- Email: [email protected]
TAKING CORONARY CARE TO THE PATIENT
1145 mental S.M.O.N. commission and a virus expert of the National Institute of Health protested in a newspaper interview against the court’s hint of the possibility that a virus might be another cause of S.M.O.N. in addition to clioquinol. An editorial in Japan Times (March 4) said that the Kanazawa court decision "may be viewed as a vital milestone in the history of pharmaceutical administration in Japan" and that "the ruling is likely to have a far-reaching impact on other suits that are either pending or likely to occur... Another area it will inevitably affect is legislation ... the revised law should be more specific in spelling out the responsibilities of both the Government and pharmaceutical companies in approving the manufacture and marketing of drugs". Some 20 S.M.O.N. law suits are still in progress in Japan. The court decisions in Tokyo and Fukuoka are expected by June this year. The number of plaintiffs exceeds 4000. However, there are probably 20 000 S.M.O.N. victims in Japan. Clioquinol is still marketed around the world despite reports of S.M.O.N. from many countries outside Japan. Many of the manufacturers have still not given adequate warnings about clioquinol nor have they provided sound evidence of its therapeutic value in relation to the risks of irreversible and severe nerve damage.2 A growing opinion4 is now urging a worldwide ban on clioquinol. As a result of the Kanazawa court decision lawyers representing the Japanese S.M.O.N. patients have started an international campaign against clioquinol.
United States INTEGRATION CUTS BOTH WAYS
The verdict in the Bakke cases still has to emerge from the lucubrations of the Supreme Court, but portents of a storm can be seen. The Equal Employment Opportunity Commissioner has made her view clear: "neither the set-aside places of the Bakke case nor the occasional quotas court orders are central to affirmative action". This claim brought immediate protests from certain groups and individuals who were not impressed by the accompanying statement that "affirmative action is far more complicated, more subtle and more effective than an occasional quota case". In fact, recent reports of a reduction in the income differentials between Black and White males ascribe the change not to affirmative action but to better education. Better education is the route taken by others of the under-privileged in this country and it is encouraging that it seems to be paying off. But the way is hard in Black education, and affirmative action cuts both ways. The Administration is taking action in North Carolina to get more Black students and teachers into the predominantly White State university set-up. In Alabama, a federal judge has cracked down on the Alabama State University because it was found to have only 36 White teachers on its 196-strong faculty and 4 Whites in its 56 administrative officers, while 12 White faculty members stated they had been dismissed on grounds of race. There was no doubt that this Black university was guilty of blatant racial discrimination and the judge ruled that it should immediately put a stop to its "pattern and practice of discrimination against whites" in recruiting staff. More lies behind the decision than at first sight appears. The universities and colleges which were White preserves have been forced to integrate, both staff and students. There are many Black colleges in the South which have long struggled to provide college education for the Black people in the then segre-
gated States, a struggle marked by many successes, of which they can be justifiably proud, especially considering the often very limited backing they received both from official and unofficial
The easiest way for the White universities to integrate was to poach staff and students from the Black colleges. The more successful this poaching was, the worse the situation has become for the Black colleges, robbed of their best students and staff. It is an open question if such institutions can survive desegregation and compete against the larger and better financed higher educational facilities. 5. ibid. 1977, i, 1139. sources.
Letters
to
the Editor
TAKING CORONARY CARE TO THE PATIENT
SIR,-Observations on patients with acute myocardial infarction outside hospital from both sides of the Atlantic, not cited by Dr Hill and his colleagues (April 22, p. 838), are relevant to cost/benefit analysis in this area.I-7 Our data’-4 not only support the Nottingham team’s contention that, for certain patients, admission to hospital carries little advantage in terms of mortality but also suggest that care outside hospital is the major determinant of outcome. The Nottingham cardiac ambulance team favourably influenced both randomised and unrandomised groups. However, we do not agree that mortality from myocardial infarction in the community has not changed with pre-hospital coronary care and that such a service is expensive. We have added the year 1976 to our analysisl-4 in a district of 2068 km2 incorporating a city of 40 000 and a suburbanrural county of 40 000 within a radius of 29 km from our hospital. We provided care, before hospital admission, to 172 patients with proven acute myocardial infarction: 33 (19%) needed resuscitation, 30 D.c. shock for centricular fibrillation, 5 precordial "thump" version, and 3 fist pacing. 152 (88%) lived and 20 (12%) died; 9 (5%) had cardiogenic shock. 22 (67%) of the 33 who were promptly resuscitated (<5 min) outside hospital resumed active life in the community, including 18 (67%) of 27 aged 30-69. In the 5 years preceding introduction of pre-hospital coronary care 84 (30%) of 282 coronary deaths outside hospital took place in the presence of emergency personnel answering 15 369 ambulance calls.2 In the 4 years (1971-73, and 1976) 26 (13%) of 194 coronary deaths occurred during 14 792 ambulance calls. Coronary death at the ambulance interface thus fell by 67% (P<10); resuscitation outside hospital yearly saved 15 lives long-term per 100 000 people aged 30-69 years. Coronary deaths fell by 20% outside hospital (p=0.02), by 18-5% (P=0-002) in the community, and by 14% in hospital (not significant). The 5% frequency of shock indicated lowered
morbidity.
of our reduced community coronary death-rate be ascribed to the life-saving efforts of our mobile team. However, in 1973 and 1976, lives saved by pre-hospital care could not, by themselves, account for reduction of deaths. We assumed that coronary deaths had declined spontaneously in our community alone (they rose by 6% in the rest of Virginia 4) or that early pre-hospital care had averted an undeterminable number of cardiac arrests, deaths, and cardiac invalids by permitting prompt relief of pain and abolition of dysrrhythmias and rapid reduction of the s-T segments of acute cardiac injury.’-5 Such treatment may also have prevented shock.5 (Incidentally why did the general practitioners in Nottingham not carry the inexpensive British miniature defibrillator (’Pantridge 280’, Cardiac Recorders, London]5 and drugs to stabilise rhythm’-5 along with their drugs for pain relief and heart-failure ? Doctors in the U.S.A. have enlarged their armamentarium in this way and have improved early care outside A quarter
can
hospital.1,3,4) We calculated the extra ambulance costs ascribable to the of pre-hospital coronary care and used a theoretical calculation for vlue of a life saved.6 At 1976 figures our yearly
provision
1. 2.
Crampton, R. S., Aldrich, R. F., Gascho, J. A. Lancet, 1974, i, 1106. Crampton, R. S., Michaelson, S. P., Aldrich, R. F., Gascho, J. A. ibid. 1974, ii, 101. 3. Crampton, R. S., Aldrich, R. F., Gascho, J. A., Miles, J. R., Stillerman, R. Am. J. Med. 1975, 58, 151. 4. Crampton, R. S. in Current Cardiovascular Topics: Acute Myocardial Infarction (edited by E. Donoso and J. Lipski); p. 27. New York, 1978. 5. Pantridge, J. F., Adgey, A. A. J., Geddes, J. S., Webb, S. W. The Acute Coronary Attack. London, 1975. 6. Sidel, V. W., Acton, J., Lown, B. Am. J. Cardiol. 1969, 24, 674.
1146 extra
ambulance
costs
were$13 544 while yearly life-saves
ted$422 626 per 100 000 people aged 30-69,4
a
net-
cost/benefii
ratio of 1 to 32. We have not had a major accident in over 2000 cardiac ambulance calls, even though winters in Piedmont Virginia arc far worse than they are in Nottingham. We share their disappointment at the rate of long-term survival after resuscitatior outside hospital; this was much lower than rates reported frorr.
Belfast, Ballymena, Dublin, Edinburgh, Brighton, Seattle, and
Charlottesville.3 In Seattle over three-quarters of patients dismissed from hospital after pre-hospital removal of ventriculal fibrillation were alive 3 years later.’7 We believe that intensive care of patients with acute myocardial infarction outside hospital-whether it is rendered by a cardiac ambulance team or by a specially trained and equipped family doctor-reduces community mortality. Cardiology Division and Emergency Medical Service, University of Virginia, Charlottesville, Virginia 22901, U.S.A.
RICHARD CRAMPTON JOSEPH GASCHO EARL MARTIN
FATTY ACIDS AND ISCHÆMIC HEART-DISEASE
SIR,-Dr Logan and his colleagues in Edinburgh and Stock(May 6, p. 949) have identified several factors which
holm
the mortality-rate from ischasmic heart-disthan three times greater in Edinburgh men. Among these factors are striking differences in the relative linoleic-acid content of plasma-triglycerides and of plasma-cholesterol esters, with lower levels in the Edinburgh men. Adipose tissue in the Edinburgh men had a lower polyunsaturated/ saturated (P/S) fatty-acid ratio and a strikingly lower relative linoleic-acid content. We agree that these findings are almost certainly due to differences in the diet between these populations and may be indicative of their basic susceptibility to atherosclerosis and to ischaemic heart-disease. We would like to report the findings of a dietary intervention study which seems relevant to the findings of the Edinburgh/Stockholm study. Men aged 40-49 working in two Government departments in London participated in a study aimed at changing their
might explain why ease
7.
is
more
Cobb, L. A., Baum, R. S., Alvarez, H. A., Schaffer, W. A. Circulation, 1975, 52, suppl. III, p. 223. EFFECT OF INCREASING DIETARY
intake of saturated and polyunsaturated fatty acids.l,2 Their diets were measured by means of a 7-day weighed record, after which one group was given simple dietary recommendations while the other received no advice and acted as the control group. The recommendations were aimed at achieving a dietary P/S ratio of 0.8 and actually achieved approximately 0.6. After 4 months, the men in both groups again carried out a 7-day weighed record of their diet. Blood-samples were taken before and after each of the 7-day dietary survey periods and among many measurements made, plasma-cholesterol esters and triglyceride fatty acids were analysed by chromatography (Prof. T. Pilkington, St. George’s Hospital). The fatty-acid content of the diets was estimated from tables of food composi-
dietary
tion.3 The table shows that the London Civil Servants in the diet group before changes were made and in the control group on both occasions were strikingly similar to the Edinburgh men in terms of the relative linoleic-acid content of both plasmacholesterol esters_and plasma-triglycerides. After the change in diet made by the diet group, the plasma-lipid composition is strikingly similar to that reported by Logan et al. in Stockholm men. Serum-cholesterol levels were not significantly different in the Edinburgh and Stockholm men. In our study, the dietary change over the 4-month period was associated with a 10% mean decrease in serum-cholesterol in the diet group. If it is considered desirable to possess the plasma-lipid fatty-acid composition seen in the Stockholm men, it is evident that this can be achieved relatively easily in middle-aged men in Britain. In the Seven Countries Study by Keys et al.,4 the dietary P/S ratio showed a consistent relationship to the incidence of coronary heart-disease. Crude information from twenty countries, using F.A.O. and W.H.O. data, showed a relationship between P/S ratio and mortality from C.H.D.5 Examining this data, we have suggested that a dietary P/S ratio of 05-0.6 might be a reasonable community objective in countries such as the U.K., U.S.A., or Finland.6 Such P/S ratios are associ-
A. G., Marr, J. W. in Lipid Metabolism and Atherosclerosis; p. 43. Amsterdam, 1973. 2. Marr, J. W., Shaper, A. G. Nutrition, 1974, 28, 372. 3. Hilditch, T. P., Williams, P. N. in The Chemical Constitution of Natural Fats. London, 1964. 4. Keys, A. Circulation, 1970, 41, suppl. no. 1. 5. Stamler, J., Stamler, R., Shekelle, R. B. in Ischæmic Heart Disease (edited by J. H. de Haas, H. C. Hemker, and H. A. Snellen); p. 84. London, 1970. 6. Shaper, A. G., Marr, J. W. Br. med. J. 1977, i, 867. 1.
P/S
Shaper,
RATIO ON PLASMA-LIPIDS
United States INTEGRATION CUTS BOTH WAYS
The verdict in the Bakke cases still has to emerge from the lucubrations of the Supreme Court, but portents of a storm can be seen. The Equal Employment Opportunity Commissioner has made her view clear: "neither the set-aside places of the Bakke case nor the occasional quotas court orders are central to affirmative action". This claim brought immediate protests from certain groups and individuals who were not impressed by the accompanying statement that "affirmative action is far more complicated, more subtle and more effective than an occasional quota case". In fact, recent reports of a reduction in the income differentials between Black and White males ascribe the change not to affirmative action but to better education. Better education is the route taken by others of the under-privileged in this country and it is encouraging that it seems to be paying off. But the way is hard in Black education, and affirmative action cuts both ways. The Administration is taking action in North Carolina to get more Black students and teachers into the predominantly White State university set-up. In Alabama, a federal judge has cracked down on the Alabama State University because it was found to have only 36 White teachers on its 196-strong faculty and 4 Whites in its 56 administrative officers, while 12 White faculty members stated they had been dismissed on grounds of race. There was no doubt that this Black university was guilty of blatant racial discrimination and the judge ruled that it should immediately put a stop to its "pattern and practice of discrimination against whites" in recruiting staff. More lies behind the decision than at first sight appears. The universities and colleges which were White preserves have been forced to integrate, both staff and students. There are many Black colleges in the South which have long struggled to provide college education for the Black people in the then segre-
gated States, a struggle marked by many successes, of which they can be justifiably proud, especially considering the often very limited backing they received both from official and unofficial
The easiest way for the White universities to integrate was to poach staff and students from the Black colleges. The more successful this poaching was, the worse the situation has become for the Black colleges, robbed of their best students and staff. It is an open question if such institutions can survive desegregation and compete against the larger and better financed higher educational facilities. 5. ibid. 1977, i, 1139. sources.
Letters
to
the Editor
TAKING CORONARY CARE TO THE PATIENT
SIR,-Observations on patients with acute myocardial infarction outside hospital from both sides of the Atlantic, not cited by Dr Hill and his colleagues (April 22, p. 838), are relevant to cost/benefit analysis in this area.I-7 Our data’-4 not only support the Nottingham team’s contention that, for certain patients, admission to hospital carries little advantage in terms of mortality but also suggest that care outside hospital is the major determinant of outcome. The Nottingham cardiac ambulance team favourably influenced both randomised and unrandomised groups. However, we do not agree that mortality from myocardial infarction in the community has not changed with pre-hospital coronary care and that such a service is expensive. We have added the year 1976 to our analysisl-4 in a district of 2068 km2 incorporating a city of 40 000 and a suburbanrural county of 40 000 within a radius of 29 km from our hospital. We provided care, before hospital admission, to 172 patients with proven acute myocardial infarction: 33 (19%) needed resuscitation, 30 D.c. shock for centricular fibrillation, 5 precordial "thump" version, and 3 fist pacing. 152 (88%) lived and 20 (12%) died; 9 (5%) had cardiogenic shock. 22 (67%) of the 33 who were promptly resuscitated (<5 min) outside hospital resumed active life in the community, including 18 (67%) of 27 aged 30-69. In the 5 years preceding introduction of pre-hospital coronary care 84 (30%) of 282 coronary deaths outside hospital took place in the presence of emergency personnel answering 15 369 ambulance calls.2 In the 4 years (1971-73, and 1976) 26 (13%) of 194 coronary deaths occurred during 14 792 ambulance calls. Coronary death at the ambulance interface thus fell by 67% (P<10); resuscitation outside hospital yearly saved 15 lives long-term per 100 000 people aged 30-69 years. Coronary deaths fell by 20% outside hospital (p=0.02), by 18-5% (P=0-002) in the community, and by 14% in hospital (not significant). The 5% frequency of shock indicated lowered
morbidity.
of our reduced community coronary death-rate be ascribed to the life-saving efforts of our mobile team. However, in 1973 and 1976, lives saved by pre-hospital care could not, by themselves, account for reduction of deaths. We assumed that coronary deaths had declined spontaneously in our community alone (they rose by 6% in the rest of Virginia 4) or that early pre-hospital care had averted an undeterminable number of cardiac arrests, deaths, and cardiac invalids by permitting prompt relief of pain and abolition of dysrrhythmias and rapid reduction of the s-T segments of acute cardiac injury.’-5 Such treatment may also have prevented shock.5 (Incidentally why did the general practitioners in Nottingham not carry the inexpensive British miniature defibrillator (’Pantridge 280’, Cardiac Recorders, London]5 and drugs to stabilise rhythm’-5 along with their drugs for pain relief and heart-failure ? Doctors in the U.S.A. have enlarged their armamentarium in this way and have improved early care outside A quarter
can
hospital.1,3,4) We calculated the extra ambulance costs ascribable to the of pre-hospital coronary care and used a theoretical calculation for vlue of a life saved.6 At 1976 figures our yearly
provision
1. 2.
Crampton, R. S., Aldrich, R. F., Gascho, J. A. Lancet, 1974, i, 1106. Crampton, R. S., Michaelson, S. P., Aldrich, R. F., Gascho, J. A. ibid. 1974, ii, 101. 3. Crampton, R. S., Aldrich, R. F., Gascho, J. A., Miles, J. R., Stillerman, R. Am. J. Med. 1975, 58, 151. 4. Crampton, R. S. in Current Cardiovascular Topics: Acute Myocardial Infarction (edited by E. Donoso and J. Lipski); p. 27. New York, 1978. 5. Pantridge, J. F., Adgey, A. A. J., Geddes, J. S., Webb, S. W. The Acute Coronary Attack. London, 1975. 6. Sidel, V. W., Acton, J., Lown, B. Am. J. Cardiol. 1969, 24, 674.
1146 extra
ambulance
costs
were$13 544 while yearly life-saves
ted$422 626 per 100 000 people aged 30-69,4
a
net-
cost/benefii
ratio of 1 to 32. We have not had a major accident in over 2000 cardiac ambulance calls, even though winters in Piedmont Virginia arc far worse than they are in Nottingham. We share their disappointment at the rate of long-term survival after resuscitatior outside hospital; this was much lower than rates reported frorr.
Belfast, Ballymena, Dublin, Edinburgh, Brighton, Seattle, and
Charlottesville.3 In Seattle over three-quarters of patients dismissed from hospital after pre-hospital removal of ventriculal fibrillation were alive 3 years later.’7 We believe that intensive care of patients with acute myocardial infarction outside hospital-whether it is rendered by a cardiac ambulance team or by a specially trained and equipped family doctor-reduces community mortality. Cardiology Division and Emergency Medical Service, University of Virginia, Charlottesville, Virginia 22901, U.S.A.
RICHARD CRAMPTON JOSEPH GASCHO EARL MARTIN
FATTY ACIDS AND ISCHÆMIC HEART-DISEASE
SIR,-Dr Logan and his colleagues in Edinburgh and Stock(May 6, p. 949) have identified several factors which
holm
the mortality-rate from ischasmic heart-disthan three times greater in Edinburgh men. Among these factors are striking differences in the relative linoleic-acid content of plasma-triglycerides and of plasma-cholesterol esters, with lower levels in the Edinburgh men. Adipose tissue in the Edinburgh men had a lower polyunsaturated/ saturated (P/S) fatty-acid ratio and a strikingly lower relative linoleic-acid content. We agree that these findings are almost certainly due to differences in the diet between these populations and may be indicative of their basic susceptibility to atherosclerosis and to ischaemic heart-disease. We would like to report the findings of a dietary intervention study which seems relevant to the findings of the Edinburgh/Stockholm study. Men aged 40-49 working in two Government departments in London participated in a study aimed at changing their
might explain why ease
7.
is
more
Cobb, L. A., Baum, R. S., Alvarez, H. A., Schaffer, W. A. Circulation, 1975, 52, suppl. III, p. 223. EFFECT OF INCREASING DIETARY
intake of saturated and polyunsaturated fatty acids.l,2 Their diets were measured by means of a 7-day weighed record, after which one group was given simple dietary recommendations while the other received no advice and acted as the control group. The recommendations were aimed at achieving a dietary P/S ratio of 0.8 and actually achieved approximately 0.6. After 4 months, the men in both groups again carried out a 7-day weighed record of their diet. Blood-samples were taken before and after each of the 7-day dietary survey periods and among many measurements made, plasma-cholesterol esters and triglyceride fatty acids were analysed by chromatography (Prof. T. Pilkington, St. George’s Hospital). The fatty-acid content of the diets was estimated from tables of food composi-
dietary
tion.3 The table shows that the London Civil Servants in the diet group before changes were made and in the control group on both occasions were strikingly similar to the Edinburgh men in terms of the relative linoleic-acid content of both plasmacholesterol esters_and plasma-triglycerides. After the change in diet made by the diet group, the plasma-lipid composition is strikingly similar to that reported by Logan et al. in Stockholm men. Serum-cholesterol levels were not significantly different in the Edinburgh and Stockholm men. In our study, the dietary change over the 4-month period was associated with a 10% mean decrease in serum-cholesterol in the diet group. If it is considered desirable to possess the plasma-lipid fatty-acid composition seen in the Stockholm men, it is evident that this can be achieved relatively easily in middle-aged men in Britain. In the Seven Countries Study by Keys et al.,4 the dietary P/S ratio showed a consistent relationship to the incidence of coronary heart-disease. Crude information from twenty countries, using F.A.O. and W.H.O. data, showed a relationship between P/S ratio and mortality from C.H.D.5 Examining this data, we have suggested that a dietary P/S ratio of 05-0.6 might be a reasonable community objective in countries such as the U.K., U.S.A., or Finland.6 Such P/S ratios are associ-
A. G., Marr, J. W. in Lipid Metabolism and Atherosclerosis; p. 43. Amsterdam, 1973. 2. Marr, J. W., Shaper, A. G. Nutrition, 1974, 28, 372. 3. Hilditch, T. P., Williams, P. N. in The Chemical Constitution of Natural Fats. London, 1964. 4. Keys, A. Circulation, 1970, 41, suppl. no. 1. 5. Stamler, J., Stamler, R., Shekelle, R. B. in Ischæmic Heart Disease (edited by J. H. de Haas, H. C. Hemker, and H. A. Snellen); p. 84. London, 1970. 6. Shaper, A. G., Marr, J. W. Br. med. J. 1977, i, 867. 1.
P/S
Shaper,
RATIO ON PLASMA-LIPIDS