316 A PROFESSOR EMIGRATES
StR,—Professor McLachlan (March 27, p. 685) is a welltrained, gifted, mature radiologist with a desire to devote his professional life to the pursuit of the academic side of radiology. He was appointed to the chair at Leeds, which had been time, and resigned because he
was unable to prospect ahead of him. It is not, perhaps, without relevance that his other academic colleague is, likewise, emigrating. Most radiologists would be proud and delighted to have either of these two men associated with them.
vacant see a
for
some
convincing
So, why
are
career
they emigrating?
Professor Dudley (April 10, p. 795) writes from a well-established department, and in his comments on Professor McLachlan’s reasons for departure he speaks from a position of strength, and with, I suspect, a total lack of appreciation of the problems involved. Some of these problems are outlined by Professor Brumfitt and his colleagues (May 15, p. 1072) in their letter-sympathetically because the problems of ancillary departments, especially those bearing on morale, are peculiar to themselves. Having been in British radiology for twenty-five years and at the very hub of it for ten, I feel there are certain points which need to be made to get the picture straight. The diagnostic side of the Faculty (now Royal College) of Radiologists has been pressing for academic departments, not just chairs, for over twenty years. The reasons were the same as those which justify the creation of any and all academic units anywhere. They were: because it was felt that radiology provides an ideal medium for teaching pathological processes to undergraduates; because radiology plays a large role in the care of patients and a knowledge of its use and abuse is, therefore, a necessity in the education of most doctors; because it is a basic essential service, perhaps the most expensive one, the proper evolution of which should proceed logically and not to be left to the whims of individual interest, enthusiasm, and expertise; and because radiology provides valuable research opportunity in the study of many disease processes. These pressures have been blocked by three main countering factors-lack of support by most of our clinical colleagues; the lure of private practice, at least in the London area; and luke-warm endorsement by influential radiotherapists. In London, two academic departments have evolved, one in a postgraduate school and one in a combined research and service hospital. They have both proved their worth. Two personal chairs have recently been awarded; one in a postgraduate and one in a neurological environment. Outside London, in contrast, four academic departments have been developed in undergraduate teaching centres, to the credit of the universities and individuals concerned. Others are projected. But what went wrong at Leeds, as Professor Dudley asks? The matter at issue seems to be the basic requirements for academic departments in order that they may function successfully. The appointment of one or two individuals in an N.H.S. or private practice milieu is not sufficient. The whole project must be properly planned and staffed, and so provided with space, facilities, and personnel that it may act as a centre of professional stimulation to the teaching hospital and surrounding community. It seems that the basic requirement is four or five experts in general and specialised radiology of consultant level, with supporting junior staff. The academic base must comprise at least two non-committed radiographic rooms where specialised studies can be done without interfering with service requirements. There must be space for both teaching and research, a library, a photographic department, and so on. But this does not still touch the core of the problem when, in most instances, the department is to be grafted onto an established set-up-namely, the professor’s status and responsibilities with regard to the existing diagnostic department, its budget, staffing, and service requirements. This is thin ice, over which skating must take place if a working compromise is to result. In a new medical schoool, these matters may be settled by
preliminary discussion, design, and planning, but when an academic department is to be grafted onto an existing medicalschool/hospital complex it is most unlikely that it will get enough space, staff, or money to give it a proper start. It will almost certainly have to evolve in an atmosphere of prejudice, reaction, and suspicion, especially if the personnel are brought in from outside. If there is a requirement for, and the means to afford, academic departments of radiology in Britain, let them be properly planned, staffed, and financed. There will be no dearth of first-class doctors to inhabit them and, carry worthily the torch of medical quality. Nor, I believe, will these doctors then wish to emigrate. Department of Diagnostic Radiology, Yale University School of Medicine,
JOHN HODSON
New Haven, Connecticut 06510, U.S.A.
ANÆMIA AND IMMUNE RESPONSE
SIR,-Srikantia et al. have demonstrated impaired cell-mediated immune response in nutritional anaemia. Experience with parenterally hyperalimented patients at this institution may lend support to their observations. 100 patients receiving total parenteral nutrition were studied retrospectively. Their ages ranged from 2 to 89 years with a mean of 51.8 years. Total parenteral nutrition was used for a variety of reasons. Three-quarters of the patients received parenteral nutrition in the preoperative and postoperative periods. Most patients had gastrointestinal disease (e.g., peptic ulcer, pancreatitis, regional enteritis, and diverticulitis) or malignancy. There were 7 episodes of’sepsis in this group of patients-5 with Candida, 1 with Pneumococcus, and 1 with Enterococcus. CHARACTERISTICS OF SEPTIC AND NON-SEPTIC GROUPS IN TOTAL PARENTERAL NUTRITION
(T.P.N.):
MEAN±S.E.M.
Several factors distinguished the septic group of patients from the non-septic group (table). Among these were a longer duration of hyperalimentation, a lower serum-phosphorus, and a lower haematocrit. All other indices, including previous infection, prior antibiotic therapy, age, leucocyte-count, serum-creatinine, and serum-albumin were comparable in the, two
groups.
Anasmia may interfere with immune response as suggested by Srikantia et al. and by others.23 In addition, the observations presented here suggest that anaemia may predispose to infection in hyperalimented patients. It must be emphasised, however, that other factors, such as hypophosphataemia, frequently accompany nutritional deficiency and may also play a role in the integrity of the immune system. It has been shown, for example, that chemotaxis of polymorphonuclear leucocytes is depressed in hypophosphataemia.4 Future studies must take into account the multiple interacting factors affecting host defence. Department of Medicine, University Hospitals of Cleveland, Cleveland, Ohio 44105, U.S.A.
PHILIP
J. SPAGNUOLO
Srikantia, S. G., Prasad, J. S., Bhaskaram, C., Krishnamachari, K. A. V. R. Lancet, 1976, i, 1307. 2. Joynson, D. H. M., Jacobs, A., Murraywalker, D., Dolby, A. E. ibid. 1972, ii, 1058. 3. Bhaskaram, C., Reddy, V. Br. med. J. 1975, iii, 552. 4. Craddock, R., Yawata, Y., VanSanten, L., Gilberstadt, S., Silvis, S., Jacob, H. S. New Engl. J. Med. 1974, 290, 1403. 1.
StR,—Professor McLachlan (March 27, p. 685) is a welltrained, gifted, mature radiologist with a desire to devote his professional life to the pursuit of the academic side of radiology. He was appointed to the chair at Leeds, which had been time, and resigned because he
was unable to prospect ahead of him. It is not, perhaps, without relevance that his other academic colleague is, likewise, emigrating. Most radiologists would be proud and delighted to have either of these two men associated with them.
vacant see a
for
some
convincing
So, why
are
career
they emigrating?
Professor Dudley (April 10, p. 795) writes from a well-established department, and in his comments on Professor McLachlan’s reasons for departure he speaks from a position of strength, and with, I suspect, a total lack of appreciation of the problems involved. Some of these problems are outlined by Professor Brumfitt and his colleagues (May 15, p. 1072) in their letter-sympathetically because the problems of ancillary departments, especially those bearing on morale, are peculiar to themselves. Having been in British radiology for twenty-five years and at the very hub of it for ten, I feel there are certain points which need to be made to get the picture straight. The diagnostic side of the Faculty (now Royal College) of Radiologists has been pressing for academic departments, not just chairs, for over twenty years. The reasons were the same as those which justify the creation of any and all academic units anywhere. They were: because it was felt that radiology provides an ideal medium for teaching pathological processes to undergraduates; because radiology plays a large role in the care of patients and a knowledge of its use and abuse is, therefore, a necessity in the education of most doctors; because it is a basic essential service, perhaps the most expensive one, the proper evolution of which should proceed logically and not to be left to the whims of individual interest, enthusiasm, and expertise; and because radiology provides valuable research opportunity in the study of many disease processes. These pressures have been blocked by three main countering factors-lack of support by most of our clinical colleagues; the lure of private practice, at least in the London area; and luke-warm endorsement by influential radiotherapists. In London, two academic departments have evolved, one in a postgraduate school and one in a combined research and service hospital. They have both proved their worth. Two personal chairs have recently been awarded; one in a postgraduate and one in a neurological environment. Outside London, in contrast, four academic departments have been developed in undergraduate teaching centres, to the credit of the universities and individuals concerned. Others are projected. But what went wrong at Leeds, as Professor Dudley asks? The matter at issue seems to be the basic requirements for academic departments in order that they may function successfully. The appointment of one or two individuals in an N.H.S. or private practice milieu is not sufficient. The whole project must be properly planned and staffed, and so provided with space, facilities, and personnel that it may act as a centre of professional stimulation to the teaching hospital and surrounding community. It seems that the basic requirement is four or five experts in general and specialised radiology of consultant level, with supporting junior staff. The academic base must comprise at least two non-committed radiographic rooms where specialised studies can be done without interfering with service requirements. There must be space for both teaching and research, a library, a photographic department, and so on. But this does not still touch the core of the problem when, in most instances, the department is to be grafted onto an established set-up-namely, the professor’s status and responsibilities with regard to the existing diagnostic department, its budget, staffing, and service requirements. This is thin ice, over which skating must take place if a working compromise is to result. In a new medical schoool, these matters may be settled by
preliminary discussion, design, and planning, but when an academic department is to be grafted onto an existing medicalschool/hospital complex it is most unlikely that it will get enough space, staff, or money to give it a proper start. It will almost certainly have to evolve in an atmosphere of prejudice, reaction, and suspicion, especially if the personnel are brought in from outside. If there is a requirement for, and the means to afford, academic departments of radiology in Britain, let them be properly planned, staffed, and financed. There will be no dearth of first-class doctors to inhabit them and, carry worthily the torch of medical quality. Nor, I believe, will these doctors then wish to emigrate. Department of Diagnostic Radiology, Yale University School of Medicine,
JOHN HODSON
New Haven, Connecticut 06510, U.S.A.
ANÆMIA AND IMMUNE RESPONSE
SIR,-Srikantia et al. have demonstrated impaired cell-mediated immune response in nutritional anaemia. Experience with parenterally hyperalimented patients at this institution may lend support to their observations. 100 patients receiving total parenteral nutrition were studied retrospectively. Their ages ranged from 2 to 89 years with a mean of 51.8 years. Total parenteral nutrition was used for a variety of reasons. Three-quarters of the patients received parenteral nutrition in the preoperative and postoperative periods. Most patients had gastrointestinal disease (e.g., peptic ulcer, pancreatitis, regional enteritis, and diverticulitis) or malignancy. There were 7 episodes of’sepsis in this group of patients-5 with Candida, 1 with Pneumococcus, and 1 with Enterococcus. CHARACTERISTICS OF SEPTIC AND NON-SEPTIC GROUPS IN TOTAL PARENTERAL NUTRITION
(T.P.N.):
MEAN±S.E.M.
Several factors distinguished the septic group of patients from the non-septic group (table). Among these were a longer duration of hyperalimentation, a lower serum-phosphorus, and a lower haematocrit. All other indices, including previous infection, prior antibiotic therapy, age, leucocyte-count, serum-creatinine, and serum-albumin were comparable in the, two
groups.
Anasmia may interfere with immune response as suggested by Srikantia et al. and by others.23 In addition, the observations presented here suggest that anaemia may predispose to infection in hyperalimented patients. It must be emphasised, however, that other factors, such as hypophosphataemia, frequently accompany nutritional deficiency and may also play a role in the integrity of the immune system. It has been shown, for example, that chemotaxis of polymorphonuclear leucocytes is depressed in hypophosphataemia.4 Future studies must take into account the multiple interacting factors affecting host defence. Department of Medicine, University Hospitals of Cleveland, Cleveland, Ohio 44105, U.S.A.
PHILIP
J. SPAGNUOLO
Srikantia, S. G., Prasad, J. S., Bhaskaram, C., Krishnamachari, K. A. V. R. Lancet, 1976, i, 1307. 2. Joynson, D. H. M., Jacobs, A., Murraywalker, D., Dolby, A. E. ibid. 1972, ii, 1058. 3. Bhaskaram, C., Reddy, V. Br. med. J. 1975, iii, 552. 4. Craddock, R., Yawata, Y., VanSanten, L., Gilberstadt, S., Silvis, S., Jacob, H. S. New Engl. J. Med. 1974, 290, 1403. 1.
