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Drug use in developing countries

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174 relationship remains the same and the obligations owed by the survivor to the deceased are no doubt altered by death, but by no means terminated. The same would be true of a solicitor-client relationship, the former continues to have some obligations arising out of the living relationship to the latter, notwithstanding death... There is no reason why the word ’patient’ should be read down for the purpose of the regulations as being confined to living patients capable of receiving treatment". The judge directed the jury to acquit. The Crown had sought leave to appeal (before Green C7 and Neasey and Crawford, JJ) that the judge’s direction to the jury had been based on an error. In the absence of anything in the statute or regulations which indicated that "patient" should be given a meaning other than which it ordinarily bore, it should be taken to mean "a living person who was under medical treatment". There was nothing in the statute or the regulations to show that any different meaning was intended-indeed, the Crown argued, several provisions supported the proposition that "medical attendance" and "patient" meant professional attendances upon a living person for purposes relating to treatment. The appeal judges (Crawford J dissenting because he was not satisfied that there was evidence on which the doctor could or would have been convicted whatever the direction of the trial judge) allowed the appeal. In this case the doctor clearly knew that his patient was dead before the visit. However, the reasoning of the Tasmanian Appeal Court, if taken to its logical conclusion, suggests that on clinical death there is no "patient". A person clinically dead therefore cannot, according to this definition, be a "patient". If there is no live patient then no duty of care legally would seem to attach to the doctor. In my view, however, a doctor is under a duty of care to a patient to examine him with a view to making sure that the patient is dead. I would go further: the doctor has a duty to ascertain, at least prima facie, the cause of death and whether it appeared to be natural and expected. The decision in R v Pawsey is not a happy one when taken outside its narrow facts. Diana Brahams Noticeboard Is bone density screening worth while? Bone density screening will lead to the prevention of no more than 5% of fractures in elderly women and should not be offered routinely to menopausal women, says a new bi-monthly bulletin distributed free by the Department of Health to 27 000 purchasers and providers of health care. The first issue of Effective Health Care/ devoted to screening for osteoporosis, concludes from a review of published studies that bone density measurements are poor at identifying women who will be at risk of fractures in later life and that fewer than 25% of women are likely both to attend for screening and to take hormone replacement therapy (HRT) long term. The review, prepared by public-health research workers from Leeds and York Universities and two Yorkshire health authorities, indicates that the impact of screening has previously been considerably overestimated because compliance has been assumed to be 100%. Savings from the reduction in incidence of fractures would not offset the costs of screening and HRT, the research team claims. A dual-energy X-ray absorptiometry machine costs about 50 000 and has a useful life of around seven years. Accommodation, maintenance, and staff can cost up to C85 000 a year. Apart from the costs of the initial screen, there are the costs of HRT, which with two general-practitioner check-ups amount to £ 60 a year. Despite substantial evidence of a protective effect of oestrogens against bone loss, from both prospective2 and epidemiological3 studies, the bulletin argues that "the effectiveness of HRT in preventing fractures much later in life when taken for ten years after the menopause by women with low bone density is not proven". However, bone screening is already offered by private clinics and some health authorities, and there has been substantial pressure to set up population bone-screening programmes for women as part of public health policy. 1. Screening for osteoporosis to prevent fractures. Effective Health Care no 1 January, 1991. Inquries to Nick Freemantle, Effective Health Care, School of Public Health, University of Leeds, 32 Hyde Terrace, Leeds LS2 9LN, UK. 2. Lindsay R, Hart DM, Forrest C, Baird C. Prevention of spinal osteoporosis m oophorectomised women. Lancet 1980; ii: 1151-54. 3. Hutchinson TA, Polansky SM, Feinstein A. Postmenopausal oestrogens protect against fractures of hip and distal radius. Lancet 1979; ii: 705-09. Antimalarial action of chloroquine The quinoline-containing drugs, such as chloroquine and quinine, act specifically against the intra-erythrocytic stages of pigment-producing malaria parasites. How do they work? When the parasite degrades haemoglobin for food in its digestive vacuole, haem is produced. To detoxify the haem the parasite incorporates it into haemozoin, or malaria pigment. Haemozoin is a polymer of haem. Slater and Ceramil have identified and characterised activity of a haem polymerase enzyme and have found that this enzyme is inhibited by quinoline-containing drugs. They suggest that their finding paves the way for the rational design of new classes of antimalarial agents. In an accompanying commentary, Wellens2 explains that malaria parasites actively concentrate quinoline-ring compounds, and resistant organisms have an efflux mechanism that releases the drug 40-50 times faster than do sensitive parasites. He points out that since various compounds can partly reverse resistance by inhibiting efflux, it is unlikely that resistance is due to mutations or structural alterations in haem polymerase. Thus polymerisation seems to be a vulnerable target in antimalarial therapy. 1. Slater AFG, Cerami A. Inhibition by chloroqume of a novel haem polymerase enzyme activity in malaria trophozoites. Nature 1992; 355: 167-69. 2. Wellens TE How chloroquine works. Nature 1992; 355: 108-09. Objections to a trial The Department of Health in London acknowledges that the general issue of cholesterol and cardiovascular disease is fundamental to one of the most important causes of mortality in the UK. It has been looking at the proposal for a study into the use of 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitors to reduce cholesterol and thus cardiovascular morbidity and mortality. Here are two of the DH’s reasons, in an unofficial document, for opposing the trial: "the importance of not inadvertently undermining the key recommendations of a DH statutory committee, the Standing Medical Advisory Committee" and "the real danger that a ’positive’ result from the trial (particularly when manipulated by the pharmaceutical industry) could lead to widespread and inappropriate use of lipid-lowering drugs and to disregard of dietary and other methods of lipid reduction". Drug use in developing countries Inappropriate drug use seems to be the rule rather than the exception in developing countries, says a report from Health Action International (HAI).’ Drugs that are not essential to recovery, of proven efficacy, acceptably safe, or reasonably priced are widely used and are just as likely to be bought from a grocery store or travelling drug pedlar as from a pharmacy. Potent medicines that should be available on prescription only are often bought over the counter, and diarrhoea is commonly treated with drugs instead of
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relationship remains the same and the obligations owed bythe survivor to the deceased are no doubt altered by death,but by no means terminated. The same would be true of asolicitor-client relationship, the former continues to havesome obligations arising out of the living relationship to thelatter, notwithstanding death... There is no reason why theword ’patient’ should be read down for the purpose of theregulations as being confined to living patients capable ofreceiving treatment". The judge directed the jury to acquit.The Crown had sought leave to appeal (before Green C7and Neasey and Crawford, JJ) that the judge’s direction tothe jury had been based on an error. In the absence ofanything in the statute or regulations which indicated that"patient" should be given a meaning other than which itordinarily bore, it should be taken to mean "a living personwho was under medical treatment". There was nothing inthe statute or the regulations to show that any differentmeaning was intended-indeed, the Crown argued, severalprovisions supported the proposition that "medicalattendance" and "patient" meant professional attendancesupon a living person for purposes relating to treatment. Theappeal judges (Crawford J dissenting because he was notsatisfied that there was evidence on which the doctor couldor would have been convicted whatever the direction of thetrial judge) allowed the appeal.

In this case the doctor clearly knew that his patient wasdead before the visit. However, the reasoning of theTasmanian Appeal Court, if taken to its logical conclusion,suggests that on clinical death there is no "patient". Aperson clinically dead therefore cannot, according to thisdefinition, be a "patient". If there is no live patient then noduty of care legally would seem to attach to the doctor. In myview, however, a doctor is under a duty of care to a patient toexamine him with a view to making sure that the patient isdead. I would go further: the doctor has a duty to ascertain,at least prima facie, the cause of death and whether it

appeared to be natural and expected. The decision in R vPawsey is not a happy one when taken outside its narrowfacts.

Diana Brahams

Noticeboard

Is bone density screening worth while?

Bone density screening will lead to the prevention of no morethan 5% of fractures in elderly women and should not be offeredroutinely to menopausal women, says a new bi-monthly bulletindistributed free by the Department of Health to 27 000 purchasersand providers of health care. The first issue of Effective HealthCare/ devoted to screening for osteoporosis, concludes from areview of published studies that bone density measurements arepoor at identifying women who will be at risk of fractures in later lifeand that fewer than 25% of women are likely both to attend forscreening and to take hormone replacement therapy (HRT) longterm. The review, prepared by public-health research workers fromLeeds and York Universities and two Yorkshire health authorities,indicates that the impact of screening has previously been

considerably overestimated because compliance has been assumedto be 100%.

Savings from the reduction in incidence of fractures would notoffset the costs of screening and HRT, the research team claims. Adual-energy X-ray absorptiometry machine costs about 50 000and has a useful life of around seven years. Accommodation,maintenance, and staff can cost up to C85 000 a year. Apart from thecosts of the initial screen, there are the costs of HRT, which withtwo general-practitioner check-ups amount to £ 60 a year.

Despite substantial evidence of a protective effect of oestrogens

against bone loss, from both prospective2 and epidemiological3studies, the bulletin argues that "the effectiveness of HRT inpreventing fractures much later in life when taken for ten years afterthe menopause by women with low bone density is not proven".However, bone screening is already offered by private clinics andsome health authorities, and there has been substantial pressure toset up population bone-screening programmes for women as part ofpublic health policy.

1. Screening for osteoporosis to prevent fractures. Effective Health Care no 1 January,1991. Inquries to Nick Freemantle, Effective Health Care, School of Public Health,University of Leeds, 32 Hyde Terrace, Leeds LS2 9LN, UK.

2. Lindsay R, Hart DM, Forrest C, Baird C. Prevention of spinal osteoporosis moophorectomised women. Lancet 1980; ii: 1151-54.

3. Hutchinson TA, Polansky SM, Feinstein A. Postmenopausal oestrogens protect against fractures of hip and distal radius. Lancet 1979; ii: 705-09.

Antimalarial action of chloroquine

The quinoline-containing drugs, such as chloroquine andquinine, act specifically against the intra-erythrocytic stages ofpigment-producing malaria parasites. How do they work? Whenthe parasite degrades haemoglobin for food in its digestive vacuole,haem is produced. To detoxify the haem the parasite incorporates itinto haemozoin, or malaria pigment. Haemozoin is a polymer ofhaem. Slater and Ceramil have identified and characterised activityof a haem polymerase enzyme and have found that this enzyme isinhibited by quinoline-containing drugs. They suggest that theirfinding paves the way for the rational design of new classes ofantimalarial agents. In an accompanying commentary, Wellens2explains that malaria parasites actively concentrate quinoline-ringcompounds, and resistant organisms have an efflux mechanism thatreleases the drug 40-50 times faster than do sensitive parasites. Hepoints out that since various compounds can partly reverse

resistance by inhibiting efflux, it is unlikely that resistance is due tomutations or structural alterations in haem polymerase. Thuspolymerisation seems to be a vulnerable target in antimalarialtherapy.

1. Slater AFG, Cerami A. Inhibition by chloroqume of a novel haem polymerase enzymeactivity in malaria trophozoites. Nature 1992; 355: 167-69.

2. Wellens TE How chloroquine works. Nature 1992; 355: 108-09.

Objections to a trial

The Department of Health in London acknowledges that thegeneral issue of cholesterol and cardiovascular disease isfundamental to one of the most important causes of mortality in theUK. It has been looking at the proposal for a study into the use of3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductaseinhibitors to reduce cholesterol and thus cardiovascular morbidityand mortality. Here are two of the DH’s reasons, in an unofficialdocument, for opposing the trial: "the importance of not

inadvertently undermining the key recommendations of a DHstatutory committee, the Standing Medical Advisory Committee"and "the real danger that a ’positive’ result from the trial

(particularly when manipulated by the pharmaceutical industry)could lead to widespread and inappropriate use of lipid-loweringdrugs and to disregard of dietary and other methods of lipidreduction".

Drug use in developing countries

Inappropriate drug use seems to be the rule rather than theexception in developing countries, says a report from Health ActionInternational (HAI).’ Drugs that are not essential to recovery, ofproven efficacy, acceptably safe, or reasonably priced are widelyused and are just as likely to be bought from a grocery store ortravelling drug pedlar as from a pharmacy. Potent medicines thatshould be available on prescription only are often bought over thecounter, and diarrhoea is commonly treated with drugs instead of

175

oral rehydration therapy. The public-health consequences ofirrational drug use have not been documented; but, says HAI, ahigh incidence of untoward effects and treatment failures is to beexpected. HAI’s conclusions are based on a review of published(and a few unpublished) studies of drug use in developing countries.An annotated list of these references forms the bulk of the report.

1 The provision and use of drugs in developing countries. By Anita Hardon, Sjaak vander Geest, Hanna Geerling, and Amanda le Grand. Amsterdam: Health ActionInternational. 1991. ISBN 9073052173.

Death rites

In England, death as a conversational topic is rare; the word itselfis shrouded in euphemisms ("fell asleep", "passed over", "is nolonger with us"), nervous humour ("popped his clogs", "kicked thebucket", "snuffed it"), and plain embarrassment. That death wasnot always so regarded can be seen at a new exhibition at the Victoriaand Albert Museum, London (Jan 8-March 22), which bringstogether an impressive range of objects designed for the death ritualin England between 1500 and 1800. Then, death was recognisedopenly as a universal human experience: it was confronted ratherthan ignored. This is not to say that people were any less frightenedof death than they are now; but to deal with it they surroundedthemselves with reminders of their mortality. The stages of thedeath ritual from contemplation of the hour of death, throughtreatment of the body and last rites, to mourning andcommemorative paraphernalia are the principal features of the Artof Death. The visitor will see death masks, coffms, commemorativeart, burial garments, and mourning jewellery; many exhibits

The Tor Abbey Jewel (circa 1545-50).

Probably English but possibly made in Pans, enamel on gold. Victoriaand Albert Museum.

underscore the importance of the death ritual in everyday life-eg,the Tor Abbey Jewel (figure), a pendant found in Devon in the 19thcentury that would have been worn as a memento mori. The

exhibition, which is accompanied by a book,’ also aims to encouragedebate and a re-examination of the role and nature of the modemdeath ritual. However, even the V and A seems unable to overcomethis taboo of modem British society: the exhibition was postponedlast year because of the Gulf war.

1 The art of death: visual culture in the English death ritual, 1500-1800. By NigelLlewellyn. London: Reaction Books. 1991 Pp 160. £9.95. (Available also from theVictoria and Albert Museum)

Louis Jeantet prizeThe 1992 Louis Jeantet prize for medicine has been awarded to

Prof Paul Nurse (Imperial Cancer Research Fund Cell CycleGroup, Oxford University), Prof Christiane Niisslein-Volhard(Max-Planck Institute, Tubingen), and Dr Alain Townsend(Institute of Molecular Medicine, John Radcliffe Hospital,Oxford).

Opportunities for women in the NHS

The NHS is a member of Opportunity 2000, a campaign for abalanced workforce. An early step taken as part of the campaign wasthe setting up of a women’s unit. Now the NHS ManagementExecutive has defmed eight goals to be achieved by 1994.1 They are(i) to increase the number of women in general management postsfrom 18% in 1991 to 30% in 1994; (ii) to increase the number ofqualified women accountants; (iii) to increase by 10% annually thepercentage of women consultants, from 15-5% in 1991 to 20% by1994, and to accelerate the increase in proportion of those in surgicalspecialties, from 9-7% per annum to 15%; (iv) to increase theproportion of female members of NHS Authorities or Trusts from29% in 1991 to 35%; (v) to introduce a programme to help potentialwomen managers to develop their skills; (vi) to improve recuitmentand retention of nurses and midwives; (vii) to ensure that womenreturning to part-time work or a job share after maternity leave cando so without dropping work grade; and (viii) to ensure that womendo not take longer than men to reach nursing management posts.

1. Women in the NHS. An action guide to the Opportunity 2000 campaign. London.Department of Health, 1991. Pp 8.

Withdrawal of tienilic acid in France

Tienilic acid, developed in France, was the first uricosuricdiuretic. It was marketed very successfully throughout the world inthe late 1970s, but soon cases of renal failure, liver damage, andother serious problems began to be reported, and in 1980 the drugwas withdrawn in the USA and most other countries. In France,however, the authorities merely issued warnings, without

publishing any data that would have justified its continued use.1 Inthe past 10 years the regional centres of pharmacovigilance havereceived reports of an unknown number of cases of liver injury dueto the drug, but only two cases of fulminant hepatitis have beenpublished.2.3 It may be that the second of these reports led themanufacturer, Laboratoires Anphar-Rolland, to stop sales andexports of tienilic acid (’Diflurex’’).1 Supplies have been withdrawnfrom wholesalers, but some pharmacies may still have a stock.This story and others indicate that the French national

pharmacovigilance system lacks vigour and needs renovation.’

1 Gerson M. Diflurex: un arrêt de commercialisation bien tardif Rev Prescr 1992; 12:26-28.

2. Lechevalier L, Lebrec D, Lam X, et al. Hépatite aigue, hépatite chronique et cirrhose àl’acide tiénilique. Gastroenterol Clin Biol 1987; 11: 262-63.

3. Biour M, Pougol A, Chazovilleres O, Housset C, Giral P, Poupou R. Fulminanthepatitis due to tienilic acid. Lancet 1991; 338: 891.

4 Bardelay D, Mignot G. L’année 1991 du Rayon des Nouveautés. Rev Prescr 1992; 12:22-25.

International Diary1992

A meeting on The Biological and Epidemiological Basis forRadiation Protection Standards is to take place in Oxford on April 1-2:Dr D. N. S. Dixon, Programme Committee Secretary, Society for

Radiological Protection, 67 Oatlands Park, Linlithgow, West Lothian EH496AS, UK (031-244 2779).

A postgraduate course entitled Why Do We Care? is to take place in NewYork on April 2-5: Mary Callaway, Program Coordinator, MemorialSloan-Kettering Cancer Center, Box 52, 1275 York Avenue, New York10021, USA (212 639 7456).

17th annual meeting of the Society of Cardiovascular andInterventional Radiology will take place in Washington DC, USA, onApril 4-9: SCVIR, 1891 Preston White Drive, Reston, Virginia 22091, USA(703-648 8980).

A course on Techniques and Applications of Molecular Biology is tobe held in Coventry on April 7-10: Dr Stephen Hicks, Department ofBiological Sciences, University of Warwick, Coventry CV4 7AL, UK (0203523540).


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