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TROPICAL MEGALOBLASTIC ANEMIA
337
calculated the saving in cost to the National Health Service which has resulted from our use of the X-ray service. We with the thought that a patient referred for treatment " a count as second attenddiagnosis already made should " ance (see table 11). We have not included negative X-rays in the costing, although it must be said that, if we had not been able to have the X-ray done at our own direct request, we should almost certainly have referred the patients to an outpatient department and the final figure for cost saving would have been higher. It is not necessary to set out the cost of X-rays done at our request since these would have otherwise have had to be done at the request of the hospital outpatient department. These costs therefore cancel
there are approximately half a million people in the Sheffield area. It seems, therefore, that each year E55,000 might be saved in Sheffield-or approximately E51 /4 million in England and Wales. By accepting the responsibility for treating these patients, the general practitioner will not only have to spend considerable time on their care, but will also have to accept the responsibility for prescribing for them. The pricing bureaux will have to appreciate that, as diagnostic services become more readily available, general-practitioner prescribing costs will rise.
out.
practice with
Since
we
saved El 10 in three months it is reasonable
to
that, at this rate, we shall probably save the Health Service E440 per year in this practice. These figures relate to a practice of 4000 patients and
assume
Conferences TROPICAL MEGALOBLASTIC ANEMIA Wellcome Trust Project SINCE 1961 the Wellcome Trust has sponsored a collaborative study of the pathogenesis of tropical megaloblastic anaemia (other than that associated with pregnancy) and its relation to tropical sprue. On July 19-23 the participating groups met in London at the Royal Army Medical College, Millbank, to discuss their findings. In Nairobi Dr. H. Foy and Dr. ATHENA KoNDi have confirmed that the severe megaloblastic anxmia which is so common there is not associated with intestinal malabsorption, and that tropical sprue does not occur in East Africa. The megaloblastic ansemia is principally due to folate deficiency, the cause of which may be defective intake, but there is no evidence on this point and the problem needs further investigation. In Singapore Lieut.-Colonel W. O’BRIEN and Lieut.Colonel N. W. J. ENGLAND (R.A.M.C.) studied 44 European patients with megaloblastic ansemia and 20 Asian patients with severe megaloblastic ansemia. As in East Africa, the megaloblastic anaemia was usually due to folate deficiency, but, in striking contrast to the results in Nairobi, megaloblastic anaemia in Europeans in Singapore was always associated with tropical sprue. The relationship between folate deficiency and tropical sprue was obscure. The deficiency itself does not cause tropical sprue, for severe folate deficiency occurs elsewhere without sprue. Nevertheless, treatment with folic acid cured the anaemia, and the manifestations of intestinal disorder in patients with acute sprue disappeared. There was also suggestive evidence that folate deficiency predisposes to tropical sprue. In all the patients studied in Singapore there was defective absorption of vitamin Bl2, but severe Bl2 deficiency did not develop at this early stage of the disease. Treatment with broad-spectrum antibiotics exacerbated the condition of patients with acute sprue. Dr. D. L. MOLLIN and Dr. C. C. BOOTH at the Postgraduate Medical School of London studied 13 patients with chronic tropical sprue. 7 had developed symptoms in the tropics which had persisted despite removal to a temperate climate. The other 6 gave no history of sprue in the tropics, but developed symptoms from six months to twenty-two years after leaving the Far East. These 6 either showed the classical picture of sprue with diarrhcea, or presented without intestinal symptoms but with megaloblastic anxmia and subacute combined degeneration of the cord due to severe B12 deficiency. The intestinal defect in these 13 patients resembled that observed in the more severe cases of acute sprue seen in
SUMMARY
is given of the experience, in a two-man 4000 patients, of the first three months of open access to an X-ray service. The saving in cost to the National Health Service is calculated and, by extrapolation, it is estimated that in the whole country E51/4 million might be saved in one year. An
account
Singapore. Unlike the Singapore cases, however, intestinal malabsorption often persisted despite treatment with folic acid or B12. The reason for this was uncertain, but it may be because they were untreated for a long time. In these patients the intestinal defect was reversed after varying periods of time by treatment with broad-spectrum antibiotics. Prof. S. J. BAKER at the Christian Medical College Hospital, Vellore, South India, studied 77 cases of megaloblastic anaemia. Widespread dietary deficiency of B12 in the area was probably one of the important factors influencing the pattern of anaemia there. In distinct contrast to the findings in East Africa, only 1 of the 77 patients had no clinical or laboratory evidence of intestinal malabsorption. Two-thirds of the patients were suffering from a syndrome which was similar either to that seen in Singapore or to the more chronic condition seen in London. One-third of the patients differed in that the intestinal defect was milder and the patients absorbed Bl2 normally. Whether the absence of Bl2 malabsorption was a reflection of the mildof the disease or was due to a difference in intestinal bacterial flora is uncertain and needs further investigation. It is of particular interest that a number of patients with the clinical picture of classical tropical sprue came from areas in which sprue was epidemic. The main findings of the joint study (to which we refer in an annotation on p. 329) are, therefore, that the megaloblastic anaemia of East Africa is not associated with intestinal malabsorption, whereas in Vellore and in Europeans in Singapore megaloblastic anaemia is almost always associated with tropical sprue. The features of tropical sprue as seen in Singapore, Vellore, and London appear to be the varying manifestations of a single syndrome of as yet unknown aetiology. ness
ASSOCIATION OF PHYSICIANS OF EAST AFRICA THE annual conference of the Association was held in Nairobi on June 23-26 and was opened by the Hon. J. D. OTIENDE, Minister for Health and Housing in the Kenya Government. We give here points from some of the contributions. Prof. A. S. DOUGLAS (Kenya/Glasgow) demonstrated by serial angiography the technique of thrombus formation in a Chandler’s tube and described the effects of anticoagulant therapy and streptokinase on platelet aggregation during thrombus formation. Streptokinase disrupted the fibrin tail and the platelet head of the Chandler’s thrombus when the thrombus was placed in an artificial circulation. A study of clot lysis, clot strength, and platelet adhesiveness
calculated the saving in cost to the National Health Service which has resulted from our use of the X-ray service. We with the thought that a patient referred for treatment " a count as second attenddiagnosis already made should " ance (see table 11). We have not included negative X-rays in the costing, although it must be said that, if we had not been able to have the X-ray done at our own direct request, we should almost certainly have referred the patients to an outpatient department and the final figure for cost saving would have been higher. It is not necessary to set out the cost of X-rays done at our request since these would have otherwise have had to be done at the request of the hospital outpatient department. These costs therefore cancel
there are approximately half a million people in the Sheffield area. It seems, therefore, that each year E55,000 might be saved in Sheffield-or approximately E51 /4 million in England and Wales. By accepting the responsibility for treating these patients, the general practitioner will not only have to spend considerable time on their care, but will also have to accept the responsibility for prescribing for them. The pricing bureaux will have to appreciate that, as diagnostic services become more readily available, general-practitioner prescribing costs will rise.
out.
practice with
Since
we
saved El 10 in three months it is reasonable
to
that, at this rate, we shall probably save the Health Service E440 per year in this practice. These figures relate to a practice of 4000 patients and
assume
Conferences TROPICAL MEGALOBLASTIC ANEMIA Wellcome Trust Project SINCE 1961 the Wellcome Trust has sponsored a collaborative study of the pathogenesis of tropical megaloblastic anaemia (other than that associated with pregnancy) and its relation to tropical sprue. On July 19-23 the participating groups met in London at the Royal Army Medical College, Millbank, to discuss their findings. In Nairobi Dr. H. Foy and Dr. ATHENA KoNDi have confirmed that the severe megaloblastic anxmia which is so common there is not associated with intestinal malabsorption, and that tropical sprue does not occur in East Africa. The megaloblastic ansemia is principally due to folate deficiency, the cause of which may be defective intake, but there is no evidence on this point and the problem needs further investigation. In Singapore Lieut.-Colonel W. O’BRIEN and Lieut.Colonel N. W. J. ENGLAND (R.A.M.C.) studied 44 European patients with megaloblastic ansemia and 20 Asian patients with severe megaloblastic ansemia. As in East Africa, the megaloblastic anaemia was usually due to folate deficiency, but, in striking contrast to the results in Nairobi, megaloblastic anaemia in Europeans in Singapore was always associated with tropical sprue. The relationship between folate deficiency and tropical sprue was obscure. The deficiency itself does not cause tropical sprue, for severe folate deficiency occurs elsewhere without sprue. Nevertheless, treatment with folic acid cured the anaemia, and the manifestations of intestinal disorder in patients with acute sprue disappeared. There was also suggestive evidence that folate deficiency predisposes to tropical sprue. In all the patients studied in Singapore there was defective absorption of vitamin Bl2, but severe Bl2 deficiency did not develop at this early stage of the disease. Treatment with broad-spectrum antibiotics exacerbated the condition of patients with acute sprue. Dr. D. L. MOLLIN and Dr. C. C. BOOTH at the Postgraduate Medical School of London studied 13 patients with chronic tropical sprue. 7 had developed symptoms in the tropics which had persisted despite removal to a temperate climate. The other 6 gave no history of sprue in the tropics, but developed symptoms from six months to twenty-two years after leaving the Far East. These 6 either showed the classical picture of sprue with diarrhcea, or presented without intestinal symptoms but with megaloblastic anxmia and subacute combined degeneration of the cord due to severe B12 deficiency. The intestinal defect in these 13 patients resembled that observed in the more severe cases of acute sprue seen in
SUMMARY
is given of the experience, in a two-man 4000 patients, of the first three months of open access to an X-ray service. The saving in cost to the National Health Service is calculated and, by extrapolation, it is estimated that in the whole country E51/4 million might be saved in one year. An
account
Singapore. Unlike the Singapore cases, however, intestinal malabsorption often persisted despite treatment with folic acid or B12. The reason for this was uncertain, but it may be because they were untreated for a long time. In these patients the intestinal defect was reversed after varying periods of time by treatment with broad-spectrum antibiotics. Prof. S. J. BAKER at the Christian Medical College Hospital, Vellore, South India, studied 77 cases of megaloblastic anaemia. Widespread dietary deficiency of B12 in the area was probably one of the important factors influencing the pattern of anaemia there. In distinct contrast to the findings in East Africa, only 1 of the 77 patients had no clinical or laboratory evidence of intestinal malabsorption. Two-thirds of the patients were suffering from a syndrome which was similar either to that seen in Singapore or to the more chronic condition seen in London. One-third of the patients differed in that the intestinal defect was milder and the patients absorbed Bl2 normally. Whether the absence of Bl2 malabsorption was a reflection of the mildof the disease or was due to a difference in intestinal bacterial flora is uncertain and needs further investigation. It is of particular interest that a number of patients with the clinical picture of classical tropical sprue came from areas in which sprue was epidemic. The main findings of the joint study (to which we refer in an annotation on p. 329) are, therefore, that the megaloblastic anaemia of East Africa is not associated with intestinal malabsorption, whereas in Vellore and in Europeans in Singapore megaloblastic anaemia is almost always associated with tropical sprue. The features of tropical sprue as seen in Singapore, Vellore, and London appear to be the varying manifestations of a single syndrome of as yet unknown aetiology. ness
ASSOCIATION OF PHYSICIANS OF EAST AFRICA THE annual conference of the Association was held in Nairobi on June 23-26 and was opened by the Hon. J. D. OTIENDE, Minister for Health and Housing in the Kenya Government. We give here points from some of the contributions. Prof. A. S. DOUGLAS (Kenya/Glasgow) demonstrated by serial angiography the technique of thrombus formation in a Chandler’s tube and described the effects of anticoagulant therapy and streptokinase on platelet aggregation during thrombus formation. Streptokinase disrupted the fibrin tail and the platelet head of the Chandler’s thrombus when the thrombus was placed in an artificial circulation. A study of clot lysis, clot strength, and platelet adhesiveness