- Email: [email protected]
United States
1095 50
kg
woman
has
hyperinsulinaemia
no serum
is
insulin antibodies, and her
unexplained. DISCUSSION
for insulinoma. test carried out during dynamic testing of islet-cell function. However, C-peptide assays are not yet universally available, and we preferred the simple, less invasive 72 h fast for initial There
are
several methods of
screening
Marks4 favours the C-peptide suppression
screening. 20 patients remained with no clear diagnosis despite intensive investigations. 3 patients had a diagnosis of epilepsy confirmed during the study. A small but significant percentage was found to have an insulinoma. Their excellent response to surgical treatment underlines the importance of intensive evaluation of patients with "funny turns". Fast Tme (hours)
Fig. 1-Plasma glucose levels in 23 and
patients during
72 h fast
(means
ranges).
The normal lower limit is ’made
represent the values,
on
arbitrarily at 2 - 2 mmol/1. The dots repeated overnight fasts, from the 2 patients found to
have insulinomas.
We thank the medical and nursing staff of the neurology department, Southern General Hospital, Glasgow, for their help and Mrs L. E. MacGregor for secretarial assistance.
Correspondence should be addressed to M. G. H., Building 36, Room 3A 17, B., National Institute Bethesda, Maryland 20205, USA. L. G. C.
of Mental
Health, 9000 Rockville Pike,
60
I
REFERENCES
H, Creutzfeldt W. Hypoglycaemia. 1. Insulin secreting tumours Clins Endocr Metab 1976; 5: 747-67. 2. Frerichs H, Track NS. Pharmacotherapy of hormone-secreting tumours. Clins Gastroenterol 1974; 3: 721-32. 3. Matthews WB. Blackouts. In: Practical neurology. London: Blackwell Scientific Publications, 1975 41. 4. Marks V. The investigation of hypoglycaemia In: Marks V, Rose FC, eds. Hypoglycaemia. London: Blackwell Scientific Publications, 1981: 411-63. 5. Turner RC, Oakley NW, Nabarro JDN. Control of basal insulin secretion, with special reference to the diagnosis of insulinomas Br Med J1971; ii: 132. 1. Frerichs
0
24
28
48
Fast Tme
2-Plasma insulin levels in 22 and ranges).
Fig.
Round the World
72
52
(hours)
patients during 72
h fast
(means
The normal upper fasting plasma insulin limit is 13 mUll in our laboratory; higher levels usually indicate an insulinoma. The dots represent the 2 patients who were also hypoglycaemic. The dotted line joins the values of the patient with normal plasma glucose but high plasma insulin levels.
From
our
correspondents
United States REPORTING OF MALPRACTICE
Dr David Axelrod, a physician and head of the New York State Health Department, has said that as many as 10% of all physicians become professionally impaired at some point in their careers. In New York State alone, that would come to 4500 doctors; nationwide, 40 000. The Medical Society of New York State and the Hospital Association of New York were indignant. The 10% estimate, a spokesman told the New York Times, was "patent nonsense; a cheap shot." Dr’ Axelrod is accused of publicly undermining confidence in the many doctors who go through entire careers without being sued for malpractice.
Still, no-one disputes that there are doctors who jeopardise the health, sometimes the lives, of their patients. So it is worth examining Dr Axelrod’s evidence, as a basis for comparison with
Fast Time (hours)
Fig. 3-Insulin/glucose (I/G) ratios5
of 22
patients during
72 h fast
(means and ranges). The three horizontal dashed lines are our laboratory normal upper limits for non-obese and obese patients and the lower limit for our insulinoma patients. The dots represent the 2 patients who had hypoglycaemia and hyperinsulinaemia. The dotted line joins the values of the patient (not obese) who had normal plasma glucose but high plasma insulin levels.
conditions elsewhere. His reason for bringing all this up is that he believes physicians and hospitals are vastly underreporting cases of malpractice to the authorities. Last year, for example, 670 malpractice cases were reported in New York State. Of these, only 28 came from physicians, 33 from hospitals, and all the rest from patients and other members of the public. Since an untrained patient is least likely to recognise medical misconduct when he sees it, Dr Axelrod is certain that doctors and hospitals are holding back. He is threatening disciplinary action against physicians and hospitals failing to report malpractice cases. A distressing example occurred in Binghamton, New York. A urologist operated to correct a hernia and remove a testicle. In closing the wound, a portion of the patient’s bowel was punctured in nine places. After corrective surgery, the patient died. A subsequent
1096 of the urologist found that often, in the operating room, "his gait and stance were unsteady and his speech and memory processes were not acute". In voluntarily surrendering his
investigation
to being "habitually drunk" between 1977 and 1980. Only about half the States have a law specifying incompetence in a physician as cause for disciplinary action. Dr Robert C. Derbyshire I that during 26 years as a member of the New Mexico Board of Medical Examiners, the Board revoked the licences of only three physicians for professional incompetence. "Moreover," he says, "in two of three cases the board had to base its action on technicalities because of difficulty of obtaining expert testimony
licence, the doctor admitted
reports
from physicians."
That would seem to support Axelrod’s claim of a doctor’s reluctance to tell on a colleague and thus ruin his career and his life. Derbyshire differs from Axelrod’s estimate of 10% incompetence: his calculation is 5%. He bases that on the incidence of addiction to alcohol and other drugs and "the countless physicians who lapse into senescence or complete obsolescence each year."
Derbyshire believes that now, at least, the medical profession is beginning to recognise there is a problem. In 1965, he received a stack of angry complaints from physicians after his first article on physician incompetence was published.2About 10 years later, when he told the New York Times that 5% of all American doctors were incompetent, most doctors who wrote him said his estimate was too low. REDUCING THE DEATH RATE
IN 1979, the US death-rate dropped to its lowest level. Life expectancy increased to a new high, while the infant mortality rate fell to the lowest ever recorded. Indications are that the death rates fell in 1981, but officials are more doubtful about what is happening to the infant mortality rate. Indeed in some states, hard hit by the recession, the rate has risen, with a substantial rise in the number of low-weight births, attributed to cuts in the program providing nutritional supplements to pregnant and nursing mothers and their offspring. These cuts may be a false economy if, as an expert on nutrition, Dr Jean Meyer, now President of Tufts University, predicts, the result is an increase in the mentally-retarded and in those with other somatic and mental deficiencies.
One group in the population is recognised as at high-risk of accidental death-the young adult, male or female. Road accidents, often related to alcohol intake, extract an enormous yearly toll in young adults. The general attitude to drunken driving has been extraordinarily tolerant: guilty persons have been leniently treated by the courts, penalties have been light, and driving privileges only slightly hampered. But all this has begun to change rapidly as the high mortality due to drunken driving has become more widely
recognised. In several states the minimum age for drinking has been increased. More stringent regulations have been placed on those serving drinks, especially to those who appear intoxicated. A major attack has opened against drunken driving. In many states penalties for the first offence have been stiffened and,.in some, prison is mandatory for the second offence. Financial penalties and periods of licence revocation have been increased and sentences for vehicular homicide due to drunken driving have been greatly lengthened. But all these developments are of no avail unless the drunken driver is recognised and stopped, before it is to be hoped, he or she has caused an accident. Surveillance has been stepped up. Results became evident over the Christmas and New Year holiday in many areas. Repeated public warnings, increased police patrolling and check points, and more breath tests, caused a fall in incidents and in deaths. Those who celebrated with lots of alcohol preferred to be driven home, by non-drinking companions, friends, or volunteers, or to stay the night where they had celebrated. 1. 2.
Derbyshire RC. Physician competence. N Y State J Med 1979; 79: 1028-31 Derbyshire RC. What should the profession do about the incompetent physician? JAMA 1965; 194: 1287.
NOTES FOR LANCET AUTHORS
Prospective authors are referred to the statement Uniform Requirements for Manuscripts Submitted to Biomedical Journals published in the issue of Feb. 24, 1979 (Lancet 1979; i:
428-30) and to these notes:
Units. Non-metric units should not be used in scientific so pints, inches, and so on, and Fahrenheit temperatures will be changed editorially to metric units. Parts of the SI system are controversial or unfamiliar even in countries that have adopted the system-notably, in the matter of concentration of substance, gas tensions, blood-pressure, and radiological units. For these, authors should provide (separately from the text) explicit two-way conversion factors which will be printed in a prominent place in the article; if this information has to be added by the Editor, the author should check accuracy at proof stage. Abbreviations. Since there is no universally accepted list of abbreviations nor agreement on the principles on which they can be constructed, authors should use the ones they are familiar with, taking care to define them at first mention and leaving the final form to house-style. Qualifications. For the Contents page of the journal, information about full professorships and about main academic or other qualifications is needed. CopIes of typescript. A single copy will suffice, preferably the top one or a good copy on non-glossy paper. The manuscript should be typed, on one side of the paper only, with double spacing and wide margins. Length of contributions. All editors exhort authors to be brief. In The Lancet this particularly applies to Preliminary Communications (not more than 1500 words), Hypotheses (1500 words), Methods and Devices (750 words), and Letters to the Editor (500 words), all these limits to be reduced if illustrations and/or tables are included. Trade names. Proprietary names of products should be indicated, as, for example, ’Marmite’ at the first mention and marmite thereafter. If the brand name for a drug is used, the British, U.S., or international non-proprietary (approved) name should be given first. Proofs. If the author is to be on the move in the days or weeks after the article is submitted, he or she should either nominate a colleague to deal with the proofs or list his or her movements. Covering letter. In the letter accompanying the article, the author may wish to define the extent of any concessions he or she is prepared to make-for example, he or she may be willing to leave out a figure or two, a table, or even part of the text. Material such as tables and appendices can be made available to interested parties by the author, and a footnote to this effect can be included in the text. Colour printing. On the rare occasions when The Lancet has published colour illustrations the journal has borne the cost, but offers to contribute will be considered. Reprints and copyright. Within a few days of publication of a paper, 100 offprints (the pages incorporating the article) are despatched to the author (by air-mail outside Europe) free of charge, for the author’s use. Reprints can be arranged on application to the Reprint Department. The Lancet now asks contributors to assign to the journal their copyright to the words in the articles; but it has decided not to adopt the procedures of the U.S. Copyright Clearance Center. The journal holds the view which formerly prevailed-namely, that single copies for research or study could be made without permission or payment. Permission for multiple facsimile copying in any form must be had from the author and from the Editor, who will need to know the purpose for which the copies are to be used. We hope that authors will continue to consult us whenever dual publication of any contribution is contemplated whether this be before, after, or at the same time as its appearance in The Lancet.
contributions,
kg
woman
has
hyperinsulinaemia
no serum
is
insulin antibodies, and her
unexplained. DISCUSSION
for insulinoma. test carried out during dynamic testing of islet-cell function. However, C-peptide assays are not yet universally available, and we preferred the simple, less invasive 72 h fast for initial There
are
several methods of
screening
Marks4 favours the C-peptide suppression
screening. 20 patients remained with no clear diagnosis despite intensive investigations. 3 patients had a diagnosis of epilepsy confirmed during the study. A small but significant percentage was found to have an insulinoma. Their excellent response to surgical treatment underlines the importance of intensive evaluation of patients with "funny turns". Fast Tme (hours)
Fig. 1-Plasma glucose levels in 23 and
patients during
72 h fast
(means
ranges).
The normal lower limit is ’made
represent the values,
on
arbitrarily at 2 - 2 mmol/1. The dots repeated overnight fasts, from the 2 patients found to
have insulinomas.
We thank the medical and nursing staff of the neurology department, Southern General Hospital, Glasgow, for their help and Mrs L. E. MacGregor for secretarial assistance.
Correspondence should be addressed to M. G. H., Building 36, Room 3A 17, B., National Institute Bethesda, Maryland 20205, USA. L. G. C.
of Mental
Health, 9000 Rockville Pike,
60
I
REFERENCES
H, Creutzfeldt W. Hypoglycaemia. 1. Insulin secreting tumours Clins Endocr Metab 1976; 5: 747-67. 2. Frerichs H, Track NS. Pharmacotherapy of hormone-secreting tumours. Clins Gastroenterol 1974; 3: 721-32. 3. Matthews WB. Blackouts. In: Practical neurology. London: Blackwell Scientific Publications, 1975 41. 4. Marks V. The investigation of hypoglycaemia In: Marks V, Rose FC, eds. Hypoglycaemia. London: Blackwell Scientific Publications, 1981: 411-63. 5. Turner RC, Oakley NW, Nabarro JDN. Control of basal insulin secretion, with special reference to the diagnosis of insulinomas Br Med J1971; ii: 132. 1. Frerichs
0
24
28
48
Fast Tme
2-Plasma insulin levels in 22 and ranges).
Fig.
Round the World
72
52
(hours)
patients during 72
h fast
(means
The normal upper fasting plasma insulin limit is 13 mUll in our laboratory; higher levels usually indicate an insulinoma. The dots represent the 2 patients who were also hypoglycaemic. The dotted line joins the values of the patient with normal plasma glucose but high plasma insulin levels.
From
our
correspondents
United States REPORTING OF MALPRACTICE
Dr David Axelrod, a physician and head of the New York State Health Department, has said that as many as 10% of all physicians become professionally impaired at some point in their careers. In New York State alone, that would come to 4500 doctors; nationwide, 40 000. The Medical Society of New York State and the Hospital Association of New York were indignant. The 10% estimate, a spokesman told the New York Times, was "patent nonsense; a cheap shot." Dr’ Axelrod is accused of publicly undermining confidence in the many doctors who go through entire careers without being sued for malpractice.
Still, no-one disputes that there are doctors who jeopardise the health, sometimes the lives, of their patients. So it is worth examining Dr Axelrod’s evidence, as a basis for comparison with
Fast Time (hours)
Fig. 3-Insulin/glucose (I/G) ratios5
of 22
patients during
72 h fast
(means and ranges). The three horizontal dashed lines are our laboratory normal upper limits for non-obese and obese patients and the lower limit for our insulinoma patients. The dots represent the 2 patients who had hypoglycaemia and hyperinsulinaemia. The dotted line joins the values of the patient (not obese) who had normal plasma glucose but high plasma insulin levels.
conditions elsewhere. His reason for bringing all this up is that he believes physicians and hospitals are vastly underreporting cases of malpractice to the authorities. Last year, for example, 670 malpractice cases were reported in New York State. Of these, only 28 came from physicians, 33 from hospitals, and all the rest from patients and other members of the public. Since an untrained patient is least likely to recognise medical misconduct when he sees it, Dr Axelrod is certain that doctors and hospitals are holding back. He is threatening disciplinary action against physicians and hospitals failing to report malpractice cases. A distressing example occurred in Binghamton, New York. A urologist operated to correct a hernia and remove a testicle. In closing the wound, a portion of the patient’s bowel was punctured in nine places. After corrective surgery, the patient died. A subsequent
1096 of the urologist found that often, in the operating room, "his gait and stance were unsteady and his speech and memory processes were not acute". In voluntarily surrendering his
investigation
to being "habitually drunk" between 1977 and 1980. Only about half the States have a law specifying incompetence in a physician as cause for disciplinary action. Dr Robert C. Derbyshire I that during 26 years as a member of the New Mexico Board of Medical Examiners, the Board revoked the licences of only three physicians for professional incompetence. "Moreover," he says, "in two of three cases the board had to base its action on technicalities because of difficulty of obtaining expert testimony
licence, the doctor admitted
reports
from physicians."
That would seem to support Axelrod’s claim of a doctor’s reluctance to tell on a colleague and thus ruin his career and his life. Derbyshire differs from Axelrod’s estimate of 10% incompetence: his calculation is 5%. He bases that on the incidence of addiction to alcohol and other drugs and "the countless physicians who lapse into senescence or complete obsolescence each year."
Derbyshire believes that now, at least, the medical profession is beginning to recognise there is a problem. In 1965, he received a stack of angry complaints from physicians after his first article on physician incompetence was published.2About 10 years later, when he told the New York Times that 5% of all American doctors were incompetent, most doctors who wrote him said his estimate was too low. REDUCING THE DEATH RATE
IN 1979, the US death-rate dropped to its lowest level. Life expectancy increased to a new high, while the infant mortality rate fell to the lowest ever recorded. Indications are that the death rates fell in 1981, but officials are more doubtful about what is happening to the infant mortality rate. Indeed in some states, hard hit by the recession, the rate has risen, with a substantial rise in the number of low-weight births, attributed to cuts in the program providing nutritional supplements to pregnant and nursing mothers and their offspring. These cuts may be a false economy if, as an expert on nutrition, Dr Jean Meyer, now President of Tufts University, predicts, the result is an increase in the mentally-retarded and in those with other somatic and mental deficiencies.
One group in the population is recognised as at high-risk of accidental death-the young adult, male or female. Road accidents, often related to alcohol intake, extract an enormous yearly toll in young adults. The general attitude to drunken driving has been extraordinarily tolerant: guilty persons have been leniently treated by the courts, penalties have been light, and driving privileges only slightly hampered. But all this has begun to change rapidly as the high mortality due to drunken driving has become more widely
recognised. In several states the minimum age for drinking has been increased. More stringent regulations have been placed on those serving drinks, especially to those who appear intoxicated. A major attack has opened against drunken driving. In many states penalties for the first offence have been stiffened and,.in some, prison is mandatory for the second offence. Financial penalties and periods of licence revocation have been increased and sentences for vehicular homicide due to drunken driving have been greatly lengthened. But all these developments are of no avail unless the drunken driver is recognised and stopped, before it is to be hoped, he or she has caused an accident. Surveillance has been stepped up. Results became evident over the Christmas and New Year holiday in many areas. Repeated public warnings, increased police patrolling and check points, and more breath tests, caused a fall in incidents and in deaths. Those who celebrated with lots of alcohol preferred to be driven home, by non-drinking companions, friends, or volunteers, or to stay the night where they had celebrated. 1. 2.
Derbyshire RC. Physician competence. N Y State J Med 1979; 79: 1028-31 Derbyshire RC. What should the profession do about the incompetent physician? JAMA 1965; 194: 1287.
NOTES FOR LANCET AUTHORS
Prospective authors are referred to the statement Uniform Requirements for Manuscripts Submitted to Biomedical Journals published in the issue of Feb. 24, 1979 (Lancet 1979; i:
428-30) and to these notes:
Units. Non-metric units should not be used in scientific so pints, inches, and so on, and Fahrenheit temperatures will be changed editorially to metric units. Parts of the SI system are controversial or unfamiliar even in countries that have adopted the system-notably, in the matter of concentration of substance, gas tensions, blood-pressure, and radiological units. For these, authors should provide (separately from the text) explicit two-way conversion factors which will be printed in a prominent place in the article; if this information has to be added by the Editor, the author should check accuracy at proof stage. Abbreviations. Since there is no universally accepted list of abbreviations nor agreement on the principles on which they can be constructed, authors should use the ones they are familiar with, taking care to define them at first mention and leaving the final form to house-style. Qualifications. For the Contents page of the journal, information about full professorships and about main academic or other qualifications is needed. CopIes of typescript. A single copy will suffice, preferably the top one or a good copy on non-glossy paper. The manuscript should be typed, on one side of the paper only, with double spacing and wide margins. Length of contributions. All editors exhort authors to be brief. In The Lancet this particularly applies to Preliminary Communications (not more than 1500 words), Hypotheses (1500 words), Methods and Devices (750 words), and Letters to the Editor (500 words), all these limits to be reduced if illustrations and/or tables are included. Trade names. Proprietary names of products should be indicated, as, for example, ’Marmite’ at the first mention and marmite thereafter. If the brand name for a drug is used, the British, U.S., or international non-proprietary (approved) name should be given first. Proofs. If the author is to be on the move in the days or weeks after the article is submitted, he or she should either nominate a colleague to deal with the proofs or list his or her movements. Covering letter. In the letter accompanying the article, the author may wish to define the extent of any concessions he or she is prepared to make-for example, he or she may be willing to leave out a figure or two, a table, or even part of the text. Material such as tables and appendices can be made available to interested parties by the author, and a footnote to this effect can be included in the text. Colour printing. On the rare occasions when The Lancet has published colour illustrations the journal has borne the cost, but offers to contribute will be considered. Reprints and copyright. Within a few days of publication of a paper, 100 offprints (the pages incorporating the article) are despatched to the author (by air-mail outside Europe) free of charge, for the author’s use. Reprints can be arranged on application to the Reprint Department. The Lancet now asks contributors to assign to the journal their copyright to the words in the articles; but it has decided not to adopt the procedures of the U.S. Copyright Clearance Center. The journal holds the view which formerly prevailed-namely, that single copies for research or study could be made without permission or payment. Permission for multiple facsimile copying in any form must be had from the author and from the Editor, who will need to know the purpose for which the copies are to be used. We hope that authors will continue to consult us whenever dual publication of any contribution is contemplated whether this be before, after, or at the same time as its appearance in The Lancet.
contributions,