The natural history of waiting lists--some wider explanations for an unnecessary problem

The examination of waiting list statistics suggests that long waiting times have at most a tenuous relationship with any lack of NHS resources. Long waiting times offer strong evidence that NHS resources are not allocated rationally in that the conditions whose relative neglect is expressed in waiting lists are those conditions where clear benefits are likely to follow comparatively cheap treatments. This article offers two wider explanations for the fact that this seemingly irrational picture has continued largely unchanged since the inception of the NHS, and is still effectively tolerated. The first concerns public responses to the waiting list conditions, and the second concerns professional priorities. 'He uses statistics as a drunken man uses lamp-posts--for support rather than illumination.' Andrew Lang.

Carbonic anhydrase: a marker for the erythroid phenotype in acute nonlymphocytic leukemia

Protein markers are often used to corroborate the morphological subtyping of hematopoietic malignancy. Most commonly, surface markers are used for the phenotyping of hematopoietic cells; however, internal proteins have also been used as markers. Glycophorin, hemoglobin A, hemoglobin F, and transferrin have all been used as markers for the erythroid phenotype. We have recently shown that carbonic anhydrase is constitutively and aberrantly expressed in two erythroleukemic cell lines. We here show that it is also present in high levels in primary erythroleukemic blasts and that it is a useful marker for the M6 phenotype when classifying acute nonlymphocytic leukemia.

Social and cultural aspects of family planning programmes

In all societies fertility is an important issue imbedded within a specific cultural framework. Changes in fertility rates, in particular, where these are intended to be brought about by family planning programmes, require sensitive understanding of the interactions of belief, social organization and individual choice. The anthropological method of inquiry is very useful in this regard and is here illustrated in a study of family planning among the Huli of the Southern Highlands.

Sterile Corvac silicone gel tubes: efficacy and storage capabilities

The storage capability of the sterile Corvac silicone gel tube as a specimen collection device is evaluated. Sera collected and stored in sterile Corvac silicone gel tubes were compared with control specimens collected in regular Monoject tubes and transferred to new Monoject tubes for storage. Sera for the efficacy tests were transferred from both the gel tube and the control tube without concern for storage. Sixty-seven analytes were compared, 20 of which were included in the storage portion. Only glucose, potassium, carbon dioxide, phosphorus, alkaline phosphatase, and lactic acid dehydrogenase (LDH) were statistically different in the storage experiment and amylase, T-3 uptake, folates, HDL, and again LDH by another method, were statistically different in the efficacy experiment. These evaluations determine the validity of storing specimens in this manner for reanalysis or additional analyses.

Peripheral health workers are central to primary health care: lessons from Papua New Guinea's aid posts

This paper examines the nature of the service offered by Papua New Guinea's primary health workers and analyses the factors that influence their performance. The structural position of these peripheral health workers in the health care system set limits to the effectiveness of current Health Department policy in determining the quality and availability of local services. Instead a variety of factors are found to be important. These include the individual attributes of health workers, the expectations that their clients have of them, local priorities in health, the relationship between attitudes to health and illness and the perceived value of Western medicine, and aspects of local social organization. The implications for policy of the findings are discussed.

Intra-arterial chemotherapy using an implantable infusion pump and liver irradiation for the treatment of hepatic metastases

Liver metastases are a common cause of death in colon carcinoma. The dual blood supply of the liver permits regional perfusion while hepatic catabolism fo 5-fluorouracil (FU), floxuridine (FUdR) permit higher drug exposures than systemic (IV) administration. We have studied the effect of continuous intra-arterial chemotherapy (FU: 5-10 mg/kg/day and FUdR: 0.2 mg/kg/day) and whole liver irradiation (1000 rad every 4 weeks, total dose of 3000 rad) for metastatic colon carcinoma to liver. Eighteen patients with metastases to liver only are reported using this combination therapy. Seven patients had percutaneous placement of a catheter via the brachial artery, two had operative placement of a catheter via the gastroduodenal artery, all of which were connected to the Cormed infusor system, nine had operative placement of the Infusaid implantable pump with catheter placement into the hepatic artery via the gastroduodenal artery. The median survival for the entire group was 241 days. In those patients whose liver function tests (bilirubin and alkaline phosphatase) were less than two times normal, the median survival was 770 days. The median survival of the patients with greater than two times normal LFT's was 178 days. Two patients died of complications of the treatment. One who developed irreversible radiation hepatitis but at autopsy had only two areas of microscopic tumor foci in the liver and another who had received only 15 days of infusion and 1000 rad to liver. This patient developed irreversible chemical enteritis secondary to chemotherapy infusion into the superior mesenteric artery. Three patients have undergone abdominal reexploration and one at autopsy, who were found to have no gross evidence of tumor in the liver despite previous pathologic confirmation. It appears that some patients with minimal tumor burdens can have sterilization of their tumors. There were three cases of reversible liver function abnormalities. Complications associated with conventional intra-arterial chemotherapy (artery thrombosis, catheter sepsis and dislodgement, pump infusion variation and pump failure) were not seen with the Infusaid delivery system. The pump is refilled every 2-3 weeks via percutaneous puncture. All therapy was given on an outpatient basis. Pump acceptance and tolerance was 100%. Intra-arterial chemotherapy can now be accomplished without the morbidity associated with it in the past. The combination of chemotherapy and liver irradiation may offer improved survival in selected patients.

Conjugal bereavement amongst the Huli people of Papua New Guinea

The Huli people of the Southern Highlands Province of Papua New Guinea mourn in culturally patterned ways that differ for men and women. One difference is that women are expected to express their emotions, while man are discouraged from doing so. In this study the mortality of bereaved spouses was determined by following 100 widowers and 208 widows for four years following their bereavements. Widowers showed an excess mortality in the first year following bereavement, while widows showed no such tendency. The possible relationship between these findings and Huli mourning practices is discussed.

Maturation of hypothalamic-pituitary-thyroid response in the rat to acute cold

Groups of rats 3, 4, 5, 7, and 10 wk of age were tested for their ability to respond to acute cold (4 degrees C for 30 min). Thyroid reactions were estimated from intrathyroidal colloid droplet (CD) counts, serum thyrotropin (TSH) and thyroxine (T4) levels. Normally CD counts increased to a maximum in the 5-wk-old rats were lower in the 7-wk-old, and still lower in the 10-wk-old animals. The significant finding was that exposure to cold caused a decrease in CD counts in 3-, 4-, 5-wk-old rats but an increase in mature animals. This CD decrease was apparent within 10 min in the 4- and 5-wk-old rats, Injections of TSH and thyrotropin-releasing hormone (TRH) raised CD counts in all age groups but had little effect on response to cold. TSH serum levels were higher in the 5-wk-old than in the 3- and 4-wk-old animals; cold caused a greater TSH reduction in the 5-wk-old rats than in younger groups. Serum T4 levels were approximately the same in 3-, 4-, and 5-wk-old rats; when they were exposed to cold, the level rose despite the fact that CD counts dropped. These data indicate that in rats hypothalamic-pituitary-thyroid reactions to acute cold attain the adult pattern between 5 and 7 wk after birth.

'I am dying of man': the pathology of pollution

This paper is concerned with illnesses in men that the Huli people of Papua New Guinea ascribe to sexual intercourse at a time deemed dangerous. Against the background of the complex of beliefs surrounding sexuality and reproduction, cases of such illnesses are analysed to determine the critical variables in the selection of this diagnosis and in the choice of strategies of management.

Infusional 5-fluorouracil and X-ray therapy for non-resectable esophageal cancer

Six patients with unresectable carcinoma of the esophagus received a combined course of external radiation therapy (1000 rads in four fractions in four days commencing on day 2) combined with constant infusional 5-fluorouracil (20 mg/kg every 24 hours for five days beginning on day 1). This program was repeated every other week to give a total x-ray dose of 6000 rads. This regimen has been well-tolerated by the majority of the patients and resulted in a complete response rate within the x-ray treatment field of 83% (5/6). All patients who showed a demonstrable systemic response to 5-fluorouracil reached complete response. The median survival has not yet been reached at six months with post-treatment survivors alive and without disease (four patients) at one, six, nine, and 22 months. Our previous median survival by x-ray therapy alone was 4 1/2 months. Toxicity consists primarily of hematologic suppression at a subclinical level. Although the length of therapy is substantial (11 weeks), the program appears tolerable and is capable of inducing long-term remissions. The program is currently being studied for dose escalation because neither local nor systemic side effects of a dose-limiting nature have been observed at 20 mg/kg 5-FU.

An indication for conjoint treatment: an application based on an assessment of individual psychopathology

Conjoint treatment is advocated as the treatment of choice for a particular class of patients who do not seem able, at least initially, to benefit from individual exploratory psychotherapy. These people identify a person or persons, usually a spouse, as the primary cause of their difficulty. They show no initial capacity for self-observation. Their needs are childlike, and they show limitations in skills and a striking inability to sustain mutually gratifying relationships. The conjoint situation seems capable of initiating self-observation by confronting them with the reality of the person about which they are making claims. As a therapy, it also initiates an improvement in their marital relationship, thereby helping them potentially to gain that which they crave so desperately, but had been unable to realize except in compromise form, that is, in fantasy or in a relationship with a therapist.

The management aspect of psychotherapy with aggressive children

Psychotherapy with an aggressive child may require the imposition of rather firm limitations over aspects of the patient's aggressive behavior. The nature of this management strategy is determined by the individual child's psychopathology. The management aspects of the psychotherapy with two aggressive boys are illustrated in detail. In one case, stringent limitations were imposed when it was discovered that the boy's behavior was regressive and represented an effort to sadistically control people in his environment. In the other case, the behavior was initially left almost unchallenged; this boy's aggressive and delinquent behavior reflected an effort to achieve a sense of order in an inconsistent external and potentially chaotic internal environment.

Severe urticaria caused by a moth Euproctis sp. (Lepidoptera: Lymantriidae)

The urticating hairs of a moth Euproctis sp., were found to be the cause of a severe urticarial and pruritic rash in an expatriate family. Such incidents are probably not uncommon in Papua New Guinea, and are best solved by destroying the food tree of the caterpillars where this is feasible.

Working towards a village technology: recycling waste

An account of the Construction of a Hospital waste Digester.