1381
What’s
new
in
public health?
Public health has been enjoying a renaissance. Acheson Inquiry1 adopted the apposite defmition-"the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society". British experience of this "new" public health has two elements: (a) of the multisectoral and development health new movement; and public multidisciplinary health doctor and the (b) shaping of the new public
The
newly styled specialty of "public health medicine". The old public health was concerned largely with the consequences of unhealthy settlements and with the safety of food, air, and water; in disease terms, with the infectious, toxic, and traumatic causes of death, which predominate among young people and are associated with poverty. The new public health has emerged to of diseases-those associated increasing longevity and overpopulation, with industrialisation and industrial decline, with inequalities in health in affluent societies, with environmental damage, and with ecological imbalance. Many of the underlying factors are believed to be amenable to prevention through social, environmental, or behavioural change.2,3 The new public health has emerged during a re-evaluation of the effectiveness of therapeutic medicine. While the medical profession was being criticised for rendering individuals powerless over decisions about their own health, for creating illness, and for fostering unrealistic expectations of medical science, there was a reappraisal of the benefits reaped from massive public expenditure on curative services. McKeown4 argued powerfully that improvements in nutrition and environmental hygiene and limitation in family size had played the greatest part in improving life expectancy from the eighteenth century, with specific preventive and therapeutic interventions being responsible for smaller improvements in the late twentieth century. The need to control escalating health care costs56 and the philosophy of individual responsibility for health7 made health promotion more attractive politically. Emergence of infections caused by "new" organisms such as human immunodeficiency virus and legionella, and public
meet a
with
whole
new set
food poisoning and meningitis, served to confirm the inadequacies of curative medicine alone. The new public health movement seeks the active participation of individuals and communities in decisions that affect their health and in taking the action required to make them healthier. International direction was provided by the World Health Organisation’s Health for All by the Year 2000 strategy, whose targets8 have been vigorously adopted by some health and local authorities in the UK and elsewhere in Europe. Initiatives include the Healthy Cities Project,9 the Association of Schools of Public Health in the European Region, the UK Health For All Network, the UK Local Authorities Health Network, and the Public Health Alliance. Target one-25% reduction in inequalities in healthindicated that Health for All stands for social justice as well as for general health and environmental improvement. In Britain, after Sir Douglas Black’s politically unwelcome report on inequalities in healthy several "local Black reports" were produced on inequalities at district level which have been used as stimuli for Health for All initiatives. An article on p 1387 indicates that the issue is far from dead. The new public health movement recognises and seeks to develop the contribution to health promotion in many areas-eg, housing; town planning; environmental protection and waste management; health education in schools and colleges; healthy food procurement and catering; healthy work through economic development and environmental regulation; exercise promotion through town planning and leisure services; community development and voluntary sector activity; and crime prevention. Facilities offered by social services, education, youth and community services, leisure, housing, voluntary agencies, and police and fire departmentsll are also recognised for their contribution to health. In addition to the old public health problems, which still afflict most of the world’s population, we now have to contend with the ravages of new epidemics brought about by cigarette smoking, road accidents, industrial pollution, HIV infection, and the effects of war. In these examples the developed world is culpable in actively exporting death, disease, and environmental damage—yet more evidence of a requirement, in public health terms, for social justice and the pursuit of equity in health.13 Public health thinking is moving into a third phase by seeking to recognise the environmental impact of public health interventions and to propose public health solutions that sustain local and global ecosystems. This new environmental health14 acknowledges the interdependence of ecosystems and health systems, and fosters concepts of "reciprocal maintenance" (we should look after the things that look after us) and "sustainable development" (improvements in health standards are genuine only when resources used in their achievement can be concern over
EDITORIALS
1382
renewed).13°is.l6 There is also growing recognition of the need for joint action on common concerns of health and environmental promotion such as economic dependence on tobacco, armaments, and motor vehicles." Public health practitioners could benefit from a greater understanding of economics to appraise health care and other social policy options17 and to muster their forces against anti-health and interests. 13 Economic vested diversification towards healthier manufactured goods and services,18 and pursuit of a socially useful "green" economy are potentially powerful tools for improving the public health. In the UK, as a direct consequence of the Acheson report, a central role has been fashioned for public health physicians at the forefront of health authorities’ service planning.1,19,20 Directors of public health are to be responsible for assessment of health needs, for advice on appropriate services, and for evaluating outcomes; their findings are to be published in annual reports.21 Health authorities are also required to ensure effective arrangements for control of infection, prevention of disease, and promotion of health.120 The Government’s consultation document The Health of the Nation, published this week (see p 1406), proposes for the first time targets for some conditions,
environmental
diabetes, asthma, strokes, and cardiovascular disease, for which a health service can
including
be expected to deliver beneficial outcomes for patients and for the population as a whole. It is already being criticised for its failure to grapple with the social origins of health inequalities-eg, poverty and poor
housing. The role of public health medicine appears similar that envisaged by Morris for the then specialty of community medicine. The community physician was to be responsible for the community diagnosis-for providing the intelligence necessary for efficient and effective administration of the health service. He would conduct studies to provide a sound basis for discussion of rationing and other issues involving the morality of medical care.22 Public health departments should maintain the service functions of communicable disease control, dental public health, population medicine services (eg, screening, immunisation coordination, and health promotion), and occupational health. Directors will need access to resources and skills of a range of disciplines in environmental, health care, biological, and social sciences, both within and outside the health service. There is suspicion about where the power of rationing may be vested in the new National Health Service, 23 but the process of rationing could be legitimised, within the spirit of the new public health, if communities were actively involved in decisions about their health care, and if the process was extended to the full range of public health interventions, in which therapeutic options are but one part of the spectrum of responses available to improve health. Pilot studies are needed whereby local
to
help to assess health and health care priorities; by analogy, small-scale local developments of the Oregon experiment.24 communities
Let us now return to the Acheson report that has done so much for the rebirth of the public health movement. Sir Donald holds that directors of public health should not make politically sensitive remarksexcept possibly in their annual reports. One can readily see why it would be politically uncomfortable for them to do so, but surely if the specialty is to flourish and if the directors are to do their job properly they will have to speak out on sensitive issues. The medical code declares that a doctor’s first duty is to the patient (or in this case the community), not to the employer; doctors should be free to exercise professional judgment. Part of the reason that public health medicine has fared so poorly in the UK is that public health doctors have sometimes been seen as mere cogs on the machine. They tend to become visible only when they make unpopular decisions: they risk being execrated when they challenge some much-cherished clinical practices or ambitions and they face dismissal if they challenge their authorities. Often they have not been given credit for very substantial achievements-eg, for the steady improvement in immunisation rates. Another reason is the eternal conflict between preventive and curative services. More than ever before, public health medicine needs a strong independent voice. In the arbitration between treatment and preventive strategies, public health physicians can expect to make enemies on all sides, not least from clinicians whose services are threatened. Moreover, they will be the perfect foil for politicians who are embarrassed by the lack of facilities for their constituents. The best public health physicians will continue to generate action on local and wider issues. The task of public health physicians is to be well informed, and to be brave enough to act on the information. If they are successful in this enterprise, public health locally, nationally, and globally will be greatly advanced. 1.
Department of Health. Public health in England (the Acheson report). London: HM Stationery Office, 1988.
2. Acheson ED. Edwin Chadwick and the world we live in. Lancet 1990; 336: 1482-85. 3. Ashton J, Seymour H. The new public health. Milton Keynes: Open University Press, 1988. 4. McKeown T. The role of medicine. Oxford: Blackwell, 1979. 5. Department of Health and Social Security. Prevention and health: everybody’s business. London: HM Stationery Office, 1976. 6. Lalonde M. A new perspective on the health of Canadians. Ottawa: Information Canada, 1974. 7. Currie E. Lifelines. London: Sidgwick and Jackson, 1989. 8. European Office of the World Health Organisation. Targets in support of health for all by the year 2000 in the European region. Copenhagen: WHOEURO, 1985. 9. Ashton J, Grey P, Barnard K. Healthy cities: WHO’s new public health initiative. Health Promotion 1986; 1: 319-24. 10. Townsend P, Davidson N, eds. Inequalities in health: the Black report. Harmondsworth: Penguin, 1982. 11. Proceedings of a working conference on healthy public policy. Beyond health care. Can J Public Health 1985; 76 (suppl 1): 1-104. 12. North R. The real cost. London: Chatto and Windus, 1986. 13. United Nations Organisation. Report of the expert group on development and disarmament. (Thorsson report). New York: United Nations Organisation, 1981.
1383
14. Ashton J. Sanitarian becomes ecologist: the new environmental health. Br Med J 1991; 302: 189-90. 15. Bruntland G, ed. Our common future: the report of the World Commission on Environment and Development. Oxford: Oxford University Press, 1987. 16. Starke L, ed. State of the world 1990. Worldwatch Institute report on progress towards a sustainable society. New York: WW Norton, 1990. 17. Mooney GH, Russell EM, Weir R. Choices for health care. Basingstoke: MacMillan, 1980. 18. Renner M. Swords into plowshares: converting to a peace economy. Washington: Worldwatch Institute, 1990. (Worldwatch paper 96). 19. Secretaries of state for health, Wales, Northern Ireland and Scotland. Working for patients. London: HM Stationery Office, 1989. (CN555). 20. Department of Health. Health of the population: responsibilities of health authorities. (Health circular HC (88) 64.) London: Department of Health, 1988. 21. Middleton J, Binysh K, Chishty V, Pollock G. How to write the annual report of the director of public health. Br Med J 1991; 302: 521-24. 22. Morris JN. Tomorrow’s community physician. Lancet 1969; ii: 811-16. 23. Godber G. Rationing health care. Br Med J 1991; 302: 529. 24. Dixon J, Welch HG. Priority setting: lessons from Oregon. Lancet 1991; 337: 891-94.
Cardiac myoplasty with the latissimus dorsi muscle At the Fourth World Symposium on Transformed Skeletal Muscle for Cardiac Assist in Palm Springs last October it was estimated that over 100 cardiomyoplasties had been carried out. For this operation the patient’s latissimus dorsi muscle is mobilised, electrically trained, and used to augment left ventricular function.1 About two-thirds of the clinical experience has accrued in three centresBroussais Hospital, Paris,2 Sao Paolo, Brazil,3and Allegheny General Hospital, Pittsburgh4-but the progress that has been made reflects an international collaboration between biologists, engineers, and surgeons.
Doctors have resorted to this approach because the outlook for patients in heart failure remains extremely poor. Although medical treatment with diuretics,
vasodilators, angiotensin converting enzyme inhibitors, and orally available inotropes will modify some manifestations, most of these patients die within few years. It is from this group that candidates for cardiac transplantation are drawn, but the supply of donor hearts places a ceiling on the number that can be helped, and those who receive transplants spend the rest of their lives being steered on a course between infection and rejection. Neither fully implantable mechanical hearts nor animal donors are practical alternatives for these patients. Cardiomyoplasty would put to use some of their own plentiful and under-used skeletal muscle, and sidestep the ethical and immunological, and some of the economic, dilemmas associated with mechanical or donor heart a
replacement. The first step depends on a knowledge of the physiology and molecular biology of skeletal muscle. The existence of red and white meat, or slow and fast contracting muscle, has been known for hundreds of years, but in 1960 Buller et al5 reported an experiment in which they cross-anastomosed the nerves of fast and slow muscles5-the fast muscle became slower and the slow muscle became faster. Salmons and
Sreter6 showed that the change was due to the different pattern of firing in the motor neuron, and that stimulation at 10 Hz over several weeks would result in transformation of the fibres within a fast muscle to slow type.6The major fibre types of skeletal muscle can be divided into slow-twitch type I fibres, which have oxidative metabolism and a high mitochondrial content, and fast-twitch type II fibres, which are more susceptible to fatigue and have a predominantly glycolytic metabolism.7 Although muscle is a well differentiated tissue it retains the genetic potential to express various phenotypes; depending on the stimulus to which it is exposed, different protein isoforms are encoded with aminoacid sequences specific for the muscle fibre types7 and with detectable changes in messenger RNA.Myosin type,9 histological appearance,10 and ability to resist fatigue are all changed. and Pacemaker implantable defibrillator have been techniques deployed in systems that will transform skeletal muscle to behave like cardiac muscle. The pulse train generator will then sense the cardiac contraction and drive the transformed, transplanted latissimus dorsi to contract in synchrony. If cardiac activity is delayed it will pace both the heart and its skeletal muscle support. If the cardiac action is too fast it will drive the augmenting muscle at 2:1, 3:1, or 4:1 to allow adequate filling and to reduce fatigue of the transformed skeletal muscle.l1 Plastic surgeons are very familiar with the use of pedicled muscle flaps in reconstruction after injury, burns, or surgical resection. The latissimus dorsi has a dominant arteriovenous pedicle, which favours mobilisation, and a single motor nerve, which simplifies pacing. This large, sheet-like muscle can be fashioned into structures other than a chest wall component, in which role it is expendable, the functional loss being well tolerated.12 Moreover, the latissimus dorsi is within easy reach of the heart. There are several ways in which the muscle may be used to aid the failing left ventricle. The technique used most commonly is to wrap the sheet of latissimus dorsi around the heart.13 Yacoub’s group, experimenting with these techniques, call this "cardiomyopexy" and reserve the word "cardiomyoplasty" for an inlay graft after resection of left ventricular scar or aneurysm,but they seem to be in the minority with this nomenclature. Other proposals are to use the muscle as a wrap around the descending aorta or some other tube in communication with the arterial system to provide diastolic counterpulsation.7,14 Clinical experience so far relates to use of the ventricular wrap technique, usually called cardiomyoplasty. A serious drawback of the technique is that the muscle cannot be used immediately to support the heart. A major advantage of cardiac surgery, which applies to surgery for critical ischaemia, valve operations, and transplantation, is that benefit is available immediately. With myoplasty the muscle
What’s
new
in
public health?
Public health has been enjoying a renaissance. Acheson Inquiry1 adopted the apposite defmition-"the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society". British experience of this "new" public health has two elements: (a) of the multisectoral and development health new movement; and public multidisciplinary health doctor and the (b) shaping of the new public
The
newly styled specialty of "public health medicine". The old public health was concerned largely with the consequences of unhealthy settlements and with the safety of food, air, and water; in disease terms, with the infectious, toxic, and traumatic causes of death, which predominate among young people and are associated with poverty. The new public health has emerged to of diseases-those associated increasing longevity and overpopulation, with industrialisation and industrial decline, with inequalities in health in affluent societies, with environmental damage, and with ecological imbalance. Many of the underlying factors are believed to be amenable to prevention through social, environmental, or behavioural change.2,3 The new public health has emerged during a re-evaluation of the effectiveness of therapeutic medicine. While the medical profession was being criticised for rendering individuals powerless over decisions about their own health, for creating illness, and for fostering unrealistic expectations of medical science, there was a reappraisal of the benefits reaped from massive public expenditure on curative services. McKeown4 argued powerfully that improvements in nutrition and environmental hygiene and limitation in family size had played the greatest part in improving life expectancy from the eighteenth century, with specific preventive and therapeutic interventions being responsible for smaller improvements in the late twentieth century. The need to control escalating health care costs56 and the philosophy of individual responsibility for health7 made health promotion more attractive politically. Emergence of infections caused by "new" organisms such as human immunodeficiency virus and legionella, and public
meet a
with
whole
new set
food poisoning and meningitis, served to confirm the inadequacies of curative medicine alone. The new public health movement seeks the active participation of individuals and communities in decisions that affect their health and in taking the action required to make them healthier. International direction was provided by the World Health Organisation’s Health for All by the Year 2000 strategy, whose targets8 have been vigorously adopted by some health and local authorities in the UK and elsewhere in Europe. Initiatives include the Healthy Cities Project,9 the Association of Schools of Public Health in the European Region, the UK Health For All Network, the UK Local Authorities Health Network, and the Public Health Alliance. Target one-25% reduction in inequalities in healthindicated that Health for All stands for social justice as well as for general health and environmental improvement. In Britain, after Sir Douglas Black’s politically unwelcome report on inequalities in healthy several "local Black reports" were produced on inequalities at district level which have been used as stimuli for Health for All initiatives. An article on p 1387 indicates that the issue is far from dead. The new public health movement recognises and seeks to develop the contribution to health promotion in many areas-eg, housing; town planning; environmental protection and waste management; health education in schools and colleges; healthy food procurement and catering; healthy work through economic development and environmental regulation; exercise promotion through town planning and leisure services; community development and voluntary sector activity; and crime prevention. Facilities offered by social services, education, youth and community services, leisure, housing, voluntary agencies, and police and fire departmentsll are also recognised for their contribution to health. In addition to the old public health problems, which still afflict most of the world’s population, we now have to contend with the ravages of new epidemics brought about by cigarette smoking, road accidents, industrial pollution, HIV infection, and the effects of war. In these examples the developed world is culpable in actively exporting death, disease, and environmental damage—yet more evidence of a requirement, in public health terms, for social justice and the pursuit of equity in health.13 Public health thinking is moving into a third phase by seeking to recognise the environmental impact of public health interventions and to propose public health solutions that sustain local and global ecosystems. This new environmental health14 acknowledges the interdependence of ecosystems and health systems, and fosters concepts of "reciprocal maintenance" (we should look after the things that look after us) and "sustainable development" (improvements in health standards are genuine only when resources used in their achievement can be concern over
EDITORIALS
1382
renewed).13°is.l6 There is also growing recognition of the need for joint action on common concerns of health and environmental promotion such as economic dependence on tobacco, armaments, and motor vehicles." Public health practitioners could benefit from a greater understanding of economics to appraise health care and other social policy options17 and to muster their forces against anti-health and interests. 13 Economic vested diversification towards healthier manufactured goods and services,18 and pursuit of a socially useful "green" economy are potentially powerful tools for improving the public health. In the UK, as a direct consequence of the Acheson report, a central role has been fashioned for public health physicians at the forefront of health authorities’ service planning.1,19,20 Directors of public health are to be responsible for assessment of health needs, for advice on appropriate services, and for evaluating outcomes; their findings are to be published in annual reports.21 Health authorities are also required to ensure effective arrangements for control of infection, prevention of disease, and promotion of health.120 The Government’s consultation document The Health of the Nation, published this week (see p 1406), proposes for the first time targets for some conditions,
environmental
diabetes, asthma, strokes, and cardiovascular disease, for which a health service can
including
be expected to deliver beneficial outcomes for patients and for the population as a whole. It is already being criticised for its failure to grapple with the social origins of health inequalities-eg, poverty and poor
housing. The role of public health medicine appears similar that envisaged by Morris for the then specialty of community medicine. The community physician was to be responsible for the community diagnosis-for providing the intelligence necessary for efficient and effective administration of the health service. He would conduct studies to provide a sound basis for discussion of rationing and other issues involving the morality of medical care.22 Public health departments should maintain the service functions of communicable disease control, dental public health, population medicine services (eg, screening, immunisation coordination, and health promotion), and occupational health. Directors will need access to resources and skills of a range of disciplines in environmental, health care, biological, and social sciences, both within and outside the health service. There is suspicion about where the power of rationing may be vested in the new National Health Service, 23 but the process of rationing could be legitimised, within the spirit of the new public health, if communities were actively involved in decisions about their health care, and if the process was extended to the full range of public health interventions, in which therapeutic options are but one part of the spectrum of responses available to improve health. Pilot studies are needed whereby local
to
help to assess health and health care priorities; by analogy, small-scale local developments of the Oregon experiment.24 communities
Let us now return to the Acheson report that has done so much for the rebirth of the public health movement. Sir Donald holds that directors of public health should not make politically sensitive remarksexcept possibly in their annual reports. One can readily see why it would be politically uncomfortable for them to do so, but surely if the specialty is to flourish and if the directors are to do their job properly they will have to speak out on sensitive issues. The medical code declares that a doctor’s first duty is to the patient (or in this case the community), not to the employer; doctors should be free to exercise professional judgment. Part of the reason that public health medicine has fared so poorly in the UK is that public health doctors have sometimes been seen as mere cogs on the machine. They tend to become visible only when they make unpopular decisions: they risk being execrated when they challenge some much-cherished clinical practices or ambitions and they face dismissal if they challenge their authorities. Often they have not been given credit for very substantial achievements-eg, for the steady improvement in immunisation rates. Another reason is the eternal conflict between preventive and curative services. More than ever before, public health medicine needs a strong independent voice. In the arbitration between treatment and preventive strategies, public health physicians can expect to make enemies on all sides, not least from clinicians whose services are threatened. Moreover, they will be the perfect foil for politicians who are embarrassed by the lack of facilities for their constituents. The best public health physicians will continue to generate action on local and wider issues. The task of public health physicians is to be well informed, and to be brave enough to act on the information. If they are successful in this enterprise, public health locally, nationally, and globally will be greatly advanced. 1.
Department of Health. Public health in England (the Acheson report). London: HM Stationery Office, 1988.
2. Acheson ED. Edwin Chadwick and the world we live in. Lancet 1990; 336: 1482-85. 3. Ashton J, Seymour H. The new public health. Milton Keynes: Open University Press, 1988. 4. McKeown T. The role of medicine. Oxford: Blackwell, 1979. 5. Department of Health and Social Security. Prevention and health: everybody’s business. London: HM Stationery Office, 1976. 6. Lalonde M. A new perspective on the health of Canadians. Ottawa: Information Canada, 1974. 7. Currie E. Lifelines. London: Sidgwick and Jackson, 1989. 8. European Office of the World Health Organisation. Targets in support of health for all by the year 2000 in the European region. Copenhagen: WHOEURO, 1985. 9. Ashton J, Grey P, Barnard K. Healthy cities: WHO’s new public health initiative. Health Promotion 1986; 1: 319-24. 10. Townsend P, Davidson N, eds. Inequalities in health: the Black report. Harmondsworth: Penguin, 1982. 11. Proceedings of a working conference on healthy public policy. Beyond health care. Can J Public Health 1985; 76 (suppl 1): 1-104. 12. North R. The real cost. London: Chatto and Windus, 1986. 13. United Nations Organisation. Report of the expert group on development and disarmament. (Thorsson report). New York: United Nations Organisation, 1981.
1383
14. Ashton J. Sanitarian becomes ecologist: the new environmental health. Br Med J 1991; 302: 189-90. 15. Bruntland G, ed. Our common future: the report of the World Commission on Environment and Development. Oxford: Oxford University Press, 1987. 16. Starke L, ed. State of the world 1990. Worldwatch Institute report on progress towards a sustainable society. New York: WW Norton, 1990. 17. Mooney GH, Russell EM, Weir R. Choices for health care. Basingstoke: MacMillan, 1980. 18. Renner M. Swords into plowshares: converting to a peace economy. Washington: Worldwatch Institute, 1990. (Worldwatch paper 96). 19. Secretaries of state for health, Wales, Northern Ireland and Scotland. Working for patients. London: HM Stationery Office, 1989. (CN555). 20. Department of Health. Health of the population: responsibilities of health authorities. (Health circular HC (88) 64.) London: Department of Health, 1988. 21. Middleton J, Binysh K, Chishty V, Pollock G. How to write the annual report of the director of public health. Br Med J 1991; 302: 521-24. 22. Morris JN. Tomorrow’s community physician. Lancet 1969; ii: 811-16. 23. Godber G. Rationing health care. Br Med J 1991; 302: 529. 24. Dixon J, Welch HG. Priority setting: lessons from Oregon. Lancet 1991; 337: 891-94.
Cardiac myoplasty with the latissimus dorsi muscle At the Fourth World Symposium on Transformed Skeletal Muscle for Cardiac Assist in Palm Springs last October it was estimated that over 100 cardiomyoplasties had been carried out. For this operation the patient’s latissimus dorsi muscle is mobilised, electrically trained, and used to augment left ventricular function.1 About two-thirds of the clinical experience has accrued in three centresBroussais Hospital, Paris,2 Sao Paolo, Brazil,3and Allegheny General Hospital, Pittsburgh4-but the progress that has been made reflects an international collaboration between biologists, engineers, and surgeons.
Doctors have resorted to this approach because the outlook for patients in heart failure remains extremely poor. Although medical treatment with diuretics,
vasodilators, angiotensin converting enzyme inhibitors, and orally available inotropes will modify some manifestations, most of these patients die within few years. It is from this group that candidates for cardiac transplantation are drawn, but the supply of donor hearts places a ceiling on the number that can be helped, and those who receive transplants spend the rest of their lives being steered on a course between infection and rejection. Neither fully implantable mechanical hearts nor animal donors are practical alternatives for these patients. Cardiomyoplasty would put to use some of their own plentiful and under-used skeletal muscle, and sidestep the ethical and immunological, and some of the economic, dilemmas associated with mechanical or donor heart a
replacement. The first step depends on a knowledge of the physiology and molecular biology of skeletal muscle. The existence of red and white meat, or slow and fast contracting muscle, has been known for hundreds of years, but in 1960 Buller et al5 reported an experiment in which they cross-anastomosed the nerves of fast and slow muscles5-the fast muscle became slower and the slow muscle became faster. Salmons and
Sreter6 showed that the change was due to the different pattern of firing in the motor neuron, and that stimulation at 10 Hz over several weeks would result in transformation of the fibres within a fast muscle to slow type.6The major fibre types of skeletal muscle can be divided into slow-twitch type I fibres, which have oxidative metabolism and a high mitochondrial content, and fast-twitch type II fibres, which are more susceptible to fatigue and have a predominantly glycolytic metabolism.7 Although muscle is a well differentiated tissue it retains the genetic potential to express various phenotypes; depending on the stimulus to which it is exposed, different protein isoforms are encoded with aminoacid sequences specific for the muscle fibre types7 and with detectable changes in messenger RNA.Myosin type,9 histological appearance,10 and ability to resist fatigue are all changed. and Pacemaker implantable defibrillator have been techniques deployed in systems that will transform skeletal muscle to behave like cardiac muscle. The pulse train generator will then sense the cardiac contraction and drive the transformed, transplanted latissimus dorsi to contract in synchrony. If cardiac activity is delayed it will pace both the heart and its skeletal muscle support. If the cardiac action is too fast it will drive the augmenting muscle at 2:1, 3:1, or 4:1 to allow adequate filling and to reduce fatigue of the transformed skeletal muscle.l1 Plastic surgeons are very familiar with the use of pedicled muscle flaps in reconstruction after injury, burns, or surgical resection. The latissimus dorsi has a dominant arteriovenous pedicle, which favours mobilisation, and a single motor nerve, which simplifies pacing. This large, sheet-like muscle can be fashioned into structures other than a chest wall component, in which role it is expendable, the functional loss being well tolerated.12 Moreover, the latissimus dorsi is within easy reach of the heart. There are several ways in which the muscle may be used to aid the failing left ventricle. The technique used most commonly is to wrap the sheet of latissimus dorsi around the heart.13 Yacoub’s group, experimenting with these techniques, call this "cardiomyopexy" and reserve the word "cardiomyoplasty" for an inlay graft after resection of left ventricular scar or aneurysm,but they seem to be in the minority with this nomenclature. Other proposals are to use the muscle as a wrap around the descending aorta or some other tube in communication with the arterial system to provide diastolic counterpulsation.7,14 Clinical experience so far relates to use of the ventricular wrap technique, usually called cardiomyoplasty. A serious drawback of the technique is that the muscle cannot be used immediately to support the heart. A major advantage of cardiac surgery, which applies to surgery for critical ischaemia, valve operations, and transplantation, is that benefit is available immediately. With myoplasty the muscle
