98
people and that, within the time-frame considered (1990-2005), public health/health education measures would be unlikely to alter the prevalence of obesity appreciably. Existing and expected demographic changes then imply that in the Netherlands there will be a slight increase in IDDM and a large increase in non-insulin dependent diabetes (NIDDM); overall, the increase could be as much as 40% (or 75% compared with 1980), the largest changes occurring in the 45-65 and over-80 age groups. Overall prevalence would then be about 2 % of the population, about 33 % of whom would be treated with diet alone, 44% with tablets, and 23% with insulin. Organising services for the care of patients with diabetes involves many people and agencies--eg, hospital-based and primary care diabetes teams, community services, patients themselves, with whom responsibility for much day-to-day management rests, and the general population among whom they live and work. Such large numerical changes will have appreciable effects on all these groups. Projections for other developed countries are likely to resemble the Dutch calculations; for developing countries, in which life expectancy is still increasing rapidly, they may be even more striking. Third, the report identifies the need to develop a diabetes research policy. The areas that may have a major impact on future services are specifieddevelopment and evaluation of education and information for patients; need for specialist research directed towards the quality of life for diabetic patients; development and cost implications of new treatments such as glucose sensors, beta-cell transplantation, and immunomodulation or prevention of IDDM; evaluation of experimental approaches to provision of care, including their relation to prevention of complications; establishing the true prevalence of NIDDM and evaluating screening programmes; and introducing methods of continuous monitoring for trends in diabetes. This last research objective is central to the fourth, and perhaps the most important, observation-the need for information. The group found that their efforts were severely hampered by lack of data. All of their work was based on ad hoc studies and hospital activity information that was known to be fragmentary, unreliable, and out of date. There is now an international consensus on desirable standards and outcomes for diabetes health care, but provision of adequate resources for health care programmes, ensuring the quality of care, and planning for demographic and technological pressures will require more than a set of uncontentious objectives. Operational decisions now and future planning should be guided by accurate data. Without such information further exercises, such as that carried out by the Dutch group, will be fruitless. Without information, all the charters, guidelines, standards, and statements of good intent will achieve little now or in the future for most diabetic patients because it will be impossible to
monitor whether
they are being implemented efficiently, effectively, and comprehensively. 1. Pracon Incorporated. Center for Economic Studies in Medicine. Direct and indirect costs of diabetes in the United States 1987. Alexandria, VA: American Diabetes Association, 1988. 2. Gerard K, Donaldson C, Maynard A. The cost of diabetes. Diab Med 1989; 6: 164-70. 3. Laing W, William R. Diabetes: a model for health care management. London: Office of Health Economics, 1989. 4. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diab Care 1989; 12: 365-68. 5. WHO and IDF Europe. Diabetes mellitus in Europe: a problem at all ages in all countries. A model for prevention and self care. St Vincent, Italy, Oct 11-12, 1989. 6. The British Diabetic Association. What diabetics are to expect. Patients’ Charter. London: BDA, 1990. 7. Alberti KGMM, Gries FA. Management of non-insulin-dependent diabetes in Europe: a consensus view. Diab Med 1988; 5: 275-81. 8. World Health Organisation. Guidelines for the development of a national programme for diabetes mellitus: Geneva: WHO, 1991. 9. Steering Committee on Future Health Scenarios. Chronic diseases in the year 2005—scenarios on diabetes mellitus 1990-2005. Dordrecht: Kluwer, 1991.
Schizophrenia: the rocky inpatient care
road from
Schizophrenia illustrates its etymology as much in its course as in its presentation. Both are characterised by islands of normality surrounded by oceans of chaos, with bewildering variability between patients. Consequently, it is not surprising that comprehensive follow-up studies of the disorder are hard to mount and difficult to interpret.l Although detailed accounts of the course of symptoms such as those of Bland and Om2and of Bleulerare impressive, these researchers concerned themselves with selected groups of patients, so it is difficult to generalise from their observations. Larger studies have been done but
drop-out rates are unacceptably high.4 Johnstone and her colleaguess have attempted to remedy this deficiency in an ambitious study. They set out to follow up all patients with a diagnosis of schizophrenia defined according to the Feighner criteria and discharged over a period of ten years between 1975 and 1985 from Harrow, an outer London district. The investigators achieved a remarkable tracing rate of nearly 94% of the total sample of 532 patients. Each patient had an average of about five admissions to hospital during the study period, accounting for about 11 % of the total follow-up period of 10 years. At an extended followup in 1990, only 31 of the patients were inpatients. Johnstone et al noted considerable social impairment: fewer than 20% of patients were in full-time work at 10-year follow-up, and most patients had a constricted lifestyle and some social difficulties. 327 patients were interviewed and 98 (30%) had had contact with the police, but only 38 (12%) of them were convicted, mainly for minor driving offences and those against property. Many of these contacts had arisen because patients were unable to care for themselves or had behaved inappropriately in public places. Cognitive impairment was noted in many of the patients,
99
especially those with negative schizophrenic features such as flattened affect and poverty of speech. 24 of the 69 deaths reported were from unnatural causes, predominantly suicide and open verdicts, and 8 of these patients were inpatients at the time of suicide. This mortality rate was twice that expected for a comparable age group (but partly offset by a lower incidence of cancer deaths); this finding confirms that schizophrenia is associated with increased mortality. Comparison with the results of an earlier follow-up study from the same institution6 showed that, although the proportion of patients in contact with the psychiatric services had increased from 29% to 48%, there was no difference in mental state in the two samples. In both groups, patients and their relatives expressed the strong wish to continue to live outside hospital; only 2 (0-7%) wanted to return. What should we conclude from these findings ? The results offer opportunities for both critics and advocates of community care to support their views. The advocates can point to the clear preference for extra-hospital care, the high rate of continued contact with the sample (from general practitioners as well as the psychiatric services), and the large proportion of patients living in their own permanent accommodation with a reasonable degree of life satisfaction. The low rate of involvement with the police is also encouraging. These findings contrast with the dire warnings of some authorities about patients with schizophrenia dropping out of care, ceasing to have contact with any statutory services, and becoming either homeless or incarcerated in penal institutions.7,8 Nevertheless, the researchers that Harrow, as one of the least acknowledged deprived parts of the country, is far from being a representative part of the UK, and that their investigation was not a catchment area study-the researchers had a special interest in the research and treatment of schizophrenia that allowed patients from all over the country to be referred. The excellent follow-up rates might be partly a consequence of research interest in the condition which almost invariably has a bonus of attracting care that might not otherwise have been given. Old Harrovian schizophrenics are probably as privileged as their better known scholastic equivalents. Despite these caveats, the study shows that when good services are made available for the care of schizophrenia, the outcome is much less gloomy than is sometimes claimed. It is notable that the results were achieved despite the fact that psychiatric services in Harrow had few additional resources (apart from research ones); it was the commitment and interest of the staff that probably accounted for many of the positive reports. Now that case registers for "vulnerable" psychiatric patients are being established in many parts of the country (which of necessity will include most patients with schizophrenia) there is no reason why other similar follow-up studies should not be done as a natural
part of audit in psychiatry. Johnstone’s work will serve as a useful yardstick by which the results of these investigations can be measured. G, Gross G, Schuttler R, Linz M. Longitudinal studies of schizophrenic patients. Schizophrenia Bull 1980; 6: 592-605. 2. Bland RC, Orn H. 14-year outcome in early schizophrenia. Acta Psychiatr Scand 1978; 58: 327-38. 3. Bleuler M. The long-term course of the schizophrenic psychoses. Psychol 1. Huber
Med 1985; 4: 244-54. 4. Sartorius N, Jablensky A,
Ernberg G, et al. Course of schizophrenia in different countries: some results of a WHO international comparative five year follow up study. In: Hafner H, Gattaz WF, Janzarik W, eds. Search for the causes of schizophrenia. Berlin: Springer Verlag, 1987; 107-13. 5. Johnstone EC, ed. Disabilities and circumstances of schizophrenic patients: a follow-up study. Br J Psychiatry 1991; 159: (suppl 13). 6. Johnstone EC, Owens DGC, Gold A, et al. Schizophrenic patients discharged from hospital: a follow-up study. Br J Psychiatry 1984; 145: 586-90. 7. National Schizophrenia Fellowship. Home sweet nothing: the plight of sufferers from chronic schizophrenia. London: National Schizophrenia
Fellowship, 1979. 8. Weller MPI. Mental illness-who cares? Nature
1989; 339: 249-52.
Ewing’s sarcoma and its congeners: an interim appraisal New research is beginning to provide some insight into the nature of Ewing’s sarcoma and its relation to certain other round-cell tumours in children and young adults;l it seems timely to review recent evidence. Ewing’s sarcomas of bone vary in their growth patterns and cellular features. Some tumours show evidence of neural differentiation based on the presence of rosettes, ultrastructural features (cell and processes, neurosecretory granules), immunohistochemical staining. Neural differentiation has been induced in cell lines derived from Ewing’s sarcoma in vitro. More than 90% of tumours have consistent cytogenetic abnormalities, most commonly translocations between chromosomes 11 and 22-t(11;22) (q24;q12). These same features are found in a proportion of soft tissue round-cell
conventionally designated as extraosseous Ewing’s sarcoma, and in primitive neuroectodermal tumours (PNETs) of bone and soft tissue. PNETs, especially if well differentiated, are sometimes called neuroepitheliomas (the PNET entity also includes Askin’s malignant small-cell tumour of the thoracopulmonary region in childhood). It is now agreed that Ewing’s sarcoma and PNETs form a single group of bone and soft tissue tumours in which typical undifferentiated Ewing’s sarcomas lie at tumours
one end of a spectrum and PNETs with clear evidence
of neural differentiation at the other. Ewing’s sarcomas with neural features merge with PNETs showing less obvious differentiation in the middle. According to this view, Ewing’s sarcomas and PNETs form a separate category from neuroblastoma, although neuroblastoma may be difficult or
impossible grounds.
to
distinguish
on
purely morphological
people and that, within the time-frame considered (1990-2005), public health/health education measures would be unlikely to alter the prevalence of obesity appreciably. Existing and expected demographic changes then imply that in the Netherlands there will be a slight increase in IDDM and a large increase in non-insulin dependent diabetes (NIDDM); overall, the increase could be as much as 40% (or 75% compared with 1980), the largest changes occurring in the 45-65 and over-80 age groups. Overall prevalence would then be about 2 % of the population, about 33 % of whom would be treated with diet alone, 44% with tablets, and 23% with insulin. Organising services for the care of patients with diabetes involves many people and agencies--eg, hospital-based and primary care diabetes teams, community services, patients themselves, with whom responsibility for much day-to-day management rests, and the general population among whom they live and work. Such large numerical changes will have appreciable effects on all these groups. Projections for other developed countries are likely to resemble the Dutch calculations; for developing countries, in which life expectancy is still increasing rapidly, they may be even more striking. Third, the report identifies the need to develop a diabetes research policy. The areas that may have a major impact on future services are specifieddevelopment and evaluation of education and information for patients; need for specialist research directed towards the quality of life for diabetic patients; development and cost implications of new treatments such as glucose sensors, beta-cell transplantation, and immunomodulation or prevention of IDDM; evaluation of experimental approaches to provision of care, including their relation to prevention of complications; establishing the true prevalence of NIDDM and evaluating screening programmes; and introducing methods of continuous monitoring for trends in diabetes. This last research objective is central to the fourth, and perhaps the most important, observation-the need for information. The group found that their efforts were severely hampered by lack of data. All of their work was based on ad hoc studies and hospital activity information that was known to be fragmentary, unreliable, and out of date. There is now an international consensus on desirable standards and outcomes for diabetes health care, but provision of adequate resources for health care programmes, ensuring the quality of care, and planning for demographic and technological pressures will require more than a set of uncontentious objectives. Operational decisions now and future planning should be guided by accurate data. Without such information further exercises, such as that carried out by the Dutch group, will be fruitless. Without information, all the charters, guidelines, standards, and statements of good intent will achieve little now or in the future for most diabetic patients because it will be impossible to
monitor whether
they are being implemented efficiently, effectively, and comprehensively. 1. Pracon Incorporated. Center for Economic Studies in Medicine. Direct and indirect costs of diabetes in the United States 1987. Alexandria, VA: American Diabetes Association, 1988. 2. Gerard K, Donaldson C, Maynard A. The cost of diabetes. Diab Med 1989; 6: 164-70. 3. Laing W, William R. Diabetes: a model for health care management. London: Office of Health Economics, 1989. 4. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diab Care 1989; 12: 365-68. 5. WHO and IDF Europe. Diabetes mellitus in Europe: a problem at all ages in all countries. A model for prevention and self care. St Vincent, Italy, Oct 11-12, 1989. 6. The British Diabetic Association. What diabetics are to expect. Patients’ Charter. London: BDA, 1990. 7. Alberti KGMM, Gries FA. Management of non-insulin-dependent diabetes in Europe: a consensus view. Diab Med 1988; 5: 275-81. 8. World Health Organisation. Guidelines for the development of a national programme for diabetes mellitus: Geneva: WHO, 1991. 9. Steering Committee on Future Health Scenarios. Chronic diseases in the year 2005—scenarios on diabetes mellitus 1990-2005. Dordrecht: Kluwer, 1991.
Schizophrenia: the rocky inpatient care
road from
Schizophrenia illustrates its etymology as much in its course as in its presentation. Both are characterised by islands of normality surrounded by oceans of chaos, with bewildering variability between patients. Consequently, it is not surprising that comprehensive follow-up studies of the disorder are hard to mount and difficult to interpret.l Although detailed accounts of the course of symptoms such as those of Bland and Om2and of Bleulerare impressive, these researchers concerned themselves with selected groups of patients, so it is difficult to generalise from their observations. Larger studies have been done but
drop-out rates are unacceptably high.4 Johnstone and her colleaguess have attempted to remedy this deficiency in an ambitious study. They set out to follow up all patients with a diagnosis of schizophrenia defined according to the Feighner criteria and discharged over a period of ten years between 1975 and 1985 from Harrow, an outer London district. The investigators achieved a remarkable tracing rate of nearly 94% of the total sample of 532 patients. Each patient had an average of about five admissions to hospital during the study period, accounting for about 11 % of the total follow-up period of 10 years. At an extended followup in 1990, only 31 of the patients were inpatients. Johnstone et al noted considerable social impairment: fewer than 20% of patients were in full-time work at 10-year follow-up, and most patients had a constricted lifestyle and some social difficulties. 327 patients were interviewed and 98 (30%) had had contact with the police, but only 38 (12%) of them were convicted, mainly for minor driving offences and those against property. Many of these contacts had arisen because patients were unable to care for themselves or had behaved inappropriately in public places. Cognitive impairment was noted in many of the patients,
99
especially those with negative schizophrenic features such as flattened affect and poverty of speech. 24 of the 69 deaths reported were from unnatural causes, predominantly suicide and open verdicts, and 8 of these patients were inpatients at the time of suicide. This mortality rate was twice that expected for a comparable age group (but partly offset by a lower incidence of cancer deaths); this finding confirms that schizophrenia is associated with increased mortality. Comparison with the results of an earlier follow-up study from the same institution6 showed that, although the proportion of patients in contact with the psychiatric services had increased from 29% to 48%, there was no difference in mental state in the two samples. In both groups, patients and their relatives expressed the strong wish to continue to live outside hospital; only 2 (0-7%) wanted to return. What should we conclude from these findings ? The results offer opportunities for both critics and advocates of community care to support their views. The advocates can point to the clear preference for extra-hospital care, the high rate of continued contact with the sample (from general practitioners as well as the psychiatric services), and the large proportion of patients living in their own permanent accommodation with a reasonable degree of life satisfaction. The low rate of involvement with the police is also encouraging. These findings contrast with the dire warnings of some authorities about patients with schizophrenia dropping out of care, ceasing to have contact with any statutory services, and becoming either homeless or incarcerated in penal institutions.7,8 Nevertheless, the researchers that Harrow, as one of the least acknowledged deprived parts of the country, is far from being a representative part of the UK, and that their investigation was not a catchment area study-the researchers had a special interest in the research and treatment of schizophrenia that allowed patients from all over the country to be referred. The excellent follow-up rates might be partly a consequence of research interest in the condition which almost invariably has a bonus of attracting care that might not otherwise have been given. Old Harrovian schizophrenics are probably as privileged as their better known scholastic equivalents. Despite these caveats, the study shows that when good services are made available for the care of schizophrenia, the outcome is much less gloomy than is sometimes claimed. It is notable that the results were achieved despite the fact that psychiatric services in Harrow had few additional resources (apart from research ones); it was the commitment and interest of the staff that probably accounted for many of the positive reports. Now that case registers for "vulnerable" psychiatric patients are being established in many parts of the country (which of necessity will include most patients with schizophrenia) there is no reason why other similar follow-up studies should not be done as a natural
part of audit in psychiatry. Johnstone’s work will serve as a useful yardstick by which the results of these investigations can be measured. G, Gross G, Schuttler R, Linz M. Longitudinal studies of schizophrenic patients. Schizophrenia Bull 1980; 6: 592-605. 2. Bland RC, Orn H. 14-year outcome in early schizophrenia. Acta Psychiatr Scand 1978; 58: 327-38. 3. Bleuler M. The long-term course of the schizophrenic psychoses. Psychol 1. Huber
Med 1985; 4: 244-54. 4. Sartorius N, Jablensky A,
Ernberg G, et al. Course of schizophrenia in different countries: some results of a WHO international comparative five year follow up study. In: Hafner H, Gattaz WF, Janzarik W, eds. Search for the causes of schizophrenia. Berlin: Springer Verlag, 1987; 107-13. 5. Johnstone EC, ed. Disabilities and circumstances of schizophrenic patients: a follow-up study. Br J Psychiatry 1991; 159: (suppl 13). 6. Johnstone EC, Owens DGC, Gold A, et al. Schizophrenic patients discharged from hospital: a follow-up study. Br J Psychiatry 1984; 145: 586-90. 7. National Schizophrenia Fellowship. Home sweet nothing: the plight of sufferers from chronic schizophrenia. London: National Schizophrenia
Fellowship, 1979. 8. Weller MPI. Mental illness-who cares? Nature
1989; 339: 249-52.
Ewing’s sarcoma and its congeners: an interim appraisal New research is beginning to provide some insight into the nature of Ewing’s sarcoma and its relation to certain other round-cell tumours in children and young adults;l it seems timely to review recent evidence. Ewing’s sarcomas of bone vary in their growth patterns and cellular features. Some tumours show evidence of neural differentiation based on the presence of rosettes, ultrastructural features (cell and processes, neurosecretory granules), immunohistochemical staining. Neural differentiation has been induced in cell lines derived from Ewing’s sarcoma in vitro. More than 90% of tumours have consistent cytogenetic abnormalities, most commonly translocations between chromosomes 11 and 22-t(11;22) (q24;q12). These same features are found in a proportion of soft tissue round-cell
conventionally designated as extraosseous Ewing’s sarcoma, and in primitive neuroectodermal tumours (PNETs) of bone and soft tissue. PNETs, especially if well differentiated, are sometimes called neuroepitheliomas (the PNET entity also includes Askin’s malignant small-cell tumour of the thoracopulmonary region in childhood). It is now agreed that Ewing’s sarcoma and PNETs form a single group of bone and soft tissue tumours in which typical undifferentiated Ewing’s sarcomas lie at tumours
one end of a spectrum and PNETs with clear evidence
of neural differentiation at the other. Ewing’s sarcomas with neural features merge with PNETs showing less obvious differentiation in the middle. According to this view, Ewing’s sarcomas and PNETs form a separate category from neuroblastoma, although neuroblastoma may be difficult or
impossible grounds.
to
distinguish
on
purely morphological
