- Email: [email protected]
TROPICAL WORLD IN ATHENS
1068
resulted from selective catheter arteriography to demonstrate parathyroid adenomas, and the other case followed angiography of the posterior fossa. The case of paraplegia followed an attempted renal angiogram. Two of the patients with tetraplegia died. Margolis 49 has studied the xtiology of spinal-cord damage after abdominal aortography in a classic series of animal experiments. Any factor which decreases the outflow of contrast medium from the aorta into the peripheral vascular bed will increase the diversion of the contrast to the spinal cord. In some cases this effect may be caused by an organic blockage-as, for example, in the iliac or femoral vessels. However, a similar effect may follow administration of vasopressor drugs. These produce peripheral vasoconstriction with hypertension in the somatic circulation. The spinal-cord vasculature does not participate in the general vasoconstrictor response, so that an excessive dose of contrast medium may be diverted from the high-pressure area in the aorta to the low-pressure area in the spinal circulation. Even physiological stimuli, such as breath-holding, may have a similar effect. When aortography is performed in the supine position, the gravitational effect of the heavy contrast medium may also increase its flow to the spinal cord. If multiple doses of contrast medium are used, the vasodilator action of the initial (and possibly subtoxic) dose may open up the medullary circulation and alter the endothelial barrier, so that the later dose produces severe neurological damage. Once spinal-cord damage had occurred there was, until lately, little that could be done to prevent its progress. Mishkin et al. 48noted that the iodine content of the cerebrospinal fluid was raised after these neurological complications of angiography, and this observation is the basis of a new emergency treatment scheme. Immediate lumbar puncture is performed and the cerebrospinal fluid is withdrawn in 10 ml. aliquots with replacement by isotonic saline. The patient is also placed in a head-up posture so that contrast medium gravitates downwards, away from the brain. Mishkin and his colleagues have now used this treatment in eight consecutive cases. A rapid reduction of the c.s.F. iodine levels was achieved and there was concomitant improvement of the neurological No clinical details of these status in the patients. cases are given, but the prognosis is otherwise so serious that this relatively simple procedure certainly deserves an extended trial. There may also be a case for systemic steroid therapy to diminish oedema in the damaged cord. A still rarer cause of spinal-cord damage during vertebral angiography or translumbar aortography may result from accidental misplacement of the needle into the spinal theca. If the mistake is not recognised and angiographic contrast medium is injected into the subarachnoid space, this will cause ascending myoclonic spasms which may prove fatal. This syndrome has also been treated successfully by irrigation of the subarachnoid space with saline and a head-up posture of the patient. In these cases, curare with artificial ventilation may also be required to control the extensor 49. 50.
spasms.""
Margolis, G. Invest. Radiol. 1970, 5, 392. McCleery, W. N. C., Lewtas, N. A. Br. J. Radiol. 1966, 39, 112.
TROPICAL WORLD IN ATHENS THE Ninth International Congress of Tropical Medicine and Malaria in Athens last month brought together some 1200 participants from all over the world, but, because of the Arab-Israeli war, several Middle-Eastern and North African countries could It was also regrettable that the not be represented. countries most closely concerned with the developing of the subject-matter congress were under-represented it for financial reasons. If its main seems, - mainly,
function was to create or improve personal contacts and to generate much mutual good will, then the Athens congress reached its objective. On the other hand, if its principal aim was to increase the exchange of scientific knowledge, to promote research, and to widen areas of its application, then its impact could have been greater. No-one has yet devised a recipe which makes a meeting large, multinational, and attractive to the widest circles of people involved in tropical medicine and allied sciences and yet also of immediate relevance to people with some narrow specialist interest. Like its predecessors the Athens meeting wavered between these approaches. Of the two plenary sessions one was devoted to new concepts in tropical medicine in relation to socioeconomic advance, while the other dealt with the global importance of malaria in a changing. world. A distinctive feature was the congress’s preoccupation with the future. There is a growing need for reassessment of the very concept of tropical medicine. It is not a collection of weird and wonderful diseases ranging from blackwater fever to elephantiasis of the scrotum, but a broad perspective of tropical community health within all the environmental, social, and economic constraints of the vicious circle of high fertility, high morbidity and mortality from malnutrition and communicable disease, bad environmental conditions, predominance of rural population, shortage of staff, inadequate financial resources, and low educational level. Clearly, even half-hearted application of modern biomedical technology on a large scale is bound to increase the population pressure in countries with high reproductive potential and it may eventually slow down socioeconomic advance. In such a situation the strategy of health-care delivery cannot be based on models evolved in the West: the policy must be based on local circumstances, and in the new strategies medical auxiliaries will be playing an important part. Likewise a complete reorientation of medical education is needed for better management techniques and more realistic social priorities. Because of the general of funds and the call for more aid from the shortage the national countries, developed promoters of better health will have to strengthen their case by showing long-term economic benefits as the result of decreasing of mortality and morbidity. New priorities lie less in the pursuit of new knowledge and more in making full use of the existing knowledge for the benefit of the greatest number. This, then, was the general message of the congress and it was largely supported by the key papers in the division of malaria. Here, the appraisal of the global eradication programme showed that, while much progress has been made, the remaining quarter of the task will be more difficult than anything done before.
1069
There is evidence of resurgence of malaria in some areas, and measures to control the disease deserve urgent reconsideration wherever eradication is proving difficult. Malaria is part of the dilemma of socioeconomic development of the tropics, and successful control (let alone eradication) depends on the will and the means of the affected countries themselves.
TWO EXPERIMENTS IN INTEGRATED CARE THE cottage hospital at Wallingford, Oxfordshire, has been redesigned and rebuilt as a community hospital. What does this mean ? Above all, it is a symbol that a national policy, by which all cottage hospitals were to have been closed, is being reversed. Sir Keith Joseph has said recently that up to a quarter of all general beds in hospitals may, in time, be provided in community hospitals. But how does the community differ from the cottage and the district hospital ? The distinction from a district hospital is obvious. The community hospital serves a much smaller population (perhaps 30,000), is nearer the homes of its patients, has no operating-theatre, and is
doctored basically by general practitioners, though certain specialists pay regular visits. The distinction from a cottage hospital is less clear. The new name essentially represents an effort of deliberate planning and appropriate resources to produce a hospital as part of primary medical care. Inpatients must be in the care of their general practitioners (there is no house-doctor), even if a specialist is also involved. It is symbolic that the general practitioner’s name appears over the bed. There is a deliberate effort to provide close at hand what the local community needs-a day hospital with no long journey to it and beds into which are accepted patients with chronic as well as acute disorders; a preponderance of older patients is expected, not resented. The wards are small, carpeted, and furnished in a manner to remind of home. The " outpatients " consists basically of a group practice of five generalists with their team, but there are consulting-rooms for specialists and rooms for public-health clinics included in the same building. General practitioner and consultant share a casefolder so that letters to and fro are not required. Perhaps between this new hospital at Wallingford and the best of the cottage hospitals there is no essential difference, but a reversal of policy called for anew name. At the same time a report on the first five years of the Livingston project has been published by the Scottish Home and Health Department. This is, of course, a more ambitious experiment, planning a new structure of health services for a new town of 70,000 people. At Livingston the (district) hospital is the central point, although there will be peripheral health centres.
The
small lists and
general practitioners have unusually
expected to work in the hospital part-time specialists in a department of their choice, although they also have access to generalpractitioner beds. They require and get a special training of 3 years’ duration for this combined role; are
as
Livingston Project—the First Five Years. Edited by A. H. Duncan. Scottish Health Services Studies no. 29. Scottish Home and Health Department, 1973.
1. The
little different from the usual pattern of vocational training for general practice. Meanwhile, the consultants in the hospital are encouraged to work in the health centres and to develop their advisory function outside the hospital. Here then are two experiments in integrated care, one too new to be fully at work, the other 5 years old and flourishing. Do they satisfy their communities and the doctors who work in them ? Do they offer patterns for other areas to copy ? It is too soon for evidence from Wallingford, but the Livingston report indicates a high level of satisfaction in the patients. The adverse criticisms are those which it is
a
might apply to any group (or health-centre), as opposed to individual, practice. " The health centre concept has everything to commend it except the feeling of confidentiality, and here feeling is the operative word." " It is hard for the patient to believe that only the doctor will know the details of his case when, at the point of reception, he sees so many people handling papers, looking through files, consulting records." " While at Livingston there has been real gain in clinical efficiency, there may have been some loss in personal relationship between doctor and patient and patient’s family." Application lists of fifty for general practitioners in Livingston, while posts in neighbouring areas were hard to fill, suggests that this pattern of combined general and specialist practice is attractive to doctors. This is indeed what was to be expected. Undergraduates are still trained to look after patients in hospital beds, predominantly and the divorce of general practice from hospital work has long been a cause of dissatisfaction, low recruitment, and emigration. But it is clear from the report that the integration of the Livingston practitioners into the hospital team has not been achieved without difficulty. It is also noticeable that, of a total of fourteen doctors so far appointed, three have left quite quickly. However, this may not have been due to dissatisfaction-" Highly trained doctors may be attracted elsewhere by other opportunities." Should the general practitioner be introduced into hospital as a specialist, as at Livingston, or as a generalist (Wallingford) ? Great efforts have had to be made at Livingston to avoid the general practitioner having a separate subsidiary profession when he works in hospital. Special training was needed. At Wallingford the practitioners’ role in the hospital attached to their health centre seems to be a more immediate extension of their role in the consulting-room or patient’s home. But even here some new knowledge, skills, and attitudes are needed-for example, concerning rehabilitation. Both these experiments are warmly welcomed as contributions to solving the problem of relating generalist to specialist practice and as possible patterns for the future. Their evaluation calls for rigidly controlled studies which, difficult anywhere, may be a little easier at Wallingford than Livingston. Meanwhile, the satisfactions which they both offer to their communities and doctors are more important than the differences between their patterns. But for those who are concerned about the future pattern of general practice, the differences are important ; the successes and difficulties of each experiment will be watched with great interest.
resulted from selective catheter arteriography to demonstrate parathyroid adenomas, and the other case followed angiography of the posterior fossa. The case of paraplegia followed an attempted renal angiogram. Two of the patients with tetraplegia died. Margolis 49 has studied the xtiology of spinal-cord damage after abdominal aortography in a classic series of animal experiments. Any factor which decreases the outflow of contrast medium from the aorta into the peripheral vascular bed will increase the diversion of the contrast to the spinal cord. In some cases this effect may be caused by an organic blockage-as, for example, in the iliac or femoral vessels. However, a similar effect may follow administration of vasopressor drugs. These produce peripheral vasoconstriction with hypertension in the somatic circulation. The spinal-cord vasculature does not participate in the general vasoconstrictor response, so that an excessive dose of contrast medium may be diverted from the high-pressure area in the aorta to the low-pressure area in the spinal circulation. Even physiological stimuli, such as breath-holding, may have a similar effect. When aortography is performed in the supine position, the gravitational effect of the heavy contrast medium may also increase its flow to the spinal cord. If multiple doses of contrast medium are used, the vasodilator action of the initial (and possibly subtoxic) dose may open up the medullary circulation and alter the endothelial barrier, so that the later dose produces severe neurological damage. Once spinal-cord damage had occurred there was, until lately, little that could be done to prevent its progress. Mishkin et al. 48noted that the iodine content of the cerebrospinal fluid was raised after these neurological complications of angiography, and this observation is the basis of a new emergency treatment scheme. Immediate lumbar puncture is performed and the cerebrospinal fluid is withdrawn in 10 ml. aliquots with replacement by isotonic saline. The patient is also placed in a head-up posture so that contrast medium gravitates downwards, away from the brain. Mishkin and his colleagues have now used this treatment in eight consecutive cases. A rapid reduction of the c.s.F. iodine levels was achieved and there was concomitant improvement of the neurological No clinical details of these status in the patients. cases are given, but the prognosis is otherwise so serious that this relatively simple procedure certainly deserves an extended trial. There may also be a case for systemic steroid therapy to diminish oedema in the damaged cord. A still rarer cause of spinal-cord damage during vertebral angiography or translumbar aortography may result from accidental misplacement of the needle into the spinal theca. If the mistake is not recognised and angiographic contrast medium is injected into the subarachnoid space, this will cause ascending myoclonic spasms which may prove fatal. This syndrome has also been treated successfully by irrigation of the subarachnoid space with saline and a head-up posture of the patient. In these cases, curare with artificial ventilation may also be required to control the extensor 49. 50.
spasms.""
Margolis, G. Invest. Radiol. 1970, 5, 392. McCleery, W. N. C., Lewtas, N. A. Br. J. Radiol. 1966, 39, 112.
TROPICAL WORLD IN ATHENS THE Ninth International Congress of Tropical Medicine and Malaria in Athens last month brought together some 1200 participants from all over the world, but, because of the Arab-Israeli war, several Middle-Eastern and North African countries could It was also regrettable that the not be represented. countries most closely concerned with the developing of the subject-matter congress were under-represented it for financial reasons. If its main seems, - mainly,
function was to create or improve personal contacts and to generate much mutual good will, then the Athens congress reached its objective. On the other hand, if its principal aim was to increase the exchange of scientific knowledge, to promote research, and to widen areas of its application, then its impact could have been greater. No-one has yet devised a recipe which makes a meeting large, multinational, and attractive to the widest circles of people involved in tropical medicine and allied sciences and yet also of immediate relevance to people with some narrow specialist interest. Like its predecessors the Athens meeting wavered between these approaches. Of the two plenary sessions one was devoted to new concepts in tropical medicine in relation to socioeconomic advance, while the other dealt with the global importance of malaria in a changing. world. A distinctive feature was the congress’s preoccupation with the future. There is a growing need for reassessment of the very concept of tropical medicine. It is not a collection of weird and wonderful diseases ranging from blackwater fever to elephantiasis of the scrotum, but a broad perspective of tropical community health within all the environmental, social, and economic constraints of the vicious circle of high fertility, high morbidity and mortality from malnutrition and communicable disease, bad environmental conditions, predominance of rural population, shortage of staff, inadequate financial resources, and low educational level. Clearly, even half-hearted application of modern biomedical technology on a large scale is bound to increase the population pressure in countries with high reproductive potential and it may eventually slow down socioeconomic advance. In such a situation the strategy of health-care delivery cannot be based on models evolved in the West: the policy must be based on local circumstances, and in the new strategies medical auxiliaries will be playing an important part. Likewise a complete reorientation of medical education is needed for better management techniques and more realistic social priorities. Because of the general of funds and the call for more aid from the shortage the national countries, developed promoters of better health will have to strengthen their case by showing long-term economic benefits as the result of decreasing of mortality and morbidity. New priorities lie less in the pursuit of new knowledge and more in making full use of the existing knowledge for the benefit of the greatest number. This, then, was the general message of the congress and it was largely supported by the key papers in the division of malaria. Here, the appraisal of the global eradication programme showed that, while much progress has been made, the remaining quarter of the task will be more difficult than anything done before.
1069
There is evidence of resurgence of malaria in some areas, and measures to control the disease deserve urgent reconsideration wherever eradication is proving difficult. Malaria is part of the dilemma of socioeconomic development of the tropics, and successful control (let alone eradication) depends on the will and the means of the affected countries themselves.
TWO EXPERIMENTS IN INTEGRATED CARE THE cottage hospital at Wallingford, Oxfordshire, has been redesigned and rebuilt as a community hospital. What does this mean ? Above all, it is a symbol that a national policy, by which all cottage hospitals were to have been closed, is being reversed. Sir Keith Joseph has said recently that up to a quarter of all general beds in hospitals may, in time, be provided in community hospitals. But how does the community differ from the cottage and the district hospital ? The distinction from a district hospital is obvious. The community hospital serves a much smaller population (perhaps 30,000), is nearer the homes of its patients, has no operating-theatre, and is
doctored basically by general practitioners, though certain specialists pay regular visits. The distinction from a cottage hospital is less clear. The new name essentially represents an effort of deliberate planning and appropriate resources to produce a hospital as part of primary medical care. Inpatients must be in the care of their general practitioners (there is no house-doctor), even if a specialist is also involved. It is symbolic that the general practitioner’s name appears over the bed. There is a deliberate effort to provide close at hand what the local community needs-a day hospital with no long journey to it and beds into which are accepted patients with chronic as well as acute disorders; a preponderance of older patients is expected, not resented. The wards are small, carpeted, and furnished in a manner to remind of home. The " outpatients " consists basically of a group practice of five generalists with their team, but there are consulting-rooms for specialists and rooms for public-health clinics included in the same building. General practitioner and consultant share a casefolder so that letters to and fro are not required. Perhaps between this new hospital at Wallingford and the best of the cottage hospitals there is no essential difference, but a reversal of policy called for anew name. At the same time a report on the first five years of the Livingston project has been published by the Scottish Home and Health Department. This is, of course, a more ambitious experiment, planning a new structure of health services for a new town of 70,000 people. At Livingston the (district) hospital is the central point, although there will be peripheral health centres.
The
small lists and
general practitioners have unusually
expected to work in the hospital part-time specialists in a department of their choice, although they also have access to generalpractitioner beds. They require and get a special training of 3 years’ duration for this combined role; are
as
Livingston Project—the First Five Years. Edited by A. H. Duncan. Scottish Health Services Studies no. 29. Scottish Home and Health Department, 1973.
1. The
little different from the usual pattern of vocational training for general practice. Meanwhile, the consultants in the hospital are encouraged to work in the health centres and to develop their advisory function outside the hospital. Here then are two experiments in integrated care, one too new to be fully at work, the other 5 years old and flourishing. Do they satisfy their communities and the doctors who work in them ? Do they offer patterns for other areas to copy ? It is too soon for evidence from Wallingford, but the Livingston report indicates a high level of satisfaction in the patients. The adverse criticisms are those which it is
a
might apply to any group (or health-centre), as opposed to individual, practice. " The health centre concept has everything to commend it except the feeling of confidentiality, and here feeling is the operative word." " It is hard for the patient to believe that only the doctor will know the details of his case when, at the point of reception, he sees so many people handling papers, looking through files, consulting records." " While at Livingston there has been real gain in clinical efficiency, there may have been some loss in personal relationship between doctor and patient and patient’s family." Application lists of fifty for general practitioners in Livingston, while posts in neighbouring areas were hard to fill, suggests that this pattern of combined general and specialist practice is attractive to doctors. This is indeed what was to be expected. Undergraduates are still trained to look after patients in hospital beds, predominantly and the divorce of general practice from hospital work has long been a cause of dissatisfaction, low recruitment, and emigration. But it is clear from the report that the integration of the Livingston practitioners into the hospital team has not been achieved without difficulty. It is also noticeable that, of a total of fourteen doctors so far appointed, three have left quite quickly. However, this may not have been due to dissatisfaction-" Highly trained doctors may be attracted elsewhere by other opportunities." Should the general practitioner be introduced into hospital as a specialist, as at Livingston, or as a generalist (Wallingford) ? Great efforts have had to be made at Livingston to avoid the general practitioner having a separate subsidiary profession when he works in hospital. Special training was needed. At Wallingford the practitioners’ role in the hospital attached to their health centre seems to be a more immediate extension of their role in the consulting-room or patient’s home. But even here some new knowledge, skills, and attitudes are needed-for example, concerning rehabilitation. Both these experiments are warmly welcomed as contributions to solving the problem of relating generalist to specialist practice and as possible patterns for the future. Their evaluation calls for rigidly controlled studies which, difficult anywhere, may be a little easier at Wallingford than Livingston. Meanwhile, the satisfactions which they both offer to their communities and doctors are more important than the differences between their patterns. But for those who are concerned about the future pattern of general practice, the differences are important ; the successes and difficulties of each experiment will be watched with great interest.