31 than an hour of my time, in a series of about 8 or 10 ten-minute sessions. Set against the many hours which may be required by other psychotherapeutic approaches, this represents an important saving to a strained Health
more
Service. Stanley Royd Hospital, Wakefield, Yorkshire WF1 4DQ.
R. P. SNAITH.
TREATMENT OF PRIMARY HYPERTENSION
SIR,—The report of Professor Sackett and his colleagues (May 31, p. 1205) describes preliminary experience of a randomised study of different approaches to antihypertensive therapy. The results might appear to suggest that attempts to facilitate access or enhance patient education have little impact on outcome. However, these conclusions should be viewed with an awareness of several important aspects of the research design. Hypertensive steelworkers were randomised into study groups only if they had not lately received hypotensive therapy. In fact, only 4-6% of the whole population participated in the study. These 230 employees probably represent about one-third of the entire hypertensive population1 and may well include a disproportionate share of employees who assiduously resist medical care. This self-selection may, in turn, explain the remarkably unsatisfactory outcome, in that less than 25% were both compliant and at therapeutic goal. Categorising outcome as the sum of compliance and blood-pressure reduction is somewhat confusing. Although adherence to a therapeutic regimen (which cannot be assessed by change in serum potassium or uric-acid levels 2,3) should correlate with blood-pressure decline, the only significant issue is whether the pressure fell, and by how much. Furthermore, while a diastolic pressure of less than 90 mm. Hg may be a desirable goal, there is good evidence that, failing this, a 10% reduction offers very substantial benefit.4 In certain situations this might be the appropriate therapeutic goal.5 Compliance is indeed the name of the game in hypotensive therapy. However, compliance, and therefore outcome, are not likely to be changed by piecemeal modification of the setting in which care is delivered. Successful hypertension control programmes all share a comprehensive approach to the long-term care of asymptomatic adults. 6-8 Convenience and enhanced education are only components of these systems. They are effective not as isolated additions to the existing system of care, but rather as integral parts of a total care system. As long as the system remains the same with one physician individually treating one patient, the outcome, as Professor Sackett and his colleagues have so elegantly demonstrated, is almost certain to be dismal.9,10 This second phase of the steelworkers’ study promises to be more illuminating. The authors now propose to evaluate changes in the whole system of care tailored to meet the actual needs of patients, 1. National Health Survey, U.S. Department of Health, Education and Welfare, National Center for Health Statistics, series 11, no. 13, 1966. 2. Wilkinson, P. R., Hesp, R., Issler, H., Raftery, E. B. Lancet, 3. 4. 5. 6. 7. 8. 9. 10.
April 5, 1975, p. 759. Bengtsson, C., Johnson, G., Sannerstedt, R., Werko, L. Br. med. J. 1975, i, 197. Taguchi, J., Freis, E. D. New Engl. J. Med. 1974, 291, 329. Freis, E. D. J. Am. med. Ass. 1975, 232, 1017. Finnerty, F. A., Shaw, L. W., Himmelsbach, C. K. Circulation, 1973, 47, 76. Wilber, J. A., Barrow, J. G. Am. J. Med. 1972, 52, 653. Alderman, M. H., Schoenbaum, E. E. New Engl. J. Med. 1975, 293 (in the press). Schoenberger, J. A., Stamler, J., Shekelle, R., Shekelle, S. J. Am. med. Ass. 1972, 222, 559. Langfeld, S. B. Ann. intern. Med. 1973, 78, 19.
and not merely modify the traditional system in accordance with conventional preconceptions. Department of Public Health, New York Hospital/Cornell Medical Center, New York, N.Y. 10021, U.S.A.
MICHAEL H. ALDERMAN ELLIE SCHOENBAUM.
SUBCLINICAL TROPICAL ENTEROPATHY
SIR,-Your editorial (May 3, p. 1019) states that " subclinical tropical enteropathy is ubiquitous ". This assertion is too sweeping. In the Caribbean area, evidence of subclinical enteropathy has been found only in persons who live or have resided in those countries (Puerto Rico, Cuba, Haiti, and San Domingo) where tropical sprue now exists. 1-4 In contrast there is no published evidence of either sprue or subclinical enteropathy which could have been contracted in Jamaica or in other parts of the Englishspeaking Caribbean. Intestinal biopsy studies from 20 Jamaicans without gastrointestinal disease showed normal villous patterns.5 As far as I am aware subclinical enteropathy has been recorded neither in visitors to the Englishspeaking Caribbean nor in immigrants from this area who now reside in the U.S.A. and in the U.K. The conditions, whose diagnosis depends on laboratory tests, may not have been vigorously searched for in people from those Caribbean regions where sprue is not found, but uncritical acceptance that subclinical enteropathy is ubiquitous in the tropics may be misleading. A careful study of the geographical distribution of subclinical enteropathy may reveal likely causative factors and may also resolve the uncertainty as. to whether this condition and sprue are part of the same disease spectrum. Medical Research Council
Epidemiology Unit, University of the West Indies, Kingston, Jamaica.
M. T. ASHCROFT.
PHAGOCYTOSIS IN CHRONIC GRANULOMATOUS DISEASE SIR,-Dr de Gast and co-workers (May 31, p. 1247) correctly point out the importance of the bactericidal capacity of normal leucocytes in estimating the phagocytic capacity of leucocytes from patients with chronic granulomatous disease (C.G.D.). My conclusions (May 3, p. 991) were not drawn from the morphological studies alone, as they suggest, but also from experiments using phenylbutazone which were similar to those that they were prompted to undertake. Specifically, when a bactericidal abnormality was induced in normal leucocytes by phenylbutazone, the number of intracellular bacteria increased 5-10-fold over control leucocytes, while in the same experiment the number of intracellular bacteria in c.G.D. leucocytes was as much as 300-fold. Thus, the increased number of intracellular bacteria in normal leucocytes incubated with phenylbutazone might be explained by the effect of the drug on bacterial killing. It is clear, therefore, from observations reported in my article and from the experiments of de Gast et al., that the number of intracellular bacteria in normal leucocytes depends on the cells’ ability to kill bacteria. However, since the number of intracellular bacteria in c.G.D. leucocytes was far greater than the number of intracellular bacteria in the phenylbutazone-treated normal leucocytes examined in parallel, 1. 2.
3. 4. 5.
F. A., Samloff, I. M., Smarth, G., Schenk, E. A. Am. J. clin. Nutr. 1968, 21, 1042. Klipstein, F. A., Beauchamp, I., Corcino, J. J., Maldonado, M., Tomasini, J. T., Schenk, E. A. Gastroenterology, 1972, 63, 758. Klipstein, F. A., Rubio, C., Montas, S., Tomasini, J. T., Castillo, R. G. Am. J. clin. Nutr. 1973, 26, 87. Klipstein, F. A., Falaiye, J. M. Medicine, 1969, 48, 475. Da Costa, L. R. Am. J. dig. Dis. 1972, 17, 105.
Klipstein,
more
Service. Stanley Royd Hospital, Wakefield, Yorkshire WF1 4DQ.
R. P. SNAITH.
TREATMENT OF PRIMARY HYPERTENSION
SIR,—The report of Professor Sackett and his colleagues (May 31, p. 1205) describes preliminary experience of a randomised study of different approaches to antihypertensive therapy. The results might appear to suggest that attempts to facilitate access or enhance patient education have little impact on outcome. However, these conclusions should be viewed with an awareness of several important aspects of the research design. Hypertensive steelworkers were randomised into study groups only if they had not lately received hypotensive therapy. In fact, only 4-6% of the whole population participated in the study. These 230 employees probably represent about one-third of the entire hypertensive population1 and may well include a disproportionate share of employees who assiduously resist medical care. This self-selection may, in turn, explain the remarkably unsatisfactory outcome, in that less than 25% were both compliant and at therapeutic goal. Categorising outcome as the sum of compliance and blood-pressure reduction is somewhat confusing. Although adherence to a therapeutic regimen (which cannot be assessed by change in serum potassium or uric-acid levels 2,3) should correlate with blood-pressure decline, the only significant issue is whether the pressure fell, and by how much. Furthermore, while a diastolic pressure of less than 90 mm. Hg may be a desirable goal, there is good evidence that, failing this, a 10% reduction offers very substantial benefit.4 In certain situations this might be the appropriate therapeutic goal.5 Compliance is indeed the name of the game in hypotensive therapy. However, compliance, and therefore outcome, are not likely to be changed by piecemeal modification of the setting in which care is delivered. Successful hypertension control programmes all share a comprehensive approach to the long-term care of asymptomatic adults. 6-8 Convenience and enhanced education are only components of these systems. They are effective not as isolated additions to the existing system of care, but rather as integral parts of a total care system. As long as the system remains the same with one physician individually treating one patient, the outcome, as Professor Sackett and his colleagues have so elegantly demonstrated, is almost certain to be dismal.9,10 This second phase of the steelworkers’ study promises to be more illuminating. The authors now propose to evaluate changes in the whole system of care tailored to meet the actual needs of patients, 1. National Health Survey, U.S. Department of Health, Education and Welfare, National Center for Health Statistics, series 11, no. 13, 1966. 2. Wilkinson, P. R., Hesp, R., Issler, H., Raftery, E. B. Lancet, 3. 4. 5. 6. 7. 8. 9. 10.
April 5, 1975, p. 759. Bengtsson, C., Johnson, G., Sannerstedt, R., Werko, L. Br. med. J. 1975, i, 197. Taguchi, J., Freis, E. D. New Engl. J. Med. 1974, 291, 329. Freis, E. D. J. Am. med. Ass. 1975, 232, 1017. Finnerty, F. A., Shaw, L. W., Himmelsbach, C. K. Circulation, 1973, 47, 76. Wilber, J. A., Barrow, J. G. Am. J. Med. 1972, 52, 653. Alderman, M. H., Schoenbaum, E. E. New Engl. J. Med. 1975, 293 (in the press). Schoenberger, J. A., Stamler, J., Shekelle, R., Shekelle, S. J. Am. med. Ass. 1972, 222, 559. Langfeld, S. B. Ann. intern. Med. 1973, 78, 19.
and not merely modify the traditional system in accordance with conventional preconceptions. Department of Public Health, New York Hospital/Cornell Medical Center, New York, N.Y. 10021, U.S.A.
MICHAEL H. ALDERMAN ELLIE SCHOENBAUM.
SUBCLINICAL TROPICAL ENTEROPATHY
SIR,-Your editorial (May 3, p. 1019) states that " subclinical tropical enteropathy is ubiquitous ". This assertion is too sweeping. In the Caribbean area, evidence of subclinical enteropathy has been found only in persons who live or have resided in those countries (Puerto Rico, Cuba, Haiti, and San Domingo) where tropical sprue now exists. 1-4 In contrast there is no published evidence of either sprue or subclinical enteropathy which could have been contracted in Jamaica or in other parts of the Englishspeaking Caribbean. Intestinal biopsy studies from 20 Jamaicans without gastrointestinal disease showed normal villous patterns.5 As far as I am aware subclinical enteropathy has been recorded neither in visitors to the Englishspeaking Caribbean nor in immigrants from this area who now reside in the U.S.A. and in the U.K. The conditions, whose diagnosis depends on laboratory tests, may not have been vigorously searched for in people from those Caribbean regions where sprue is not found, but uncritical acceptance that subclinical enteropathy is ubiquitous in the tropics may be misleading. A careful study of the geographical distribution of subclinical enteropathy may reveal likely causative factors and may also resolve the uncertainty as. to whether this condition and sprue are part of the same disease spectrum. Medical Research Council
Epidemiology Unit, University of the West Indies, Kingston, Jamaica.
M. T. ASHCROFT.
PHAGOCYTOSIS IN CHRONIC GRANULOMATOUS DISEASE SIR,-Dr de Gast and co-workers (May 31, p. 1247) correctly point out the importance of the bactericidal capacity of normal leucocytes in estimating the phagocytic capacity of leucocytes from patients with chronic granulomatous disease (C.G.D.). My conclusions (May 3, p. 991) were not drawn from the morphological studies alone, as they suggest, but also from experiments using phenylbutazone which were similar to those that they were prompted to undertake. Specifically, when a bactericidal abnormality was induced in normal leucocytes by phenylbutazone, the number of intracellular bacteria increased 5-10-fold over control leucocytes, while in the same experiment the number of intracellular bacteria in c.G.D. leucocytes was as much as 300-fold. Thus, the increased number of intracellular bacteria in normal leucocytes incubated with phenylbutazone might be explained by the effect of the drug on bacterial killing. It is clear, therefore, from observations reported in my article and from the experiments of de Gast et al., that the number of intracellular bacteria in normal leucocytes depends on the cells’ ability to kill bacteria. However, since the number of intracellular bacteria in c.G.D. leucocytes was far greater than the number of intracellular bacteria in the phenylbutazone-treated normal leucocytes examined in parallel, 1. 2.
3. 4. 5.
F. A., Samloff, I. M., Smarth, G., Schenk, E. A. Am. J. clin. Nutr. 1968, 21, 1042. Klipstein, F. A., Beauchamp, I., Corcino, J. J., Maldonado, M., Tomasini, J. T., Schenk, E. A. Gastroenterology, 1972, 63, 758. Klipstein, F. A., Rubio, C., Montas, S., Tomasini, J. T., Castillo, R. G. Am. J. clin. Nutr. 1973, 26, 87. Klipstein, F. A., Falaiye, J. M. Medicine, 1969, 48, 475. Da Costa, L. R. Am. J. dig. Dis. 1972, 17, 105.
Klipstein,
