Document 59jX475q5L1wGKnr2OJo1njV

`j I ?- V>< (i , / ; .'tHHtAN'CET, DECEMBER 10, 1977 1211 V'* & j THE LANCET ">/ ' `f Asbestos iv Public anxiety about asbestos has descended from its zenith a few months ago, but community- health and health-and-safety workers are stiil much X 'fctcrcised by control of the hazards in industry and the implications of environmental contamination. 'g-_ The major biological effects are asbestosis, car- dnoma of lung, and mesothelial tumours. Research is- effort is now directed towards establishing the car- v'.- cinogenicity of the different types of fibre and 0.'. determining dose-response relationships on which a national standard for asbestos dust in air can be X- based. During the past twelve months two important reviews have been published--the Zielhus report* C on the Public Health Risks of Exposure to ?; Asbestos, a report of a working-group prepared for ).the Commission of European Communities; and ,V the I.A.R.C. monograph no. 14 on asbestos.* The first concludes from information on environmental if ' contamination that no convincing evidence exists v.;- in Western Europe of increased risk through true ambient exposure to asbestos--in air, water, drugs, % _ beverages, or food--though the possibility of such a risk cannot be categorically denied. Para-occupa- tional exposures of family and neighbourhood and leisure-time working with asbestos-containing pro- '/ ducts arc singled out as an area of concern. The C I.A.R.C. report, looking at experimental as well as fi epidemiological evidence, concludes more pessimis- tically that "it is not possible to assess whether there is a level of exposure in humans below which an increased risk ofcancer would not occur". Whitwell, Scott, and Grimshaw45 have " 1 g: .t. Public Health Ruk of Exposure to Asbestot: report of working group of ' expem, Commmion of European Communitie*. Oxford, 1977. Jf. 2. IARC Monograph* on the Evaluation of Carcinogenic Risk of Chemicals to jjr * Man. Aibeitw; vol. xtv. tmcrnational Agency for Research on Cancer, 6' 1977. ,& 3. Whitwell, F., Scott. J.,Gnm*haw, M. Thorax, 1977,32,377. approached the matter from a different angle. They obtained occupational histories from 100 patients who had died from pleural mesothelioma, 100 patients with cancer of lung but no industrial dis ease, and 100 controls (no industrial disease or lung cancer). The light-visible asbestos fibre con tent was examined by phase-contrast microscopy after potash digestion. 83% of the mesothelioma patients had a history of asbestos exposure. The dried lung tissue of these patients contained over 100 000 asbestos fibres per gram. The lungs of the 23 patients with histological evidence of asbestosis nearly always showed counts of over 3 million. Lungs from control patients and from patients with cancer of bronchus but no industrial disease had counts of less than 20 000 fibres per gram, and patients with pleural plaques had counts of over 20 000 per gram. The number of asbestos fibres was related to occupation but not to home environ ment. Whitwell et al. conclude that a definite dose relationship exists between asbestos exposure and mesothelioma formation but that "sub-asbestosis" levels of asbestos exposure do not contribute to the formation of lung cancer in those not exposed industrially. The type of asbestos fibre was not identified in this investigation. Newhouse and Berry4, also found evidence of a dose-response rela tionship for mesothelial tumours among workers in a factory where most of the workers were exposed to crocidolite, amosite, and chrysotile asbestos; the incidence-rate per 100 000 man-years was six times higher among those with long and severe exposure than among the workers with low to moderate exposure for less than two years. The true risks of mesothelial tumours and car cinoma of the lung are hard to assess. The latent period for both tumours is long--for mesothelial tumours usually between twenty and forty years, and for cancer of lung probably more than twenty years--so that even with lengthy follow-up the risks may be underestimated. For cancer of the lung the effects of smoking as well as asbestos must be taken into account. Saracci5 *h9as reanalysed data from five sources*"10 1w1here risk from cancer of lung was considered in relation to both asbestos exposure and cigarette smoking. He finds the mul tiplicative model more plausible than the additive model, being consistent with work in animals. In the multiplicative model, both asbestos and smok ing are independently capable of producing lung 4. Newhouie, M. L, Berry. G. Br.J. ind. Mid. 1976,S3,147. 5. Saracci, R.tnt.J. Canetr. 1977,20,32$. 6. SclikofT, I. J., Hammond, E. C., Churj, J. J. Am, mtd. Ati. 1968,204, 106. 7. Sdlkoff, 1. J., Hammond, E. C. in Penons at Hifh Risk of Cancer (edited by J. Fraumeni). New York, 197$. *. Etmca, P. C, Simpson, M. J. Br.J, tnd. Med, 1971.29,134. 9. Beny,G. Ncwhouje, M. L. Lonctt. 1972, ii, 476. 10. Martischnig, K. M. Newel), O. J., Bamcdey, W. C Cowin, W. K., Fein- mtn,E. L., Oliver, E. Br. mcd.J. 1977, t, 746. 11. Jonet, J. S. P., Pooley, F. D.t Smith, P. G. in, IARC Scientific Publication no.13.1976. & ASARCO ALV 0005409 1212 THE LANCET, DECEMBER 10, 1977 cancer in man but with exposure to both they act synergistically. Except in miners, exposure to one fibre type has been little studied. Jones,11 in the United King dom, and McDonald and McDonald,11 in Canada, looked at people employed in making a?my gas-masks with crocidolite filters during the 1939-45 war. The incidence of mesothelial tumours is very high. The U.K. study covered 1600 workers, chiefly women, and 26 have so far died of mesothelial tumours. The Canadian study covered 199 workers, and 9 (16%) of the 56 deaths have been due to mesothelioma. Selikoff11111fo3llowed a cohort of 870 wartime workers in a factory in the United States using only amosite asbestos: by 1973 there had been 598 deaths, 9(1-5%) due to.mesothe lioma. In McDonald's14 study of 11 000 Canadian chrysotile miners and millers extending from 1910 to 1975, 11 (0-24%) of the 4547 deaths were due to mesothelial tumours. One group of anthophyilite miners followed-up till 19741S had had no deaths from mesothelial tumours. Evidently crocidolite, amosite, and chrysotile asbestos all predispose to the tumour, with crocido lite carrying the highest risk. Have the improved conditions in industry influenced the mortality of asbestos workers? Peto et al.16 have extended their study of asbestos textile factory workers by 8| years. Dust levels in the factory have steadily diminished but there is little difference between mortality before and after 1951. There is still an excess of deaths from lung cancer and chronic res piratory disease, and 5 pleural mesotheliomas have occurred. Further observation will be needed to show the effects of recent and stricter control of dust levels. Elmes and Simpson17 have also extended their study of insulation workers in Bel fast by 10 years. Of the original 162 men at work in 1940, all but 40 were dead by 1975. The excess mortality from lung cancer and mesothelial tumours has continued, but the mortality from non-malignant respiratory disease including asbestosis has declined, reflecting improved conditions in the industry. Little asbestos apart from `Maronite' board has-been used in shipbuilding in Belfast since the 1960s. An advisory committee of the Health and Safety Commission is examining not only health aspects of asbestos but also economic factors in the control of hazards and substitution by alter native materials such as man-made mineral fibres. A report is expected in 1978, and revised codes of practice and standards will doubtless follow. 11. Jones, J. S. P.( Poolcy, F. Dn Smith, P. G. in IARC Scientific Publication no. 13,1976. 12. McDonald, J. C., McDonald, A. D. Unpublished. 13. SehkofT,!. J.Rev.fr.Mal. Resp. 1976,4, tuppi. l,p.7. 14. McDonald, J. C. Contribution to Asbestos Symposium, Johannesburg, Oct ober, 1977. 13. Meurman, L. O., Kilvduto, R., Hakama, M. Br.J. ind.Med. 1974,31, 105. 16. Peto, J., Doll, R., Howard, S. V., Ktnlen, L. J., Lewisohn, H. C. ibid. 1977, 34,169. 17. Elmes, P. C, Simpson. M. J. C. ibid. p. 174 Ultrasonography of the Pancreas Ultrasound is a good test for pancreatic dis ease. In a series reported by Di Magno and others1 it proved far more reliable than isotope scanning. A positive result from ultrasonography, or from a pancreatic-function test if the ultrasound examina tion was normal, warranted endoscopic retro grade cholangiopancreatography (e.r.c.p.). This sequence of tests correctly identified 90% of patients with and without pancreatic disease. Di Magno et al. classed their ultrasound scans only as normal or abnormal. Other workers use ultrasound to explore the nature of the pancreatic abnormality.2*3 4 The performance and interpretation of an ultra sound scan of the pancreas demands considerable knowledge of anatomy and pathology coupled with skill and experience in ultrasonics. Absence of one of these ingredients jeopardises the examination. This may explain the wide disparity in the pub lished reports on pancreatic ultrasonography. Leading workers have for several years been dis playing the normal pancreas in detail.1,4 From a survey of 382 normal pancreases we can now state the normal antero-posterior and cranio-caudal dia meters of the head, body, and tail5--* *s8o9it is surpris ing to find Winship and others saying, this year, that "the normal pancreas is difficult or impossible to show".* In acute pancreatitis an enlarged, inflamed pan creas is seen in 83-90% of cases, even after the ser um-amylase has returned to normal.1,7 More im portantly, ultrasound shows whether pscudocysts are getting bigger or smaller and differentiates them from inflammatory masses, thus aiding surgi cal management.* Ultrasound will detect over 90% of pseudocysts greater than 2 cm in diameter1,1'*'11 and is far more accurate than other methods.1,1,11 The 8% false-positive rate is due to the difficulty of differentiating small cysts from small areas of nec rosis. Ultrasound reveals that about half of all attacks of acute pancreatitis are complicated by pseudocyst formation, 20-40% of the pseudocysts resolving spontaneously in the months that fol low.*-11 The ultrasound changes of chronic pancreatitis have been well described by French and German workers,1,1 who claim to detea specific changes of chronic pancreatitis in 40%12 to 94%.1 90% accur- 1.Di Magno, E. P., Milagelada, J. R.,Tavlor, W. F., Go, V. L. W. Ken Engl. J.Mcd. 1977,297,737. 2. Weill, F.. Krachcnbuhl, J. R., Becker, J. C, GUlet, M.. Bourgotn, A., Med. C/tir.Oig. 1974,3,19. V Imur. H.. FcuoKh, R,, Hofman, K. P., Rosch, U*. Klin. Vsebr. 1975* S3, 419. 4. IXhiM. B. D. Radiol. ClintN.Am. 1975,13,467. 5. Haber, K., Frcimtms, A. K., Asher, W. M. Am.J. Radiol. 1976,126, 624. 6 YX'inhip. D., Hcnsiorf, H-,Wilhelm,K. Gastroenterology. 1977,73,593. ?. Doust.B. D., Pearce, J. D. Radiology, 1976,120,653. 8. Duncan. J. G., Imrie, C. W* Blumgan, L. H. Br.J, Radiol. 1976,49,851. 9. Hancke.S.J. e/n. U/irdFotmd. 1976,4,223. 10.1 eopold. G. R. Radiology. 1972,104,365. THE LANCET, DEC acy has not be departments, s chronic pane: usually norms I than ultrasoui titis.1 In carcinorr malitics are seIi ; dfically diagn ) " Most tumours * the head or b< . have been rep ; meter.11 With 5; pancreas inen j' dnoma of the i I At present a { from localised -- easily disting V resemble a p ? lar.1,15 " Pcrcutanec ultrasound cc permits preo V dnoma of th< J pled, a posii . tumours werf aspirate was / and no posit ; without tun punctured apatients so t ? Most of the v re-punctured ) ture may av< ** the mortalit i wall time tot Vr- Computet T easier to pei ' ultrasonogr: of C.T. scan ? a start, the \t: scanner is t sound.19,10 1 | tion. Thou. 3 pitture of t % 10-20% wit tageforc.T fill ultraso further.19,11 V* _ y tl. Gonzalez, A. r* 315. l2.Uu,H.fc ; 13. Pictri, H. Ro* W.Gurct, E.M 15.WoltonA.H 16. Hancke, S.. I ,* 17. Hancke, S,,P "*. It. Andersen. R. 1977.115, sV 19.Krecl.UNVr ^ 20. Holm, H. K ll.Sunlcv, R. J. f. 22. Husband. J.1 ASARCO ALV 0005410 fjg LANCET, DECEMBER 10, 1977 1213 acy has not been achieved in British or American apartments, some of which still maintain that in chronic pancreatitis the ultrasonic picture is usually normal,1 e.r.c.p. is much more accurate than ultrasound in diagnosis of chronic pancrea- &s'5 In carcinoma of the pancreas ultrasonic abnor malities are seen in 90%,9,12 and a carcinoma is spe"cifically diagnosable in between 58%1J and 83%.2 3 Most tumours are over 2 cm in diameter and lie in the head or body. Lately, 11 carcinomas of the tail have been reported, 3 of them less than 2 cm in dia meter.15 With the incidence of carcinoma of the pancreas increasing at a rate exceeded only by car cinoma of the lung,14 early diagnosis is important. At present a small tumour is hard to distinguish from localised chronic pancreatitis. Carcinomas are easily distinguishable from cystadenomas, which 'resemble a pseudocyst but are usually multilocu- ; lar.2,15 I Percutaneous biopsy of the pancreas under 7.;'ultrasound control, a technically simple procedure, permits preoperative cytological diagnosis of car- dnoma of the pancreas. Of 20 carcinomas so sam>. pled, a positive aspirate was obtained in 17; 2 4-: tumours were too solid for aspiration and in 1 the aspirate was normal. There were no complications, and no positive results were obtained in patients ^.without tumour.16 Pseudocysts have also been punctured and drained by this means. Out of 22 .v patients so treated 2 had mild complications.17'11 f Most of the pseudocysts recurred and several were >, re-punctured. Even if not curative, repeated punc- rare may avoid operation in the acute phase, when f? the mortality-rate is highest,6 and allow the cyst J wall time to mature.1** Computerised tomography of the pancreas is a easier to perform and to interpret than pancreatic *. ultrasonography. With the increasing availability i of c.t. scanners, why bother with ultrasound? For 7. a start, the cost of buying and maintaining a C.T. scanner is ten times the equivalent cost for ultra sound.19,20 Ultrasound produces no ionising radia tion. Though c.T. scanning gives an inadequate picture of the pancreas in only 7%,21 as against 10-20% with ultrasound,12,19 clinically the advan tage for c.t. is slight: the patient with an unsuccess ful ultrasound scan will usually be investigated further.19,22 The X-ray absorption values of nor , H.Gonzalez, A. C, Bradley, E. L, dementi, J. L. Am.]. Redid. 1976,127, 315. * 12.Iutz, H. EUctromtdice. 1975* 2*3. 13. Pictri, H., Rotcllo, R., Aimino, B., Serafino, X.J. Radiol. 1976,57,610. 14. Gunct, E. tnumogtu, K. H., Nickel, VP. D. Am.J. Surg. 1977,134, 353. 1$. U'olton. A. H., Walls, W. J. Radiology. 1976.119,203. (6. Hancke. S., Holm, H. H., Koch, F. Sultry Gynec. Obstet. 1975, 140, 361. 17. Hancke, S., Pederwn, J. F. ibid. 1976,142,551. It. Andersen, R. N., Hancke, S., Nielsen, S. A. D., Schmidt, A. Ann. Surg. 1977,115,286. 19. Kreel, l_, Meire, H. B. Br. mtd.J. 1977, ii, 809. JO. Holm, H. H., Smith, H. ., Banrum, R. J.J. din. Ultrasound, 1977,5,230. 21. Stanley, R. J.,Sagcl, S. S., Levitt, R.G. Radiology. 1977,124,715. 22. Husband. J. E., Metre, H. B., Kreel, L. E.Br.J.Radtol. 1977,50,855. mal, inflamed, and cancerous pancreas are so simi lar that these conditions cannot be distinguished by C.T. scanning.21,23,24 This is not so with ultrasound, which delects much smaller density differences than X-rays, and thus displays more contrast between structures.20 Ultrasound should be the in itial investigation for most patients with suspected pancreatic disease. U.K. TRANSPLANT Since U.K. Transplant was set up in 1972, to distri bute cadaver kidneys between the 30 transplant centres in the United Kingdom and Ireland, over 3000 cadaver kidneys have been transplanted in the United Kingdom. A computer file of all patients awaiting a kidney trans plant is kept at the organisation's centre in Bristol, and from this file the best-matched recipients are chosen whenever cadaver kidneys are offered to the organisa tion for distribution. According to the annual report1 the number of patients waiting for a transplant continues to increase by about 100 each year. The latest figure is 1234. The rate of kidney transplantation has not in creased correspondingly, although last year's total of cadaver grafts (691) was some improvement over the previous year (604). About half these kidneys were transplanted by the centre which retrieved them. As in previous years, no significant improvement in graft sur vival was apparent in those patients who received wellmatched kidneys; however, a trend is discernible, and when the numbers are greater survival may prove to be correlated with matching. This is so in America, where a significant correlation between the number of HLA antigens mismatched and graft survival has at last become apparent in a series of nearly 5000 first cadaverkidney transplants.2 Achieving a perfect match for the four antigens at the HLA A and B loci remains a difficult task and last year this was accomplished in only 4% of cases transplanted in the U.K. Matching may be more important in patients who have acquired antibo dies before grafting. This group of patients do surpris ingly well, and with matching of A-locus antigens over 70% of grafts survive a year. A depressing feature of the report is the clear indication that the overall survival of kidney grafts is not improving as the years go by. In fact, cadaver-graft survival at one year has fallen from 62% to 50% during the past five years, a decline very similar to that in the United States.5 The introduction of a no-blood-transfusion policy for dialysis patients has been proposed as a cause for this, and in this year's report U.K. Transplant look carefully at the possibte influence of previous blood-transfusion on graft survi val. The analysis was done on 773 patients whose trans fusion history was accurately known, and the group of transfused patients did prove to have benefited: their graft survival was 5-10% better than that of the nontransfused group. A previous pregnancy was also associ ated with better survival. Another noteworthy observa tion was the improved graft survival if recipients were blood-group ABO identical, rather than ABO compat 23.I'etaimck, J. P-Clzrk, J. W. Cwreiei. Redid. 1976.1,201. 24. Sheedv, P. F., Stephen*. D. H., Hattery, M. D.. MicCarty, R. L. Radiology* 1977,124,731. 1. U.K. Transplant Annual Report, 1976-77. 2. Opelz, G., Mickey, M. R-, Terautt, P.!. Transplantation. 1977, 23, 490. 3.Tcrasaki, P.!., Opelz, G., Mickey, M. R. Transplant. Proe. 1976, S, 139. ASARCO ALV 0005411 121* THE LANCET, DECEMBER 10, 1977 ible, with the donor. Whereas the age of the kidney donor did not significantly influence the results, the age of the recipient was all important. For patients over the age of 50 graft survival at twelve months was only 3(M0%, and this was because many died in the first year with a functioning graft. Tables prepared from data provided by the registry of the European Dialysis and Transplant Association per mit comparisons of the treatment available in the U.K. with that in other European countries. Taking dialysis and transplantation together, 71 patients per million of the population received treatment in the United King dom in 1976. This is less than half the number treated by Switzerland, Denmark, and Israel, and at present the U.K. lies 13th in a table of 24 European countries. Most of the countries in Europe continue to open new dialysis centres and now have 3 per million of the population. By contrast, in Great Britain the number of dialysis centres is static at 1 per million of the population. The situation is not quite as bad as it seems, however, since through home dialysis these centres treat twice as many dialysis patients as do their counterparts, and the proportion of patients transplanted is higher than in most countries. Nonetheless Britain is clearly lagging, since it has the same incidence of renal failure as the rest of Europe. Last year the United Kingdom accepted 15 new patients per million of the population whereas France, the Federal Republic of Germany, and Italy were each accepting twice this number. Not only is the U.K. figure less than that for the previous year but it is also well below the average for Europe as a whole (19). Home dialysis in Britain has been a success but the number of patients who can be trained each year in existing dialysis centres is unlikely to increase. Nor is there much pros pect of a substantial increase in the rate of kidney trans plantation. At present the only way to help more patients with renal failure is to increase facilities for haemodialysis. This could be done by constructing more dialysis centres or by establishing satellite units linked to existing centres. ON PISSING IN THE BEDDE1--AND ELSEWHERE Most children's doctors can be confident about the diagnosis and management of nocturnal enuresis. Results of treatment may vary with their enthusiasm, but with a spontaneous-cure rate of about 20% per annum time is on their side. Children with day-andnight wetting seem more difficult to treat and often have other symptoms (urgency, fecal soiling) which dis tinguish them from those with nocturnal enuresis alone. Berg and others,1 in Leeds, have tried to identify such differences. They investigated 86 children--40 day-andnight wetters referred to a children's psychiatrist, 29 night wetters referred to a pediatrician, and 17 night wetters attending a child-psychiatry clinic. They assume that the degree of psychiatric disturbance dictates whether a child with nocturnal enuresis should be referred to psychiatrist or children's physician; in some parts of the country it indicates differing lengths ofwait- I.llionui Phairc'* Boke of Chyldren. 1553. 2. Rcrc.L. Fielding, D.. Meadow, R.ArektDii. Chtidh. 1977,52,651. ing-list. During an interview with a single observer, mothers gave information about the presenting disorder, social behaviour, and school performance. Urgency, soil ing (most commonly in boys), and parental exhortatior to use the lavatory were more common in day-and-nigh wetters. Although some parents in all groups had a his tory of nocturnal enuresis, current urinary symptoms such as urgency or giggle incontinence were not asked about--a surprising omission since two-thirds of the whole group of children complained of urgency and this was more common in those with any wetting pattern referred to a psychiatrist than in children with noctur nal enuresis attending a paediatrician. Understandably, parental urging of the child to toilet followed a similar pattern: some mothers are probably anxious about their own continence and project their worries on the child: others, of course, are simply exasperated with a wet and smelly child. The children's schools were visited and a standard psychological profile was completed for the patient and a control child. Again, day-and-night wetters emerged with more psychiatric disturbance--neuroticism in girls and antisocial behaviour in boys. Night wetters differed little from controls. Each child was exa mined by a paediatrician and the urine was tested. Bacteriuria was virtually confined to girls who wetted day and night, and eradication of infection did not alter that pattern. Radiology of the urinary tract was mostly nor mal. Lastly, maximum bladder capacity (m.b.c.)-- meaning the volume of urine obtained from a child at bursting point--was measured in most children and 88 controls; the m.b.c.s of all wetters were less than those of normal children. This has been reported before3 in .nocturnal enuresis; by bladder training, capacity can be increased and enuresis cured at six-month follow-up.4 The doctor has to ask himself three questions about a child with urinary incontinence. Firstly, is the child old enough, sane enough, and intelligent enough to be capable of dryness? Secondly, does the incontinence result from physical disorder? It seldom does, and a care ful examination of child and urine should resolve this point. Furthermore, as Berg and others1 observe, uri nary infection in girls with damp pants is probably a result rather than a cause of wetting. Radiography of spine and urinary tract are not therefore indicated in most children.5 6Pressure studies of bladder function may yield interesting results, such as abnormal detrusor function in patients with urgency and day-and-night wetting.* Therapeutic benefits are marginal so these in vestigations must never be a routine in childhood. Finally, is the incontinence one symptom of a wider emotional disorder? Nocturnal enuresis alone is usually a biological phenomenon which is likely to remit with tricyclic antidepressants--probably from their choliner gic effect--for as long as they are prescribed. An alarm system will be more permanently successful, if it is used in the right way by the right families and prescribed by the right doctor.7 Children who wet by day and night 3. Stirficld. R.J. Pediat. 1967,70, 777. 4. StarfcM. R, Mclliu. E. D.itid. 196S.72.4S3. 5. Meadow, S. R. in Bladder Control and Enurttit (edited by I. Kolvin, R. G. Mac Keith,and S. R. Meadow); p. U3. London, 1973. 6. ttlmctidc, C G.. Arnold, H. P.Br. mtd.J. 1975, i, 364. 7. Ditche, S. in Bladder Control and Enurem (edited by I. Kolvin, R. C. Mac Keith, and S. R.Meadow);p.2U.l.ondoa, 1973. THE LANCET,! more usuallj own skilled likely to ha\ response wh for the child THIRD 1NT The Cali ary treatmc a wheat la. Leiden, Ox ' when the ti groups in smith are u ' toxicity or The results continue tc xylose) anc other matt. sium,held: 5 The pre West of Ir< ; for the hig tic basis of - that an in< DWR3, ai tigen, is ve cf How lo i large num \ members troenteroli ; tolerance. ' London c d gluten in ; tolerance, v. followed i *. diet will l up to clai V-` in relatiox j, rate prog fl ponding t terology arising b< untreated 7" ponded tc ' The b< 5/. with unr ? Bristol a H" like skin 3 antibodic ?' being fc V, damage. reponed v the gluu f preparat f. cceliac s and phrs A ----------;i,\ . LMcNtch. cix. 1 ASARCO ALV 0005412 Vft LANCET,JDEfEMBER 10, 1977 1215 uore usually have an emotional disturbance needing its wn skilled treatment; children who wet by night are likely to have urgency. Might not this be a conditioned response which can be modified by behaviour therapy for the child--or its parents? iStt:' i third international cceliac symposium The Californians have an original approach to diet ary treatment of cceliac disease: they are trying to breed a wheat lacking in alpha-gliadin. Meanwhile, work in Leiden, Oxford, and Galway is bringing nearer the day when the toxic fraction of gluten is fully identified; and groups in Boston, Paris, Bergen, Bern, and Hammer smith are using intestinal organ cultures as indicators of - toxicity or to study the nature of the intestinal damage. ^The results tend to be non-specific, so that some workers . continue to rely on in-vivo absorptive tests (e.g., with xylose) and on sequential intestinal biopsies. These and . other matters came up at the third international sympo sium, held in University College, Galway. The prevalence of HLA B8 seems to be higher in the West of Ireland than elsewhere, presumably accounting for the high incidence of cocliac disease there. The gene\ tic basis of the disease is now becoming clearer; it seems ' that an individual with the tissue antigens HLA B8 and . DWRS, and also with a B-lymphocyte-specific alloantigen, is very likely to get cceliac disease. How long does gluten intolerance persist? 97% of a ** large number of patients with cceliac disease managed by members of the European Society of Paaiiatric Gastrocnterology were judged to have permanent gluten in. tolerance. Groups from Galway, Paris, Geneva, and . London described children with varying degrees of gluten intolerance or with apparent eventual gluten tolerance, but it was agreed that such children must be followed up assiduously and that a lifelong gluten-free J diet will be the lot of almost all. A small panel was set up to clarify and unify diagnostic criteria, particularly in relation to mucosal morphology, as the basis for accurate prognosis and continued observation. No-one res\ ponding to the European Society of Patdiatric Gastroen' terology questionnaire knew of a case of lymphoma t arising below the age of 18 years, or knew of a case of untreated childhood cceliac disease which had not res? ponded to a gluten-free diet. it-.. The benefits of zinc and other trace metals in adults f with unresponsive disease were reported from Belfast. Bristol and Oxford reported their results with Arthuslike skin reactions to gluten fractions, which, like serum antibodies to gluten, are not specific to cceliac disease, -! being found in other forms of intestinal mucosal damage. Patients' views on gluten avoidance were t1' reported from Bristol. Constipation is a big drawback of I?;, the gluten-free diet, and this is lessened by a rice-bran ,'J- preparation. The patients can get much help from a S.; cocliac society--not least, with holiday arrangements -'. and phrase sheets for use in foreign restaurants. l.McNtcholi, B., Fottrcll, P. F., McCirthy, C F. Perspective* in Qriinc Diifj' cue. Ijncoter (in the press). WHICH MEDICINE? How docs a doctor decide which drug, or which prep aration of a drug, to prescribe? In the existing system, the decision involves at least two processes. Firstly, the doctor must be made aware of the existence of a drug, and the continuing introduction of new products to a market which at present exceeds 30 000 formulations makes this a formidable proposition. Secondly he has to get information on the drug's usefulness in individual patients. In a sample of general practitioners,1 3drugcompany representatives were the prime source of infor mation about the existence of a drug, closely followed by MIMS. Almost half the practitioners admitted that they were unable to obtain an unbiased assessment of a new drug. The most helpful sources of advice were consul tants, and articles in medical journals. These observa tions raise important questions about the role and res ponsibility of the pharmaceutical industry in postgraduate education, and particularly about the in fluence of the 3000 drug-company representatives, most of whom are not medically qualified and in no position to advise on treatment of an individual patient. The pharmaceutical industry contributes towards post-gra duate education by medical meetings and films, but the cost of representatives and their activities is the main item, reckoned at about 20 million a year.1 Do we really have to continue with this two-stage approach to decision-making in prescribing? While in formation on a drug and its pharmacological properties is important, there has been a tendency to forget that clinical medicine is, or should be, directed towards the patient and his disease. At a symposium on the informa tion needs of the prescribing physician, Hunter1 said that the prescriber would be helped if the emphasis in in formation systems could be shifted from the drug to wards the disease. A clinical pharmacologist is, by train ing, both a pharmacologist and a clinician and should be able, in collaboration with his clinical colleagues, to build the basis of such a system in the hospital ser vice4'5--6 particularly ifsupported by a hospital pharmacy information centre.* Alas, these facilities are rare in hospitals, and general practitioners with ready immediate access to such advice are few indeed. Most doctors are well aware of their shortcomings in prescribing, want to do something about it, but do not know where to turn for advice at the time when they most need it. Which brings us back again to a plea we have uttered before,1 for a publica tion--perhaps a redesigned, regularly updated, costconscious British National Formulary--which would provide advice on the best treatment for a particular condition, on how to administer it, and on the potential dangers and necessary precautions. The 1976-78 BAM7, is already out-of-date in many respects, and it is disturb ing that the Department of Health has said nothing about plans for a successor. 1. Elon, G,, Piriih. P.JI. R. Coll. ten. Praciilnn. 1976, 24, tuppl. 1, p. SI. 2. Rlwlitw, M. D. Br.J. din. Pharmoc. 1977,4,2S7. 3. Hunter. K. K.Paifrod. mcd.J. 1977, S3,541. 4. Qmtcil lltirniicoiojy Section of the British Ph.rnt.coiojid Society. Be. J. din. Pharmac. (in the press). 5. Htexheimcr^ A.Postgrad, meet.J. 1977,55,55*. 6. McNulty, H. ibid. p. 556. 7. Lancet* 1976, ii, 551. I t- b *: V ; > k : !r 2 .. \I i t i Vi < H E. ! I, slI. r r f M f- ASARCO ALV 0005413