- Email: [email protected]
Organisation of pathology services
230
Noticeboard La peste "From dark corners, from basements, from cellars, from sewers, they came up in long tottering lines to stagger at the light, turn round and die near men... you might have thought that the very earth on which our houses stood was purging itself, allowing boils and pus, which until then have been at work
inside, to come to the surface".-Albert Camus Plague is endemic but intrudes into human existence only if unprotected individuals stray into the natural habitat of the host
(rodent), organism (Yersinia pestis), 47-year-old female biologist, who had
or a
A
(flea). primary plague vector
immunisation series in 1957 with boosters up to 1971, went to Bolivia on May 18, 1990. She camped in rural regions and collected small mammals, including rice rats, which were killed with a barbiturate (’Nembutal’) and then skinned. While completing this procedure she crushed fleas between her fingers. Nembutal leaves fleas unharmed. On June 14 she returned to La Paz with fever and sweats, together with painful swelling in her right axilla. A respiratory tract infection was diagnosed on June 17 and, despite intramuscular ampicillin, a dry cough developed; by June 20 (after arrival back in the District of Columbia, USA) she had a 25 cm right axillary lymph node. Culture of lymph node aspirates confirmed Y pestis. She was treated with intramuscular streptomycin (1 g twice daily) and was discharged on June 26 with an additional ten days of streptomycin. Plague continues to remain a threat in the 20th century. In 1989, 770 cases were reported from 11 countries. Since infection commonly takes place far away from a plague reference laboratory, a clinical diagnosis is often essential to allow early treatment and so prevent death. Local outbreaks demand public education campaigns to emphasise personal hygiene. Insecticides must be distributed to kill fleas, and patient contacts should be treated with tetracycline. The theme of plague was developed by Camus as an allegory for French involvement in Algeria. Yet his vivid descriptions of symptoms, routes of spread, the natural history of Ypestis, and the resultant human misery should be required reading for all those with an interest in infectious diseases. 1 Centers for Disease Control.
MMWR
Imported
bubonic
plague—District
of Columbia.
1989; 39: 895-901.
Treatment of chemical warfare
injuries
The Working Party on Chemical and Biological Weapons, in response to requests for information from members of the medical profession concerned at the possibility of having to treat victims of attack by chemical agents during the Gulf war, has issued a guide to the types of chemical agents that may be encountered during the conflict in the Middle East.1 The report considers three groups of agents, classified according to their physiological effects-nerve agents, blister agents (vesicants), and blood agents. Nerve agents, which are colourless, tasteless chemicals belonging to the same family of compounds as the organophosphorus pesticides, can kill quickly and are more potent than any other chemicals except toxins. Examples are tabun, sarin, soman, and VX. Blister agents, such as mustard gas and lewisite, bum and blister the skin within hours of exposure. Blood agents kill by interfering with oxygen uptake by the tissues. Hydrogen cyanide and cyanogen chloride are examples. The report summarises the symptoms caused by chemical agents, any delayed or long-term effects, and appropriate treatment. The guidelines emphasise that chemical warfare casualties, especially those injured by mustard gas, may need a long period of care, followed by
be hazardous-eg, the use of large quantities of water (not suitable for mustard gas) can contaminate the water run-off area. Some agents persist in the ground, in vegetation, and in buildings for weeks or months. Another useful document is a bibliography on the treatment of biological and chemical warfare injuries, assembled by the British Library’s medical information service.2 Sources include Government research reports, conference reports, and reprints from medical journals. The library can also provide copies of the source documents. can
lengthy convalescence.
Though classified according to their predominant effects, agents from all three groups can affect several body systems. Nerve gases, for instance, can have bronchopulmonary, gastrointestinal, urinary, cardiovascular, glandular, ocular, central nervous system, and muscular effects, and treatment may need to be directed at blockade of excess acetylcholine, ventilation, and reversal of acetylcholinesterase inhibition. Decontamination or neutralisation
Working Party on Chemical and Biological Weapons, Landfall, Tregullon, Bodmin, Cornwall PL30 5BH (tel 0208 831401, fax 0208 831678) 2. Available from the British Library, 96 Euston Road, London NW2 2DB (tel 071-323 7111, fax 071-323 7268). 1. Medical effects of chemical warfare agents.
Citation failures Citation rates have become a sport-a gold medal for a "citation classic" and lesser awards for being able to list enough mentions to secure tenure or advancement or to keep the unit’s head above water for another year. We hear little of the holders of the wooden spoon. How about "uncitedness"? David Pendlebury, from the Institute for Scientific Information, Philadelphia, has turned non-citation into a specialty of its own.1 How often are papers, in different disciplines, uncited in the four years after publication? In this curious race physics wins (only 36-7% uncited), medicine comes fifth at 46-4%, between the geosciences and mathematics, and the booby prize goes to the arts and humanities, where only 2.0% of papers got a mention. Papers on the theatre and American literature achieved near perfection with uncitedness rates of 99-9% and 99-8%, respectively. Engineering did uniformly badly too. Happily, nobody really knows what any of these numbers mean. 1. Hamilton DP Research papers: who’s uncited now? Science
1991, 251: 25.
Organisation of pathology services Accuracy is well monitored but laboratories should widen their concept of quality, says an Audit Commission reportl on NHS pathology services, which in England and Wales employ over 23 000 staff and costs about 400 million a year to run. Quality control has been addressed by the Royal College of Pathologists, which has tested an accreditation scheme and is refining it for wider The Audit Commission report focuses on cost-effectiveness. Financial control is difficult because of the fragmented nature of laboratory budgets-which can come from health authorities, university, or the Public Health Laboratory Service, and which may be allocated specifically to overheads, capital equipment, salaries, or consumables. Moreover, the accounting procedures are designed to control expenditure rather than to give insight into how well resources are being deployed. The Commission has developed a system of costing individual investigations to help laboratories to identify where savings can be made. For costing staff time it uses the Welcan workload measurement system, developed initially in Canada, then adapted in Wales, for deriving standard times for doing specific tests (a set of standard Welcan measures has been calculated by the College together with other pathology bodies). The Commission takes care to point out when Welcan times may not be appropriate. The report describes options for improving cost-effective use of resources under three broad headings-management of demand, planning of workflow; and deployment of staff. Protocols that set out good practice guidelines on laboratory requests are one means of demand management, and the Commission has been invited to work with the Royal College of Pathologists to develop such guidelines. The Commission points out that even if it were to be financially advantageous for laboratories to undertake as many tests as possible, it remains good practice for laboratories to give advice on appropriateness of requests. Workflow can be improved by priority grading for different kinds of work. The aim should be to deliver results on time, not necessarily as soon as possible.
use.
231
Furthermore, the possibility of centralising services should be considered. The difficulties entailed in recruitment and retention of staff are recognised, and suggestions for coping with these include sharing resources between neighbouring sites, cross-disciplinary cover, a shift rather than an on-call system, and the re-design of the remuneration system. 1 Audit Commission The Pathology Services. a management review London:HM Stationery Office 1991. Pp 60 £8.50. ISBN 0-118860356
Although some may miss those seemingly far-off lazy summer evenings filled with the enticing aromas of gently sizzling food on a barbecue grill, a report from California shows how even life’s simple 1 pleasures may carry a sting in the tail. Four members of a family presented to hospital with headache, nausea, and abdominal pains and gave a history of drinking unrefrigerated milk the previous evening. A diagnosis of infective was
made,
given, and the patients
treatment
with intravenous fluids
was
discharged home. A few hours later four more members of the same family came to the hospital complaining of similar symptoms. The same diagnosis was made, the same treatment was given, and these patients were also discharged. Several hours passed again and four more family members were admitted, one reporting that she had not had any of the milk that was thought to be the source of the infection. A clear history was difficult to obtain, because the family were non-English speaking, but an interpreter was able to find that the family often were
the house. Measurement of in carboxyhaemoglobin (HbCO) the most recently admitted family members showed increased serum concentrations in three of the four. Treatment with 100% oxygen for 2 hours led to symptomatic improvement, and a fall in the HbCO was found in one patient. A subsequent visit to the family house revealed a barbecue grill in the middle of the living room.
cooked
over
charcoal
1. Gasman JD, Varon J, Gardner 153: 656-57
in
A memorial service for Mr Michael Masser, FRCS, will be held Salisbury Cathedral on Saturday, Jan 26, at 2.30 pm.
In
England
Meningococcal infection is caused by the gram-negative diplococcus, Neisseria meningitidis. Spread is commonly by respiratory droplets from symptom-free carriers. Pili enable these organisms to stick to nasopharyngeal epithelium from where they can be endocytosed and reach the circulation. Bacteraemia results, and may lead to acute meningococcaemia and subsequently meningitis if organisms lodge in the meninges. Late complications may take place as the bacterial antigen begins to clear from the circulation and include vasculitis and arthropathy, which are thought to be due to immune-complex deposition. Chronic meningococcaemia is characterised by persistence of the bacterium in the blood and may also lead to immune-complex mediated damage. Patients usually present with a fever and rash, and a recent report emphasises the pitfalls in diagnosis on this rare condition.! 3 cases are described. All patients had fever, rash, and joint involvement (arthralgia or arthritis). Blood cultures were negative m all cases; in 2 patients these results led to a diagnosis of phenytoin-induced lupus and disseminated gonococcal infection, respectively. In the former case, prednisolone was given for nine days and it was only after 32 days of illness that blood cultures finally became positive for the meningococcus. Similarly, in the second case, positive blood cultures were first shown only after 11 days. All patients were eventually treated successfully with intravenous penicillin. Chronic meningococcaemia represents a balance-between the load of bacterium and attempted immune clearanceproducing negative blood cultures but persisting infection. Any patient with a fever, vasculitic rash, and joint symptoms merits a therapeutic trial with intravenous penicillin. Delay could be fatal.
infecting
1 Jennens ID O’Reilly M, Yung AP
Chronic meningococcal disease. Med
J Aust 1990;
Now
My Uncle Jimmy is the salt of the earth, with one major obsession-fishing. His dedication to this art takes him to his for salmon whenever the on-call rota of the weather or other commitments, and allows, irrespective with essentials to his comfort, notably several cans of complete lager, a picnic lovingly prepared by my Aunt Jeannie (glad to have him out from under her feet), and a bottle of claret "to wet the fish’s head". But the past two dry summers have been ruinous for the fishing- to the uninitiated that means that the river has been so low that the salmon are not running, and the catches have dropped from 1 or 2 a session to nil. Never beaten by such adversity, Uncle Jimmy spotted an ad in a local paper, and being an enterprising sort of chap where fishing is concerned, wrote off for details of a hotel with fishing rights "going cheap". Imagine the dismay with which he received this reply from the proprietor of a firm of "auctioneers, exporters, grocers, victuallers, dairymen, and livestock salesmen": "I herewith enclose snap and particulars of Hotel, now demolished as requested (sic). The building itself is in perfect condition, especially on the outside, little requires to be done with it. Also chimneys are good. The inside requires plastering because during removal of roof, floor, windows and doors damage was done. There is an 18-hole golf course when the tide is out. Inspection is necessary before you could really believe such a bargain, and I confidently advise immediate action as reserve has been overreached"-and not a word about the fishing. to cast
...
International Diary
JP. Revenge of the barbecue grill. WestJ Med 1990,
Chronic meningococcaemia
153: 556-59
at
favourite reaches
Beware the barbecue
gastroenteritis
Mr Michael Masser
1991 A symposium on New Neonatal Infections and Changes in Therapy will take place in London on Friday, May 17: Symposium Secretary, Royal Postgraduate Medical School, Institute of Obstetrics and Gynaecology, Queen Charlotte’s and Chelsea Hospital, Goldhawk Road, London W6 OXG
(081-7403904). 2nd international symposium on Neuroblastoma Screening will take place in Minnesota on May 22-24: Continuing Medical Education, University of Minnesota, Box 202 UMHC, 420 Delaware Street SE, Minneapolis, MN 55455, USA (612-626 7600). A workshop on Contrast Enhanced Magnetic Resonance is to be held in California on May 23-25: Society of Magnetic Resonance in Medicine, 1918 University Avenue, Suite 3C, Berkeley, California 94704, USA
(415-841 1899). 9th international meeting entitled Updates in Anesthesia and Intensive Care will take place in Pans on May 24-25: MAPAR, Hopital de Bicetre, 78 rue de General Leclerc, 94275 Le Kremlin Bicetre Cedex, France
(33-1 45 21 34 29). A course on Critical Issues in Tumor Microcirculation, Angiogenesis, and Metastasis-Biological Significance and Clinical Relevance is to take place in Pittsburgh on June 3-7: R. Hilda Diamond, Associate Director, Biomedical Engineering Program, Carnegie Mellon University, Pittsburgh, Pennsylvania 15213, USA (412-268 2521).
3rd international congress on Pancreatic and Islet Transplantation and symposium on Artificial Insulin Delivery Systems will take place in Lyon on June 6-8: Administrative Secretary, Package Organization, 45 rue Ste-Genevieve, 69006 Lyon, France (33-78 24 18 06). 7th international conference on AIDS is to be held in Florence, Italy, on June 16-21: General Secretariat, Laboratory of Virology, Istituto Superiore di Sanita’, Viale Regina Elena 299, 00161 Rome, Italy (39-6 4457888). 8th international congress on Group Medicine will take place in Helsinki June 24-26: Dr Antti Jaattela, President of the Congress and Finnish Association of Private Medical Centers, PO Box 63,00501 Helsinki, Finland. on
Noticeboard La peste "From dark corners, from basements, from cellars, from sewers, they came up in long tottering lines to stagger at the light, turn round and die near men... you might have thought that the very earth on which our houses stood was purging itself, allowing boils and pus, which until then have been at work
inside, to come to the surface".-Albert Camus Plague is endemic but intrudes into human existence only if unprotected individuals stray into the natural habitat of the host
(rodent), organism (Yersinia pestis), 47-year-old female biologist, who had
or a
A
(flea). primary plague vector
immunisation series in 1957 with boosters up to 1971, went to Bolivia on May 18, 1990. She camped in rural regions and collected small mammals, including rice rats, which were killed with a barbiturate (’Nembutal’) and then skinned. While completing this procedure she crushed fleas between her fingers. Nembutal leaves fleas unharmed. On June 14 she returned to La Paz with fever and sweats, together with painful swelling in her right axilla. A respiratory tract infection was diagnosed on June 17 and, despite intramuscular ampicillin, a dry cough developed; by June 20 (after arrival back in the District of Columbia, USA) she had a 25 cm right axillary lymph node. Culture of lymph node aspirates confirmed Y pestis. She was treated with intramuscular streptomycin (1 g twice daily) and was discharged on June 26 with an additional ten days of streptomycin. Plague continues to remain a threat in the 20th century. In 1989, 770 cases were reported from 11 countries. Since infection commonly takes place far away from a plague reference laboratory, a clinical diagnosis is often essential to allow early treatment and so prevent death. Local outbreaks demand public education campaigns to emphasise personal hygiene. Insecticides must be distributed to kill fleas, and patient contacts should be treated with tetracycline. The theme of plague was developed by Camus as an allegory for French involvement in Algeria. Yet his vivid descriptions of symptoms, routes of spread, the natural history of Ypestis, and the resultant human misery should be required reading for all those with an interest in infectious diseases. 1 Centers for Disease Control.
MMWR
Imported
bubonic
plague—District
of Columbia.
1989; 39: 895-901.
Treatment of chemical warfare
injuries
The Working Party on Chemical and Biological Weapons, in response to requests for information from members of the medical profession concerned at the possibility of having to treat victims of attack by chemical agents during the Gulf war, has issued a guide to the types of chemical agents that may be encountered during the conflict in the Middle East.1 The report considers three groups of agents, classified according to their physiological effects-nerve agents, blister agents (vesicants), and blood agents. Nerve agents, which are colourless, tasteless chemicals belonging to the same family of compounds as the organophosphorus pesticides, can kill quickly and are more potent than any other chemicals except toxins. Examples are tabun, sarin, soman, and VX. Blister agents, such as mustard gas and lewisite, bum and blister the skin within hours of exposure. Blood agents kill by interfering with oxygen uptake by the tissues. Hydrogen cyanide and cyanogen chloride are examples. The report summarises the symptoms caused by chemical agents, any delayed or long-term effects, and appropriate treatment. The guidelines emphasise that chemical warfare casualties, especially those injured by mustard gas, may need a long period of care, followed by
be hazardous-eg, the use of large quantities of water (not suitable for mustard gas) can contaminate the water run-off area. Some agents persist in the ground, in vegetation, and in buildings for weeks or months. Another useful document is a bibliography on the treatment of biological and chemical warfare injuries, assembled by the British Library’s medical information service.2 Sources include Government research reports, conference reports, and reprints from medical journals. The library can also provide copies of the source documents. can
lengthy convalescence.
Though classified according to their predominant effects, agents from all three groups can affect several body systems. Nerve gases, for instance, can have bronchopulmonary, gastrointestinal, urinary, cardiovascular, glandular, ocular, central nervous system, and muscular effects, and treatment may need to be directed at blockade of excess acetylcholine, ventilation, and reversal of acetylcholinesterase inhibition. Decontamination or neutralisation
Working Party on Chemical and Biological Weapons, Landfall, Tregullon, Bodmin, Cornwall PL30 5BH (tel 0208 831401, fax 0208 831678) 2. Available from the British Library, 96 Euston Road, London NW2 2DB (tel 071-323 7111, fax 071-323 7268). 1. Medical effects of chemical warfare agents.
Citation failures Citation rates have become a sport-a gold medal for a "citation classic" and lesser awards for being able to list enough mentions to secure tenure or advancement or to keep the unit’s head above water for another year. We hear little of the holders of the wooden spoon. How about "uncitedness"? David Pendlebury, from the Institute for Scientific Information, Philadelphia, has turned non-citation into a specialty of its own.1 How often are papers, in different disciplines, uncited in the four years after publication? In this curious race physics wins (only 36-7% uncited), medicine comes fifth at 46-4%, between the geosciences and mathematics, and the booby prize goes to the arts and humanities, where only 2.0% of papers got a mention. Papers on the theatre and American literature achieved near perfection with uncitedness rates of 99-9% and 99-8%, respectively. Engineering did uniformly badly too. Happily, nobody really knows what any of these numbers mean. 1. Hamilton DP Research papers: who’s uncited now? Science
1991, 251: 25.
Organisation of pathology services Accuracy is well monitored but laboratories should widen their concept of quality, says an Audit Commission reportl on NHS pathology services, which in England and Wales employ over 23 000 staff and costs about 400 million a year to run. Quality control has been addressed by the Royal College of Pathologists, which has tested an accreditation scheme and is refining it for wider The Audit Commission report focuses on cost-effectiveness. Financial control is difficult because of the fragmented nature of laboratory budgets-which can come from health authorities, university, or the Public Health Laboratory Service, and which may be allocated specifically to overheads, capital equipment, salaries, or consumables. Moreover, the accounting procedures are designed to control expenditure rather than to give insight into how well resources are being deployed. The Commission has developed a system of costing individual investigations to help laboratories to identify where savings can be made. For costing staff time it uses the Welcan workload measurement system, developed initially in Canada, then adapted in Wales, for deriving standard times for doing specific tests (a set of standard Welcan measures has been calculated by the College together with other pathology bodies). The Commission takes care to point out when Welcan times may not be appropriate. The report describes options for improving cost-effective use of resources under three broad headings-management of demand, planning of workflow; and deployment of staff. Protocols that set out good practice guidelines on laboratory requests are one means of demand management, and the Commission has been invited to work with the Royal College of Pathologists to develop such guidelines. The Commission points out that even if it were to be financially advantageous for laboratories to undertake as many tests as possible, it remains good practice for laboratories to give advice on appropriateness of requests. Workflow can be improved by priority grading for different kinds of work. The aim should be to deliver results on time, not necessarily as soon as possible.
use.
231
Furthermore, the possibility of centralising services should be considered. The difficulties entailed in recruitment and retention of staff are recognised, and suggestions for coping with these include sharing resources between neighbouring sites, cross-disciplinary cover, a shift rather than an on-call system, and the re-design of the remuneration system. 1 Audit Commission The Pathology Services. a management review London:HM Stationery Office 1991. Pp 60 £8.50. ISBN 0-118860356
Although some may miss those seemingly far-off lazy summer evenings filled with the enticing aromas of gently sizzling food on a barbecue grill, a report from California shows how even life’s simple 1 pleasures may carry a sting in the tail. Four members of a family presented to hospital with headache, nausea, and abdominal pains and gave a history of drinking unrefrigerated milk the previous evening. A diagnosis of infective was
made,
given, and the patients
treatment
with intravenous fluids
was
discharged home. A few hours later four more members of the same family came to the hospital complaining of similar symptoms. The same diagnosis was made, the same treatment was given, and these patients were also discharged. Several hours passed again and four more family members were admitted, one reporting that she had not had any of the milk that was thought to be the source of the infection. A clear history was difficult to obtain, because the family were non-English speaking, but an interpreter was able to find that the family often were
the house. Measurement of in carboxyhaemoglobin (HbCO) the most recently admitted family members showed increased serum concentrations in three of the four. Treatment with 100% oxygen for 2 hours led to symptomatic improvement, and a fall in the HbCO was found in one patient. A subsequent visit to the family house revealed a barbecue grill in the middle of the living room.
cooked
over
charcoal
1. Gasman JD, Varon J, Gardner 153: 656-57
in
A memorial service for Mr Michael Masser, FRCS, will be held Salisbury Cathedral on Saturday, Jan 26, at 2.30 pm.
In
England
Meningococcal infection is caused by the gram-negative diplococcus, Neisseria meningitidis. Spread is commonly by respiratory droplets from symptom-free carriers. Pili enable these organisms to stick to nasopharyngeal epithelium from where they can be endocytosed and reach the circulation. Bacteraemia results, and may lead to acute meningococcaemia and subsequently meningitis if organisms lodge in the meninges. Late complications may take place as the bacterial antigen begins to clear from the circulation and include vasculitis and arthropathy, which are thought to be due to immune-complex deposition. Chronic meningococcaemia is characterised by persistence of the bacterium in the blood and may also lead to immune-complex mediated damage. Patients usually present with a fever and rash, and a recent report emphasises the pitfalls in diagnosis on this rare condition.! 3 cases are described. All patients had fever, rash, and joint involvement (arthralgia or arthritis). Blood cultures were negative m all cases; in 2 patients these results led to a diagnosis of phenytoin-induced lupus and disseminated gonococcal infection, respectively. In the former case, prednisolone was given for nine days and it was only after 32 days of illness that blood cultures finally became positive for the meningococcus. Similarly, in the second case, positive blood cultures were first shown only after 11 days. All patients were eventually treated successfully with intravenous penicillin. Chronic meningococcaemia represents a balance-between the load of bacterium and attempted immune clearanceproducing negative blood cultures but persisting infection. Any patient with a fever, vasculitic rash, and joint symptoms merits a therapeutic trial with intravenous penicillin. Delay could be fatal.
infecting
1 Jennens ID O’Reilly M, Yung AP
Chronic meningococcal disease. Med
J Aust 1990;
Now
My Uncle Jimmy is the salt of the earth, with one major obsession-fishing. His dedication to this art takes him to his for salmon whenever the on-call rota of the weather or other commitments, and allows, irrespective with essentials to his comfort, notably several cans of complete lager, a picnic lovingly prepared by my Aunt Jeannie (glad to have him out from under her feet), and a bottle of claret "to wet the fish’s head". But the past two dry summers have been ruinous for the fishing- to the uninitiated that means that the river has been so low that the salmon are not running, and the catches have dropped from 1 or 2 a session to nil. Never beaten by such adversity, Uncle Jimmy spotted an ad in a local paper, and being an enterprising sort of chap where fishing is concerned, wrote off for details of a hotel with fishing rights "going cheap". Imagine the dismay with which he received this reply from the proprietor of a firm of "auctioneers, exporters, grocers, victuallers, dairymen, and livestock salesmen": "I herewith enclose snap and particulars of Hotel, now demolished as requested (sic). The building itself is in perfect condition, especially on the outside, little requires to be done with it. Also chimneys are good. The inside requires plastering because during removal of roof, floor, windows and doors damage was done. There is an 18-hole golf course when the tide is out. Inspection is necessary before you could really believe such a bargain, and I confidently advise immediate action as reserve has been overreached"-and not a word about the fishing. to cast
...
International Diary
JP. Revenge of the barbecue grill. WestJ Med 1990,
Chronic meningococcaemia
153: 556-59
at
favourite reaches
Beware the barbecue
gastroenteritis
Mr Michael Masser
1991 A symposium on New Neonatal Infections and Changes in Therapy will take place in London on Friday, May 17: Symposium Secretary, Royal Postgraduate Medical School, Institute of Obstetrics and Gynaecology, Queen Charlotte’s and Chelsea Hospital, Goldhawk Road, London W6 OXG
(081-7403904). 2nd international symposium on Neuroblastoma Screening will take place in Minnesota on May 22-24: Continuing Medical Education, University of Minnesota, Box 202 UMHC, 420 Delaware Street SE, Minneapolis, MN 55455, USA (612-626 7600). A workshop on Contrast Enhanced Magnetic Resonance is to be held in California on May 23-25: Society of Magnetic Resonance in Medicine, 1918 University Avenue, Suite 3C, Berkeley, California 94704, USA
(415-841 1899). 9th international meeting entitled Updates in Anesthesia and Intensive Care will take place in Pans on May 24-25: MAPAR, Hopital de Bicetre, 78 rue de General Leclerc, 94275 Le Kremlin Bicetre Cedex, France
(33-1 45 21 34 29). A course on Critical Issues in Tumor Microcirculation, Angiogenesis, and Metastasis-Biological Significance and Clinical Relevance is to take place in Pittsburgh on June 3-7: R. Hilda Diamond, Associate Director, Biomedical Engineering Program, Carnegie Mellon University, Pittsburgh, Pennsylvania 15213, USA (412-268 2521).
3rd international congress on Pancreatic and Islet Transplantation and symposium on Artificial Insulin Delivery Systems will take place in Lyon on June 6-8: Administrative Secretary, Package Organization, 45 rue Ste-Genevieve, 69006 Lyon, France (33-78 24 18 06). 7th international conference on AIDS is to be held in Florence, Italy, on June 16-21: General Secretariat, Laboratory of Virology, Istituto Superiore di Sanita’, Viale Regina Elena 299, 00161 Rome, Italy (39-6 4457888). 8th international congress on Group Medicine will take place in Helsinki June 24-26: Dr Antti Jaattela, President of the Congress and Finnish Association of Private Medical Centers, PO Box 63,00501 Helsinki, Finland. on