Referral system the answer to overcrowding in state hospitals

THE World Organisation of family doctors (WONCA) at a conference held with the WHO in Canada early this year in listing changes that should be made to meet some of the health problems facing countries in this part of world has recommended among others that the introduction of a referral system of admission of patients to State hospitals would be the best solution to meet the overcrowding and floor patients problem in these hospitals.

These recommendations were read out by the President of the College of General Practitioners Sri Lanka Dr. Preethi Wijegunawardena last week at the Precongress symposium of the annual WONCA congress held in Colombo.

Among the other recommendations of the WONCA - WHO meeting were:

Considering all these facts, I would like to draw the attention of all health planners in country, teachers of the Faculties of medicine, that there is a compelling and need to recognise the role of the family physician and the need to regard the family physician/ GP as an important, integral member of the primary care health team.

It is indeed time to establish a system at least similar to that of the National Health Scheme of the United Kingdom, where the GP can be incorporated into the state health service and appointed to provide health care in all parts of the country to a defined population. By these means, patients will not be admitted to hospitals without a referral other than for accident and emergency.

Out patient care would be provided by primary medical care doctors working outside the hospital. It would be mandatory for such doctors to obtain general/family practice training leading to the Diploma in Family Medicine, or follow the MCGP course and obtain this qualification.

It will be imperative for them to have regular re-validation in principles of general practice and earn a minimum number of CME credit in order to continue their membership.

If drastic changes are not feasible just yet, we should encourage young doctors, who will not be absorbed into Government service to go into general practice, after having followed a vocational training in General practice at least for a period of two years.

The College of General Practitioners had expressed willingness a short time ago to the Minister of Health to conduct such a vocational training programme for young doctors.

It was also recommended by the College that these trainees in family practice should be encouraged with financial assistance and other incentives to set up and establish themselves in general practice and placement of these GPs should be adequately and widely distributed throughout the country serving its people.

Such doctors would appreciate assurances that their children would be able to find placement in good schools in the nearest city.

With such incentives I'm sure that there will be many young doctors with post-graduate training in family medicine opting to set up in family practice throughout the length and breadth of the country.

This would accelerate the elimination of that scourge of the health care system in this country - the 'quacks'.

Ayurvedic and homoeopathic practitioners will then be rehabilitated and compelled to adhere to their system of medicine.

If there are sufficient numbers of post-graduate trained family physicians in a state system distributed throughout the country, there will not be a need for other Government medical officers to engage in part-time primary medical care which does not address the principles and concept of family medicine such as record keeping, continuity of care, availability and accessibility at all given times, personalised care, coordination, confidentiality and empathy. Instead Government medical officers should be paid adequate compensation.

Referral system could be strongly recommended if, as suggested, there is a National Health Scheme MODEL and admission to hospitals done strictly by referral from General/family practitioners and other primary community physicians. Over-crowding in wards with patients on the floor, will be eliminated to a considerable extent.

Even in the private sector, consultants and specialists should strictly adhere to a referral system, which should essentially be a 'to and fro' process.

More of specialists' expertise and time will then be available for the genuine needs of patients, who require adequate time, skills and opinion of a specialist.

Kathurumurunga leaves causes cancer is a baseless rumour - M.O.I.C. Cancer Hospital, Maharagama

DR. WASANTHA Dissanayake (MBBS, DM MSc) Medical Officer in Charge of the Cancer Hospital, Maharagama in a letter to the HealthWatch states "Don't get misled by baseless and false rumours that Katurumurunga leaves have an unidentified substance which could cause cancer.

"What has been well-proven is that eating red meats and too much animal fat can cause cancers.

"Also using saturated fat in frying chicken can cause bowel, breast and ovarian cancers. Eating fresh fruits, vegetables and dark green leafy vegetables which contain Vitamin A, Vitamin C, Antioxidant Vitamin E and the element Selenium can reduce the incidence of cancer, so please don't get misled by these false and baseless rumours."

Dr. Dissanayake has been replying to a letter by L. W. Gunawardene of Mampitiya, Galle, we carried in this page on October 22 where he referred to some information he had gathered that Katurumurunga leaves had some cancer causing ingredients and wished to have the correct position in relation to it from a responsible person in authority.

We thank Dr. Dissanayake for the prompt response to the letter, and here we publish Dr. Dissanayake's reply in full, which is very informative.

Is Kathurumurunga safe for consumption

Yes, of course it is safe to eat Kathurumurunga which is a very nutritious dark green leafy vegetable.

When speak of cancer causing substances (carcinogens) we can divide them into three groups.

1. Carcinogenic - Causes cancer in humans. e.g. Benzopyrene in tobacco smoke causes bronchial cancer (lung cancer).

Blue asbestos cause pleural cancer.

Vinyl chloride cause liver cancer.

Nitrate and Nitrate addictives - bowel cancer.

2. Probably carcinogenic - Probably causes cancer in humans but more research is needed to be certain.

3. Possibly carcinogenic - Some research indicate only a potential for human cancer, but more research is needed.

Kathurumurunga or passion fruit leaves does not belong to these three categories. Indeed it is a baseless rumour which is malicious has been spread by group of people who have an axe to grind by stopping people eating these locally found and nutritious food.

It is well-proven that eating red meats and too much animal fat can cause cancers. Also using saturated fat in frying chicken can cause bowel, breast and ovarian cancers.

Eating fresh fruits, vegetables and dark green leafy vegetables which contain Vitamin A, Vitamin C, Antioxidant Vitamin E and the element Selenium can reduce the incidence of cancer.

So please don't get misled by these false and baseless rumours and give your family Kathurumurunga leaves, Gotukola, Kankun, Mukunuwenna etc.

Stem cell research and likely medical marvels:

Organ transplantation to become obsolete

CONSULTANT Paediatrician, Dr. A.T.W. Gunaratne MBBS, MD, DCH, (Lond) writing on the stem cell research now in progress in the world, predicts the possibility of organ transplantation becoming obsolete and outdated in the not too distant future.

In his article to the HealthWatch on this topic Dr. Gunaratne says:

Researchers are trying to use the special ability of stem cells to produce new cells and tissues to repair and reproduce ailing and damaged tissues and organs. At present damaged or non functional tissues and organs are replaced by compatible donor tissues and organs e.g. Renal, Liver and Heart transplants.

Sometimes synthetic materials are also used for replacement of heart valves. In future it may be possible to grow the required tissue in the laboratory using stem cells. This may prevent the rejection of donor organ transplants by the recipient. Rejection of donor organs is one of the biggest problems in donor transplants.

Stem cell produced tissues are unlikely to pose this problem. Kidney, Liver or Brain tissue may be grown in the lab and given to the patient. The present transplantation of organs may become obsolete in the future.

When a sperm joins an egg, fertilization takes place. The product of this union is the embryo. Stem cells are cells found in the embryo, which are capable of reproducing any cell type. (pluripotency). In the human, there are about 200 such cell types. Eg. Brain cells, Skin cells, Red cells etc.

Stem cells are also found in adult tissues but in small numbers. E.g. Bone marrow, brain, skin etc. The umbilical cord, which carries nutrients from the mother to the baby also has stem cells.

Achievements in stem cell treatment

At present some forms of Leukaemia, Lymphoma, Sickle cell anemia, Thalassaemia are being successfully treated using compatible bone marrow transplants using adult stem cells. Thousands of patients who were doomed to die are leading normal lives due to this type of stem cell treatment.

Future possibilities of stem cell treatment

Experimenting with mice and pigs embryo stem cells were made to grow into heart muscle cells and when these were injected to mice and pigs with heart disease, they replaced the dead cells in the heart resulting in the recovery of cardiac function.

In the future we could expect patients with myocardial infarction and hear failure to be treated with stem cells.

Similar results were obtained in rats with spinal cord injuries. In the future patients with paralysis following spinal cord injury may be able to walk again.

Research is being done to treat Type I Diabetes and Rheumatoid arthritis patients on similar lines. Research is being done to treat chronic nuro degenerative diseases like Alzheimer's and Parkinson's disease using adult brain stem cells.

At present corneal transplants are done using cadavaric transplants which are sometimes rejected by the recipient.

Stem cell therapy may replace cadavaric corneal transplants in the future. Encouraging results have been obtained in animal experiments in treating retinal damage using stem cells.

Problems encountered in stem cell research

Embryonic stem cell research involves taking cells from the embryo on the fifth day, thus destroying it. As such, it is compared to performing an early abortion.

Some religions are against stem cell research as in their view an embryo, a foetus or a baby are the same, while only the time after fertilization is different. But most of the embryonic stem cell research is done on embryos left over at In Vitro fertilization clinics or hospitals.

Only a few embryos are selected for implantations, as most of the unused embryos are disposed of. In such a situation researchers are of the view that it is unfortunate to waste unused embryos as these may be used in research.

In Vitro fertilization is when the ovum and sperm are allowed to unite outside the uterus, in laboratory conditions (Test Tube Babies) and the fertilized ovum (embryo) is then implanted in the uterus. In Vitro fertilization is presently done in a large number of countries including Sri Lanka.

In most countries where embryonic stem cell research is done, strict guidelines are laid to prevent the haphazard destruction of embryos.

There is a fear that if embryonic stem cell research is allowed to go unchecked there may be embryo producing hospitals, like factories producing goods.

There is no restriction of research on adult stem cells, but adult stem cells have so far not shown the potential as embryonic stem cells. In Asia, China, South Korea and specially Singapore are the leading countries doing stem cell research.

The promise of stem cell treatment is an exciting one and with intensive research in the future a new era in medicine may dawn curing deadly diseases which at present has no treatment and invariably causing death.

Air pollution tied to increased risk of strokes

NEW YORK - Increases in particles polluting the air are associated with an increase in the number of strokes caused by a blood clot in the brain - but not the type caused by an artery rupture in the brain - new research shows.

Previous reports have shown a link between air pollution and overall risk of heart attacks and other cardiovascular events, but the specific effect on stroke risk has not been well studied, lead author Dr. Gregory A. Wellenius, from Beth Israel Deaconess Medical Center in Boston, told Reuters Health.

"Our study is the first large study in the US to address this topic," he said. The researchers evaluated the link between air pollution and stroke among Medicare recipients in nine US cities.

Specifically, they analyzed data on 155,503 artery-blockage (ischemic) strokes and 19,314 bleeding (hemorrhagic) strokes recorded as hospital admissions between 1986 and 1999.

As reported in the American Heart Association's journal Stroke, the team found that an increase in particulate air pollution from the lowest to the highest levels raised ischemic stroke admissions by 1.03 per cent on the same day.

Further analysis yielded similar results for levels of carbon monoxide, nitrogen dioxide, and sulfur dioxide. By contrast, the investigators found no association between air pollution and hospital admission for hemorrhagic stroke.

Wellenius cited three possible mechanisms, which alone or in combination might explain how air pollution promotes stroke.

"One possibility is through inflammatory effects. The other is through pulmonary reflexes that trigger changes in blood pressure or heart rate." A third possibility is changes in clotting factors that tend to promote more blood clots.

Although the increase in ischemic stroke risk is small, the number of excess strokes can be high because pollution affects the whole population.

"Taken together with previous reports, the results suggest that reducing exposure to air pollution is likely to reduce the risk of a number of health problems, including heart disease and stroke," Wellenius concluded.

SOURCE: Stroke, December 2005 REUTERS