- Email: [email protected]
HOSPITAL NURSING SERVICE
643
fore up to us at the a crash programme.
periphery
to
This letter is a formal proposal that the newly formed University of Lancaster should establish as early as 1965 the three-year university course in human biology proposed by Professor Hill. By October, 1968, the hospitals within a 40-mile radius of Lancaster would be willing and ready to accept the full output of this course for a full three-year clinical course. We speak only for the psdiatric discipline; but we are certain we could provide a full balanced paediatric course for all these students. Within this area there are hospital centres serving a population of over 11/2 million. To draw on this clinical material would not encroach in the slightest on the established teaching schools of Liverpool and Manchester. We believe that similar material and a similar willingness to teach exists in all the other disciplines, and we believe that it would be possible to start producing wellqualified doctors by 1971. Now is the moment to act. The post-war birth-rate bulge is on its way up through the grammar schools, and the peak are now 16-year-olds. They will be taking their A-levels in one or two years’ time. Even now we know perfectly well-qualified young men and women with good A-level certificates who are unable to obtain entry to the existing medical schools.
absolutely nothing to prevent this developtaking place now. We would be willing as consultants to meet and discuss this problem immediately with colleagues in other disciplines, with the university There is
ment
authorities, and with the Regional board. J. P. POUND. Blackpool. E. A. J. BYRNE. Lancaster. Wigan. Barrow-in-Furness.
Blackburn.
Burnley.
A.T.10
help immediately with
R. M. FORRESTER. A. G. HESLING. BRENDA M. MORRIS. P. D. Moss. W. M. L. TURNER.
SIR,-The publication of the valuable article by Professor Dent and Dr. Friedman (July 25) prompts me to attempt further clarification of the confusing situation concerning ’ A.T.10 ’ and pure dihydrotachysterol
(D.H.T.). The exact amount of D.H.T. which is equivalent in dose 1 ml. of A.T.10 has become important because the manufacturers are replacing the present A.T.10 with a new preparation containing only pure D.H.T. In accordance with their revised estimate of the D.H.T. equivalent of A.T.10, they are recommending that 0-25 mg. D.H.T. should be given in place of each 1.0 A.T.10 and 0.125 mg. D.H.T. given in place of each capsule of A.T.10.1 In view of this it is worth considering how this revised estimate was obtained. Chen et aJ.2 found that 0-5 ml. of ’Hytakerol ’ (the name under which A.T.10 is marketed in the U.S.) produced a slightly higher serum-calcium in rats than 0-625 mg. of pure D.H.T. when each was given daily for 3 days. However, the rats given D.H.T. lost more weight, their serum-inorganicphosphate rose higher, and more of them died. This suggested to the authors that the rise in serum-calcium was a poor indication of biological effectiveness ". In dogs they found that 1.25 mg. of pure D.H.T. produced a slightly higher serum-calcium than 1.0 ml. of hytakerol when each was given daily for 7 days. From all this, they concluded that 1-0 ml. of hytakerol was equal in biological effectiveness to 0-625 mg. of D.H.T. (instead of 1.25 mg. as claimed by the manufacturers), their only evidence for this being that these doses produced the same degree of weight loss in rats. As a result of their studies, these workers then investigated the chemical nature of hytakerol by chromatography.3 They concluded that the active principle was not D.H.T. but probably dihydrovitamin D2II (hydrocalciferol), and that, as judged by ultraviolet absorbance, there was 2-7-3-0 times as much of this substance present as the expected amount of D.H.T. In other words, hytakerol was found to contain 3-4-3-75 mg. of hydrocalciferol per ml. instead of 1.25 mg. of D.H.T. per ml. From their previous estimate of the " biological effectiveness " of hytakerol they concluded that, weight for weight, D.H.T. was approximately 5 times as potent as to
"
"
"
hydrocalciferol. HOSPITAL NURSING SERVICE
So far
SIR,-Dr. Adams (Aug. 8) and Mr. Todd (Aug. 29) are surely right when they advocate a simple basic training for all
nurses.
There can only be one proper standard of bedside nursing and all nurses should learn it. Having done so, they should all be called State-enrolled nurses. For those who wish to go higher, opportunities for further training should be greatly increased. A nurse most needs " Platt-type " student training after she has qualified in basic nursing skills, and before she assumes the responsibilities of a ward sister. Those who achieve this should be entitled to the designation " State-registered nurse ". Such a unified structure in the nursing profession would not only accord better with the realities of life in most of our hospitals today; it would also do more than anything to remove the widespread misconception, so rightly attacked by Dr. Adams, that second-class care is good enough for the elderly. The truth is that nursing the elderly requires skills as great as any other type of nursing.
The
high standard of care already offered
to
the
elderly
by
many State-enrolled nurses is sufficient evidence of what can be achieved by a two-year training. All that is needed is to remove the class-consciousness implied by having two different systems of training, for the roll and for the register. We need one training ladder
for all. Royal
East Sussex
Hastings.
Hospital,
R. E. IRVINE B. J. SMITH.
I can ascertain, this work is the only basis for the circulated by the manufacturers of A.T.10 that newer bioassay data indicate that 10 ml. of A.T.10 contains the equivalent of 0-25 mg. of crystalline D.H.T. and each capsule contains the equivalent of 0.125 mg. of crystalline D.H.T.". Clearly someone has confused two quite different problems-the dose equivalence between mg. of D.H.T. and ml. of A.T.10 on the one hand, and the dose equivalence between mg. of D.H.T. and mg. of the active principle of A.T.10 on the other. By a fortunate coincidence, all this has led to something approaching the correct answer; but it is still sufficiently wide of the mark to be a potential source of danger to patients. The data of Dent and Friedman show that even the revised figures overestimate the potency of A.T.10 in terms of D.H.T. Clearly many more observations are needed, especially on patients in whom the situation is not complicated by steatorrhoea of obscure origin or hypothyroidism. I have studied three patients with postoperative hypoparathyroidism in whom the effect of capsules of A.T.10 (in which form the dose can be more accurately controlled than with a liquid preparation) has been compared with that of pure D.H.T. in the same form and from the same source as that used by Dent and Friedman. I had been informed in November, 1962, by the Australian distributors of A.T.10 that the original claim of potency in terms of D.H.T. had been withdrawn. Consequently, the revised claim quoted above was used as the basis of comparison. (Dent and Friedman appear to have been unaware of this as
statement "
1. 2.
Goldman, L. Lancet, 1964. i, 1332. Chen, P. S., Terepka, A. R., Overslaugh, C. Endocrinology, 1962, 70,
3.
Terepka,
815.
A.
R., Chen, P. S., Jorgensen, B. A. ibid. 1961, 68, 996
fore up to us at the a crash programme.
periphery
to
This letter is a formal proposal that the newly formed University of Lancaster should establish as early as 1965 the three-year university course in human biology proposed by Professor Hill. By October, 1968, the hospitals within a 40-mile radius of Lancaster would be willing and ready to accept the full output of this course for a full three-year clinical course. We speak only for the psdiatric discipline; but we are certain we could provide a full balanced paediatric course for all these students. Within this area there are hospital centres serving a population of over 11/2 million. To draw on this clinical material would not encroach in the slightest on the established teaching schools of Liverpool and Manchester. We believe that similar material and a similar willingness to teach exists in all the other disciplines, and we believe that it would be possible to start producing wellqualified doctors by 1971. Now is the moment to act. The post-war birth-rate bulge is on its way up through the grammar schools, and the peak are now 16-year-olds. They will be taking their A-levels in one or two years’ time. Even now we know perfectly well-qualified young men and women with good A-level certificates who are unable to obtain entry to the existing medical schools.
absolutely nothing to prevent this developtaking place now. We would be willing as consultants to meet and discuss this problem immediately with colleagues in other disciplines, with the university There is
ment
authorities, and with the Regional board. J. P. POUND. Blackpool. E. A. J. BYRNE. Lancaster. Wigan. Barrow-in-Furness.
Blackburn.
Burnley.
A.T.10
help immediately with
R. M. FORRESTER. A. G. HESLING. BRENDA M. MORRIS. P. D. Moss. W. M. L. TURNER.
SIR,-The publication of the valuable article by Professor Dent and Dr. Friedman (July 25) prompts me to attempt further clarification of the confusing situation concerning ’ A.T.10 ’ and pure dihydrotachysterol
(D.H.T.). The exact amount of D.H.T. which is equivalent in dose 1 ml. of A.T.10 has become important because the manufacturers are replacing the present A.T.10 with a new preparation containing only pure D.H.T. In accordance with their revised estimate of the D.H.T. equivalent of A.T.10, they are recommending that 0-25 mg. D.H.T. should be given in place of each 1.0 A.T.10 and 0.125 mg. D.H.T. given in place of each capsule of A.T.10.1 In view of this it is worth considering how this revised estimate was obtained. Chen et aJ.2 found that 0-5 ml. of ’Hytakerol ’ (the name under which A.T.10 is marketed in the U.S.) produced a slightly higher serum-calcium in rats than 0-625 mg. of pure D.H.T. when each was given daily for 3 days. However, the rats given D.H.T. lost more weight, their serum-inorganicphosphate rose higher, and more of them died. This suggested to the authors that the rise in serum-calcium was a poor indication of biological effectiveness ". In dogs they found that 1.25 mg. of pure D.H.T. produced a slightly higher serum-calcium than 1.0 ml. of hytakerol when each was given daily for 7 days. From all this, they concluded that 1-0 ml. of hytakerol was equal in biological effectiveness to 0-625 mg. of D.H.T. (instead of 1.25 mg. as claimed by the manufacturers), their only evidence for this being that these doses produced the same degree of weight loss in rats. As a result of their studies, these workers then investigated the chemical nature of hytakerol by chromatography.3 They concluded that the active principle was not D.H.T. but probably dihydrovitamin D2II (hydrocalciferol), and that, as judged by ultraviolet absorbance, there was 2-7-3-0 times as much of this substance present as the expected amount of D.H.T. In other words, hytakerol was found to contain 3-4-3-75 mg. of hydrocalciferol per ml. instead of 1.25 mg. of D.H.T. per ml. From their previous estimate of the " biological effectiveness " of hytakerol they concluded that, weight for weight, D.H.T. was approximately 5 times as potent as to
"
"
"
hydrocalciferol. HOSPITAL NURSING SERVICE
So far
SIR,-Dr. Adams (Aug. 8) and Mr. Todd (Aug. 29) are surely right when they advocate a simple basic training for all
nurses.
There can only be one proper standard of bedside nursing and all nurses should learn it. Having done so, they should all be called State-enrolled nurses. For those who wish to go higher, opportunities for further training should be greatly increased. A nurse most needs " Platt-type " student training after she has qualified in basic nursing skills, and before she assumes the responsibilities of a ward sister. Those who achieve this should be entitled to the designation " State-registered nurse ". Such a unified structure in the nursing profession would not only accord better with the realities of life in most of our hospitals today; it would also do more than anything to remove the widespread misconception, so rightly attacked by Dr. Adams, that second-class care is good enough for the elderly. The truth is that nursing the elderly requires skills as great as any other type of nursing.
The
high standard of care already offered
to
the
elderly
by
many State-enrolled nurses is sufficient evidence of what can be achieved by a two-year training. All that is needed is to remove the class-consciousness implied by having two different systems of training, for the roll and for the register. We need one training ladder
for all. Royal
East Sussex
Hastings.
Hospital,
R. E. IRVINE B. J. SMITH.
I can ascertain, this work is the only basis for the circulated by the manufacturers of A.T.10 that newer bioassay data indicate that 10 ml. of A.T.10 contains the equivalent of 0-25 mg. of crystalline D.H.T. and each capsule contains the equivalent of 0.125 mg. of crystalline D.H.T.". Clearly someone has confused two quite different problems-the dose equivalence between mg. of D.H.T. and ml. of A.T.10 on the one hand, and the dose equivalence between mg. of D.H.T. and mg. of the active principle of A.T.10 on the other. By a fortunate coincidence, all this has led to something approaching the correct answer; but it is still sufficiently wide of the mark to be a potential source of danger to patients. The data of Dent and Friedman show that even the revised figures overestimate the potency of A.T.10 in terms of D.H.T. Clearly many more observations are needed, especially on patients in whom the situation is not complicated by steatorrhoea of obscure origin or hypothyroidism. I have studied three patients with postoperative hypoparathyroidism in whom the effect of capsules of A.T.10 (in which form the dose can be more accurately controlled than with a liquid preparation) has been compared with that of pure D.H.T. in the same form and from the same source as that used by Dent and Friedman. I had been informed in November, 1962, by the Australian distributors of A.T.10 that the original claim of potency in terms of D.H.T. had been withdrawn. Consequently, the revised claim quoted above was used as the basis of comparison. (Dent and Friedman appear to have been unaware of this as
statement "
1. 2.
Goldman, L. Lancet, 1964. i, 1332. Chen, P. S., Terepka, A. R., Overslaugh, C. Endocrinology, 1962, 70,
3.
Terepka,
815.
A.
R., Chen, P. S., Jorgensen, B. A. ibid. 1961, 68, 996