now be set for exposure to the components of oil mist.
change in codon 23 of the rhodopsin gene in 12% of their patients with autosomal dominant retinitis pigmentosa,’ have now identified three more mutations in the same gene (which is located on the long arm of chromosome 3).2 Each mutation was found exclusively in patients with autosomal dominant retinitis pigmentosa, and the three mutations together account for 6% of the cases in Dryja’s series. All three mutations correspond to a change in a single aminoacid residue in the rhodopsin molecule. Two are C-T transitions involving separate nucleotides of codon 347, which normally specifies proline but in the mutants specifies, respectively, leucine and serine. The third mutation is a C-G transition in codon 58, which in the abnormal form specifies arginine (instead of
threonine). Whether other mutations in the rhodopsin gene will surface in patients with autosomal dominant retinitis pigmentosa remains to be seen. How or indeed whether mutations in a gene thought to be expressed exclusively in rods leads eventually to widespread degeneration of cone receptors is unclear. Dryja TP, McGee TL, Reichel E, et al. A point mutation of the rhodopsin gene m one form of retinitis pigmentosa. Nature 1990; 343: 364-66 2. Dryja TP, McGee TL, Hahn LB, et al. Mutations within the rhodopsin gene in patients with autosomal dominant retinitis pigmentosa. N Engl J Med 1990; 323: 1.
1302-07.
Future of
postgraduate medical education
The Department of Health is expected to issue a policy document on the delivery of postgraduate and continuing medical education on January 7. Some of the new arrangements were announced by Mr Kenneth Clarke, when he was Secretary of State for Health, at a lecture in York in July (see Lancet Sept 29, p 780). In formulating its policy the Department had considered a report produced by the Standing Committee on Postgraduate Medical Education; SCOPME has now published this report.l Its main recommendations-that there be defined budgets for postgraduate medical education and that these be held by the regional postgraduate dean-have been accepted by the Department. Whether and to what degree its other recommendations will be taken up remain to be seen-eg, the contractual arrangements for the continuing medical education of doctors of all grades, in directly managed NHS hospitals and in those run by NHS trusts. 1.
Standing Committee on Postgraduate Medical Education. A new infrastructure for postgraduate medical training and continuing education. London: SCOPME. November, 1990. Pp 14.
Where does the money
go?
This year the world will spend 1500 billion dollars on health care. Yet too many people are beyond the reach of modem medicine and dissatisfied with their medical services. In the USA, for instance, 70% of hospital costs are spent on 7% of the population, much of it in the few months before death. The USA, because of its technology orientation, spends more on health care than any other industrialised nation—11-2% of gross domestic product (GDP). Last month, at an international conference on the Economics of Health Care: Challenges for the Nineties, held in Princeton, New Jersey, Richard Larnm, a former Governor of Colorado, called US health care expenditure "a black hole that threatens to suck in the entire budget". In the USSR, by contrast, the 3% of GDP allocated to health care is barely enough to make even basic medical services work. Infant mortality in the Soviet Union is 3-7 times higher than in Sweden and the prevalence of tuberculosis 4-8 times higher than in the west. However, under the Health Finance Reform Bill now before the Supreme Soviet, medical care will be paid for out of a payroll tax, with federal support to areas of particular need. The USSR, like the USA, has an excess of doctors-indeed the Soviet Union has the highest ratio of doctors to population of any country in the world. Nevertheless, 45% of hospitals have no central water
supply.
Even in a country affluent enough to afford choice in health care explicit decision to pay for one procedure is an implicit decision not to opt for another. And so the USA, obsessed with high technology, will spend$158 000 on intensive care of a premature infant abandoned by its cocaine-addicted mother, while 600 000 women go without antenatal care. In one week the California legislature voted both to pay for organ transplants and to drop thousands of indigent people from the medical insurance system. The crisis in US medicine seems to derive as much from mismanagement of fmances as from poor planning of services. For every physician there are four bureaucrats. There are 800 medical insurance firms competing for business, many from small employers, with the result that up to 40% of insurance costs go on administration and marketing. The US spends$80 billion a year on processing health fmance payments. This is twice the cost of all pharmaceuticals and enough to cover the uninsured population in the country. Contrary to common perception, drug costs in the USA have been steadily falling as a percentage of total health care expenditure and now account for only 7% of that total. Treatment costs tend to be expensive when only palliative therapy is available (eg, for AIDS today). As medical knowledge advances and aetiology is defined, true cost-effective technology emerges (eg, poliovaccine, fluoride in dentistry). Contemporary research permits molecular modelling and synthesis on a scale never before imagined. an
Health risks of oil mist The wheels of industry are oiled in many ways. The estimated world consumption of petroleum products in 1988 was over 3 billion tonnes. Apart from fuel, oil is the raw material for products ranging from plastics to lubricants. The health risks from oil mist formed during the production and use of oil-based products were discussed at a conference at the Institute of Petroleum, London, on Oct 18. Oil mist can be generated by evaporation, condensation, or mechanical dispersion. The metal working, mining, printing, and textile industries were noted as particular sources of oil mist, and the conference tended to concentrate on oil mist from cutting fluids used for cooling and lubrication during metal working. The skin and respiratory system are particularly vulnerable to damage by oil mist. Dermatitis is more likely to be allergic than irritant, because irritants in oil mist seldom accumulate in concentrations sufficient to cause harm. Allergens present in cutting fluids include formaldehyde, mercaptobenzothiazole, and chromium. Dermatitis from cutting fluids tends to persist-Dr R. J. G. Rycroft (St Thomas’ Hospital, London) found that 70% of clinic patients with cutting-fluid dermatitis (mainly from direct contact, but from oil mist also) still had symptoms 2 years after contact had ceased. Rycroft suggested that the best way to prevent allergic dermatitis was to prevent sensitisation, and that suppliers of cutting fluids should notify factory medical departments of their constituents. There is little evidence that exposure to oil mist can lead to lipoid pneumonia, bronchitis, or pulmonary fibrosis, and most studies show no excess of respiratory tumours in workers exposed to oil mist. However, inhalation of oil mist is now well recognised as a cause of occupational asthma. Asthma may develop soon after initial exposure or at any time during long-term exposure. A patient who does not recover within 2 years is likely to persist in an asthmatic state. The provoking factor within oil appears to vary from patient to
patient.
In the UK the occupational exposure standard (OES) for oil mist is 5 mgjm3; this standard applies to inhalation only. At this concentration factory conditions are unpleasant, so it is seldom reached without complaint from the workforce. Dr Nigel Long (Health and Safety Executive, Birmingham) noted that, on the rare
occasions it has been measured, oil-mist concentration seldom exceeded the OES, even in factories that took no precautions against exposure to oil mist. The OES was originally set for exposure to neat mineral oils; perhaps standards should now be set for exposure to the components of oil mist.