- Email: [email protected]
TESTS FOR IMMIGRANT DOCTORS
1187
(1) Increasing pressure is quite rightly being exerted upon all teachers of medical students to restrict their activities to what is clinically relevant and educationally desirable. Only medical anatomists can fulfil the first of these criteria while maintaining the second. (2) There is very little alternative. A few pure science-graduates have applied themselves to the task of mastering the morphological sciences in relation to medicine while actually employed in anatomy departments. They have been guided by their medical colleagues and have successfully completed a very difficult assignment. It would, however, be extreme folly to believe that people of such quality will come forward in sufficient numbers to staff departments completely. Furthermore, who will be there to guide them in their early years when the last medical Dodo has gone ? In this context it must be stressed that the American solution of staffing departments with PH.D.S in anatomy is not applicable The American to the British situation as it presently stands. PH.D. involves course work and these graduates have received formal training in the anatomical sciences. Very few opportunities for educating similar individuals exist in this country and it would take some years and a major U.G.C. financial injection to provide the facilities. (3) Clinicians cannot take over anatomical teaching and research (except in a restricted applied sense) unless they spend a considerable proportion of their time in being morphological scientists. At junior levels it is difficult to see how this would be attractive to (say) a young man pursuing an academic surgical career. With appointments at the N.H.S. consultant level the logistic difficulties would be considerable and the fiscal implications would make this alternative unattractive to both D.H.S.S. and D.E.S. No-one can argue that a doctor no longer needs to be a range of anatomical sciences in the modern sense of the word. It seems to me that the only way to continue to bring relevant morphology to medical students is to reintroduce a financial incentive which will enable anatomy departments to function with a medical complement of about 50%. To those of us who, as teachers, have witnessed the fall in morale and increasing confusion within anatomy departments caused by a reluctance of the profession as a whole to examine precisely what it requires from anatomists, the need for action has long been apparent. We are approaching the point of no-return, for when the last doctors retire from anatomy departments the latter will become quite out of touch with medical education. Your comment " probably medical control of basic teaching in anatomy will have to be abandoned " (April 19, p. 903) could not be more misguided.
taught
’
CONSUMER REPRESENTATION IN HEALTH-CENTRE MANAGEMENT SiR,—Like Dr Tudor Hart and Dr Haines (March 8, p. 571), my colleagues and I believe that patients should have a voice in the running of the health centre, and we have in fact been successful in appointing a patient representative to our health-centre house committee. We felt that there was a tendency for professional people to become superior and dictatorial when insulated from direct confrontation with patients’ feelings regarding management problems. Although some people can speak out face-to-face to a doctor, on the whole they are frightened to say exactly what they think for fear of upsetting their relationship with their medical team, and possibly jeopardising their future care. Our main problem was to find a suitable person to fill the role of patient representative. The need is for someone detached from the professions who is known to be receptive to complaints and problems about the health centre, and is publicly known to be approachable; and who could present these problems to a professional committee in a sensible, detached, and forceful manner with a sympathetic understanding of both sides of the health service. We also preferred the person to be a patient registered at the health centre. Mrs Brenda Soper, our local Citizens’ Advice Bureau honorary organiser, fitted all our criteria, and she was unanimously voted as a full member in November, 1974. The committee appreciated that this was an experiment, the true value of which would probably only be seen after a considerable time, and for this reason no time-limit was suggested. The appointment was announced by a prominent notice in the health-centre waiting-room, and in the Citizens’ Advice Bureau office in the town. The C.A.B. staff are practised at assessing the importance and relevance of inquiries and complaints from the public, and this adds to their value. The committee is able to rely on them to bring valid complaints from genuinely worried patients. Since her appointment, Mrs Soper has been approached by patients concerned about the confidentiality of personal problems at the health-centre receptiondesk. This is a perennial and notoriously difficult problem, but renewed discussion has produced several ideas for improving the situation. We feel that patient representation on professional health-services committees is essential for the peaceful working together of all sides of the National Health Service. Didcot Health Centre House
Committee, Didcot, Oxon.
Department of Anatomy, University of Leicester, University Road,
Britwell Road,
J. F. P. ASBURY, Chairman.
FELIX BECK.
Leicester LE1 7RH.
TESTS FOR IMMIGRANT DOCTORS MEDICINE AND HEALTH : WHAT CONNECTION ?
SIR,-Iwas interested by Dr Mac Keith’s letter (April 26, p. 975) asking if Tanzania, Zambia, Mozambique, and Zaire share
western-style hospital. The Ministers Kenya, Lesotho, Malawi, Mauritius, Swaziland, Tanzania, Uganda, and Zambia in fact only last year exchanged a protocol agreeing to admit patients requiring specialist treatment to each other’s hospitals. With the support of the Commonwealth Secretariat they are also attempting to rationalise their medical and paramedical training facilities. These examples of rational priorities hardly outweigh the irrational " investment in prestige evident in some of these countries but, as Dr Mac Keith makes clear, if they sin it is in the best company. one
of Health of Botswana,
"
Commonwealth Secretariat,
Marlborough House, Pall Mall, London SW1Y 5HX.
V. K. KYARUZI.
SIR,-Dr Cole (April 26, p. 974) asks whether it is time for the General Medical Council to arrange for overseas graduates to have their qualifications examined before they leave their native land. It has always been possible for an overseas doctor who plans to come to this country to have his qualifications assessed by the Council before he leaves home. He can be told by correspondence whether his qualifications entitle him to full or provisional registration, or are recognised for temporary registration. But it has not proved possible to arrange to test overseas the doctor’s linguistic proficiency and professional competence to the extent now thought desirable. This will be carried out in the tests now being planned by the Temporary Registration Assessment Board which will begin in June for doctors applying for temporary registration for the first time. These tests include viva-voce sessions with selected medical examiners and it would be impracticable to arrange to hold these at a number of centres overseas. The Government’s entry clearance system will be used to ensure that doctors seeking entry to this country
1188 who will need them.
to
take these
tests are
eligible to
be admitted
to
General Medical Council, 44 Hallam Street, London W1N 6AE.
M. R. DRAPER, Registrar.
40-HOUR CONTRACT FOR JUNIOR HOSPITAL DOCTORS SiR,—We, members of the junior medical staff at Glasgow Royal Infirmary, should like to express our support for the sentiments in the letters of Dr Kerr and his colleagues (April 5, p. 796) and Dr Howell and his colleagues.1 We are apprehensive about the proposed contract for several reasons:
(1) The introduction of "units of medical time ", &c., will result in a restriction of individual freedom in the exercise of professional duties. (2) The new contract would require work done to be monitored. This may accelerate the trend to administrative and eventual external control of the profession. (3) Overtime payments weaken the case for better increases in basic salary. The Review Body are very unlikely to accept the proposed 40-hour working week of the new contract as equating with the basic salary now paid. (4) The move to a payment for " work done " contract can be effected only once and any short-term monetary gain would be quickly eroded by inflation. There is a danger that the increase in remuneration would restrict subsequent increases in basic
salary. (5) Recruitment
of medical staff to paraclinical posts, where a 40-hour week is usual, will be threatened. Salary differentials will lead to division within the profession. (6) There is no provision for teaching or research duties to qualify as " units of medical time ".
We believe that junior hospital doctors should consider these points carefully in relation to the proposed contract. DESMOND MURPHY COLIN M. FURNIVAL DUNCAN MACINTYRE D. M. WARD
J. F. MACKENZIE W. F. KEAN P. STROMBERG G. M. MCKENDRICK D. BROWN G. MCINTYRE B. L. DEVINE I. N. SCOBIE D. C. C. OWENS A. STRONG A. DOUGALL D. R. T. GUNDRY C. E. LANGAN M. M. BERRY D. E. MITCHELL M. H. DELANEY J. REILLY W. G. CAMPBELL K. R. PATEL A. SHENKIN
ALLAN PACK I. ROSS MCDOUGALL
P. R. BECK M. SMITH M. MCENANEY A. D. HOWIE A. MILNE A. K. HENDERSON G. BOYD I. D. HAY C. MCKILLOP J. H. MCKILLOP J. A. BURTON P. M. KYLE I. MACKENZIE K. A. McLAY B. F. O’REILLY J. CARLIN D. L. CITRIN M. J. SMYTH J. M. SIMMS H. J. G. BURNS D. HENRY
Royal Infirmary, Glasgow G4 0SF.
W. F. BREMNER J. L. H. C. THIRD R. G. MURRAY J. V. JONES G. LOWE R. STURROCK P. J. ROONEY A. L. C. McLAY B. F. BOYCE W. D. THOMPSON W. A. REID J. RODGER R. P. O’HARE K. A. FLEMING K. O’REILLY A. M. MCNICOL W. S. STOCKWELL N. M. PETTIGREW J. M. BELL A. HARVIE D. MORGAN M. W. WALKER H. D. PUNNYADASA J. F. WINCHESTER I. M. R. ROGERS.
SCREENING
SIR,-A brief reply to the three points made by Dr (May 3, p. 1030).
Bradshaw
(1) Most progress in medicine is made against the advice of establishment experts. And those of us with practical experience of screening are entitled to remain unimpressed by the views of Professor Holland and his colleagues. Professorial ivory towers have a habit of being remote from reality. 1. Br.
med. J. April 12, 1975, p. 90.
(2) What I meant by dilution of nursing was that intelligent " tender loving care " can replace much of what goes into looking after the sick and does not need a protracted training. Similarly, nurses can " dilute " doctors. (3) Yes, the computer does and can cover the ground in a more human way than the often more perfunctory interview in outpatients or surgery. It should not-but it often does. The outpatients were delighted to be asked background questions about themselves. It was their spontaneous reaction which in turn
delighted
us.
We all need to be much more flexible in the " who does what " argument and see that no-one wastes their time and skills doing things that can equally well be done by others-even a machine. Webb House, 210 Pentonville Road, London N1 9TA.
H. BERIC
WRIGHT,
Executive Director, BUPA Medical Centre.
SERUM-ALKALINE-PHOSPHATASE DURING MAINTENANCE HÆMODIALYSIS
SIR,-Liver impairment (" haemodialysis hepatitis "),1 skeletal changes (osteomalacia or osteitis fibrosa),2 and impaired absorption of calcium from the digestive tract3 are serious complications of regular dialysis for chronic terminal renal failure. De Broe et al. and Walker&a cute; reported increased concentrations of intestinal alkaline phosphatase in sera from patients on maintenance hsmodialysis. Such an increase may be related to the deranged divalent-ion (Ca2+) metabolism found in renal failure.’6 These studies prompted us to report our experience.7 In 25 patients with chronic terminal renal failure on maintenance haemodialysis the activity of alkaline phosphatase and its isoenzymes against the substrate p-nitrophenylphosphate was determined by a modified inactivation-inhibition method and by agar-gel electrophoresis/ The results were compared with the values in a control group of 124
subjects.
The activity of alkaline phosphatase and its isoenzymes was within normal limits in only four patients, who had no signs of bone or liver disease. These patients had all been on dialysis for less than six months. Serum-alkaline-phosphatase activity was increased in all the remaining patients. In 16 the increase was more than 42 units per litre (i.e.,
+2 S.D.). The activity of the liver isoenzyme
was increased in only with patients proved hepatobiliary disease alone or with coincident bone disease (40-9827-00 units per litre,
16
0.005).
p<
Bone isoenzyme activity was increased in 12 patients with bone involvement alone or with coincident liver disease (43-98 ±61-10 units per litre, P < 0-005). Duration of dialysis therapy and bone isoenzyme activity were positively correlated (p < 005). Bone-isoenzyme activity was increased only in patients who had been on dialysis treatment for more than six months. The activity of the intestinal isoenzyme of serum-alkalinephosphatase was significantly increased (13.55 ± 15.37 units per litre, p< 0-005) in patients with signs of bone disease and in those with signs of liver impairment when compared with the control group. An increase of more 1.
Hübner, K., Fassbinder, W., Koch, K. M., Schoeppe, W. Z. Gastroenterology, 1973, 11, 371. 2. Binswanger, U., Sherrard, D., Rich, C., Curtis, F. K. Nephron, 1973, 12, 1. 3. Coburn, J. W., Koppel, M. H., Brickman, A. S., Massry, S. G. Kidney Int. 1973, 3, 264. 4. De Broe, M. E., Bosteels, V., Wieme, R. J. Lancet, 1974, i, 753, 5. Walker, A. W. ibid. p. 866. 6. Letteri, J. M., Ellis, K. J., Orofino, D. P., Ruggieri, S., Asad, S. N., Cohn, S. H. Kidney Int. 1974, 6, 45. 7. Št&ebreve;p&a cute;n, J., Pilařová, T., Votrubová, O., Melicharová, D. Čas. Lek. česk. 1974, 113, 952. 8. Št&ebreve;p&a cute;n, J., Volek, V., Št&ebreve;p&a cute;n, J. Vnitř. Lék. 1972, 18, 1003.
(1) Increasing pressure is quite rightly being exerted upon all teachers of medical students to restrict their activities to what is clinically relevant and educationally desirable. Only medical anatomists can fulfil the first of these criteria while maintaining the second. (2) There is very little alternative. A few pure science-graduates have applied themselves to the task of mastering the morphological sciences in relation to medicine while actually employed in anatomy departments. They have been guided by their medical colleagues and have successfully completed a very difficult assignment. It would, however, be extreme folly to believe that people of such quality will come forward in sufficient numbers to staff departments completely. Furthermore, who will be there to guide them in their early years when the last medical Dodo has gone ? In this context it must be stressed that the American solution of staffing departments with PH.D.S in anatomy is not applicable The American to the British situation as it presently stands. PH.D. involves course work and these graduates have received formal training in the anatomical sciences. Very few opportunities for educating similar individuals exist in this country and it would take some years and a major U.G.C. financial injection to provide the facilities. (3) Clinicians cannot take over anatomical teaching and research (except in a restricted applied sense) unless they spend a considerable proportion of their time in being morphological scientists. At junior levels it is difficult to see how this would be attractive to (say) a young man pursuing an academic surgical career. With appointments at the N.H.S. consultant level the logistic difficulties would be considerable and the fiscal implications would make this alternative unattractive to both D.H.S.S. and D.E.S. No-one can argue that a doctor no longer needs to be a range of anatomical sciences in the modern sense of the word. It seems to me that the only way to continue to bring relevant morphology to medical students is to reintroduce a financial incentive which will enable anatomy departments to function with a medical complement of about 50%. To those of us who, as teachers, have witnessed the fall in morale and increasing confusion within anatomy departments caused by a reluctance of the profession as a whole to examine precisely what it requires from anatomists, the need for action has long been apparent. We are approaching the point of no-return, for when the last doctors retire from anatomy departments the latter will become quite out of touch with medical education. Your comment " probably medical control of basic teaching in anatomy will have to be abandoned " (April 19, p. 903) could not be more misguided.
taught
’
CONSUMER REPRESENTATION IN HEALTH-CENTRE MANAGEMENT SiR,—Like Dr Tudor Hart and Dr Haines (March 8, p. 571), my colleagues and I believe that patients should have a voice in the running of the health centre, and we have in fact been successful in appointing a patient representative to our health-centre house committee. We felt that there was a tendency for professional people to become superior and dictatorial when insulated from direct confrontation with patients’ feelings regarding management problems. Although some people can speak out face-to-face to a doctor, on the whole they are frightened to say exactly what they think for fear of upsetting their relationship with their medical team, and possibly jeopardising their future care. Our main problem was to find a suitable person to fill the role of patient representative. The need is for someone detached from the professions who is known to be receptive to complaints and problems about the health centre, and is publicly known to be approachable; and who could present these problems to a professional committee in a sensible, detached, and forceful manner with a sympathetic understanding of both sides of the health service. We also preferred the person to be a patient registered at the health centre. Mrs Brenda Soper, our local Citizens’ Advice Bureau honorary organiser, fitted all our criteria, and she was unanimously voted as a full member in November, 1974. The committee appreciated that this was an experiment, the true value of which would probably only be seen after a considerable time, and for this reason no time-limit was suggested. The appointment was announced by a prominent notice in the health-centre waiting-room, and in the Citizens’ Advice Bureau office in the town. The C.A.B. staff are practised at assessing the importance and relevance of inquiries and complaints from the public, and this adds to their value. The committee is able to rely on them to bring valid complaints from genuinely worried patients. Since her appointment, Mrs Soper has been approached by patients concerned about the confidentiality of personal problems at the health-centre receptiondesk. This is a perennial and notoriously difficult problem, but renewed discussion has produced several ideas for improving the situation. We feel that patient representation on professional health-services committees is essential for the peaceful working together of all sides of the National Health Service. Didcot Health Centre House
Committee, Didcot, Oxon.
Department of Anatomy, University of Leicester, University Road,
Britwell Road,
J. F. P. ASBURY, Chairman.
FELIX BECK.
Leicester LE1 7RH.
TESTS FOR IMMIGRANT DOCTORS MEDICINE AND HEALTH : WHAT CONNECTION ?
SIR,-Iwas interested by Dr Mac Keith’s letter (April 26, p. 975) asking if Tanzania, Zambia, Mozambique, and Zaire share
western-style hospital. The Ministers Kenya, Lesotho, Malawi, Mauritius, Swaziland, Tanzania, Uganda, and Zambia in fact only last year exchanged a protocol agreeing to admit patients requiring specialist treatment to each other’s hospitals. With the support of the Commonwealth Secretariat they are also attempting to rationalise their medical and paramedical training facilities. These examples of rational priorities hardly outweigh the irrational " investment in prestige evident in some of these countries but, as Dr Mac Keith makes clear, if they sin it is in the best company. one
of Health of Botswana,
"
Commonwealth Secretariat,
Marlborough House, Pall Mall, London SW1Y 5HX.
V. K. KYARUZI.
SIR,-Dr Cole (April 26, p. 974) asks whether it is time for the General Medical Council to arrange for overseas graduates to have their qualifications examined before they leave their native land. It has always been possible for an overseas doctor who plans to come to this country to have his qualifications assessed by the Council before he leaves home. He can be told by correspondence whether his qualifications entitle him to full or provisional registration, or are recognised for temporary registration. But it has not proved possible to arrange to test overseas the doctor’s linguistic proficiency and professional competence to the extent now thought desirable. This will be carried out in the tests now being planned by the Temporary Registration Assessment Board which will begin in June for doctors applying for temporary registration for the first time. These tests include viva-voce sessions with selected medical examiners and it would be impracticable to arrange to hold these at a number of centres overseas. The Government’s entry clearance system will be used to ensure that doctors seeking entry to this country
1188 who will need them.
to
take these
tests are
eligible to
be admitted
to
General Medical Council, 44 Hallam Street, London W1N 6AE.
M. R. DRAPER, Registrar.
40-HOUR CONTRACT FOR JUNIOR HOSPITAL DOCTORS SiR,—We, members of the junior medical staff at Glasgow Royal Infirmary, should like to express our support for the sentiments in the letters of Dr Kerr and his colleagues (April 5, p. 796) and Dr Howell and his colleagues.1 We are apprehensive about the proposed contract for several reasons:
(1) The introduction of "units of medical time ", &c., will result in a restriction of individual freedom in the exercise of professional duties. (2) The new contract would require work done to be monitored. This may accelerate the trend to administrative and eventual external control of the profession. (3) Overtime payments weaken the case for better increases in basic salary. The Review Body are very unlikely to accept the proposed 40-hour working week of the new contract as equating with the basic salary now paid. (4) The move to a payment for " work done " contract can be effected only once and any short-term monetary gain would be quickly eroded by inflation. There is a danger that the increase in remuneration would restrict subsequent increases in basic
salary. (5) Recruitment
of medical staff to paraclinical posts, where a 40-hour week is usual, will be threatened. Salary differentials will lead to division within the profession. (6) There is no provision for teaching or research duties to qualify as " units of medical time ".
We believe that junior hospital doctors should consider these points carefully in relation to the proposed contract. DESMOND MURPHY COLIN M. FURNIVAL DUNCAN MACINTYRE D. M. WARD
J. F. MACKENZIE W. F. KEAN P. STROMBERG G. M. MCKENDRICK D. BROWN G. MCINTYRE B. L. DEVINE I. N. SCOBIE D. C. C. OWENS A. STRONG A. DOUGALL D. R. T. GUNDRY C. E. LANGAN M. M. BERRY D. E. MITCHELL M. H. DELANEY J. REILLY W. G. CAMPBELL K. R. PATEL A. SHENKIN
ALLAN PACK I. ROSS MCDOUGALL
P. R. BECK M. SMITH M. MCENANEY A. D. HOWIE A. MILNE A. K. HENDERSON G. BOYD I. D. HAY C. MCKILLOP J. H. MCKILLOP J. A. BURTON P. M. KYLE I. MACKENZIE K. A. McLAY B. F. O’REILLY J. CARLIN D. L. CITRIN M. J. SMYTH J. M. SIMMS H. J. G. BURNS D. HENRY
Royal Infirmary, Glasgow G4 0SF.
W. F. BREMNER J. L. H. C. THIRD R. G. MURRAY J. V. JONES G. LOWE R. STURROCK P. J. ROONEY A. L. C. McLAY B. F. BOYCE W. D. THOMPSON W. A. REID J. RODGER R. P. O’HARE K. A. FLEMING K. O’REILLY A. M. MCNICOL W. S. STOCKWELL N. M. PETTIGREW J. M. BELL A. HARVIE D. MORGAN M. W. WALKER H. D. PUNNYADASA J. F. WINCHESTER I. M. R. ROGERS.
SCREENING
SIR,-A brief reply to the three points made by Dr (May 3, p. 1030).
Bradshaw
(1) Most progress in medicine is made against the advice of establishment experts. And those of us with practical experience of screening are entitled to remain unimpressed by the views of Professor Holland and his colleagues. Professorial ivory towers have a habit of being remote from reality. 1. Br.
med. J. April 12, 1975, p. 90.
(2) What I meant by dilution of nursing was that intelligent " tender loving care " can replace much of what goes into looking after the sick and does not need a protracted training. Similarly, nurses can " dilute " doctors. (3) Yes, the computer does and can cover the ground in a more human way than the often more perfunctory interview in outpatients or surgery. It should not-but it often does. The outpatients were delighted to be asked background questions about themselves. It was their spontaneous reaction which in turn
delighted
us.
We all need to be much more flexible in the " who does what " argument and see that no-one wastes their time and skills doing things that can equally well be done by others-even a machine. Webb House, 210 Pentonville Road, London N1 9TA.
H. BERIC
WRIGHT,
Executive Director, BUPA Medical Centre.
SERUM-ALKALINE-PHOSPHATASE DURING MAINTENANCE HÆMODIALYSIS
SIR,-Liver impairment (" haemodialysis hepatitis "),1 skeletal changes (osteomalacia or osteitis fibrosa),2 and impaired absorption of calcium from the digestive tract3 are serious complications of regular dialysis for chronic terminal renal failure. De Broe et al. and Walker&a cute; reported increased concentrations of intestinal alkaline phosphatase in sera from patients on maintenance hsmodialysis. Such an increase may be related to the deranged divalent-ion (Ca2+) metabolism found in renal failure.’6 These studies prompted us to report our experience.7 In 25 patients with chronic terminal renal failure on maintenance haemodialysis the activity of alkaline phosphatase and its isoenzymes against the substrate p-nitrophenylphosphate was determined by a modified inactivation-inhibition method and by agar-gel electrophoresis/ The results were compared with the values in a control group of 124
subjects.
The activity of alkaline phosphatase and its isoenzymes was within normal limits in only four patients, who had no signs of bone or liver disease. These patients had all been on dialysis for less than six months. Serum-alkaline-phosphatase activity was increased in all the remaining patients. In 16 the increase was more than 42 units per litre (i.e.,
+2 S.D.). The activity of the liver isoenzyme
was increased in only with patients proved hepatobiliary disease alone or with coincident bone disease (40-9827-00 units per litre,
16
0.005).
p<
Bone isoenzyme activity was increased in 12 patients with bone involvement alone or with coincident liver disease (43-98 ±61-10 units per litre, P < 0-005). Duration of dialysis therapy and bone isoenzyme activity were positively correlated (p < 005). Bone-isoenzyme activity was increased only in patients who had been on dialysis treatment for more than six months. The activity of the intestinal isoenzyme of serum-alkalinephosphatase was significantly increased (13.55 ± 15.37 units per litre, p< 0-005) in patients with signs of bone disease and in those with signs of liver impairment when compared with the control group. An increase of more 1.
Hübner, K., Fassbinder, W., Koch, K. M., Schoeppe, W. Z. Gastroenterology, 1973, 11, 371. 2. Binswanger, U., Sherrard, D., Rich, C., Curtis, F. K. Nephron, 1973, 12, 1. 3. Coburn, J. W., Koppel, M. H., Brickman, A. S., Massry, S. G. Kidney Int. 1973, 3, 264. 4. De Broe, M. E., Bosteels, V., Wieme, R. J. Lancet, 1974, i, 753, 5. Walker, A. W. ibid. p. 866. 6. Letteri, J. M., Ellis, K. J., Orofino, D. P., Ruggieri, S., Asad, S. N., Cohn, S. H. Kidney Int. 1974, 6, 45. 7. Št&ebreve;p&a cute;n, J., Pilařová, T., Votrubová, O., Melicharová, D. Čas. Lek. česk. 1974, 113, 952. 8. Št&ebreve;p&a cute;n, J., Volek, V., Št&ebreve;p&a cute;n, J. Vnitř. Lék. 1972, 18, 1003.