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    were the focus of an international symposium on innovation inapproaches to disability held by the Throgmortion Society at theRoyal College of Physicians in London on April 28.A point made at the meeting was that an attempt should be made

    to rehabilitate profoundly disabled people. No longer should theybe assumed to be permanent bed-occupiers, be bypassed on wardrounds, and be the reason for staff to fear social workers, who mightinquire after the patients progress. The profoundly disabled are theones who, if community care for less disabled people takes offsuccessfully, will form the bulk of patients in rehabilitation units. Ifimprovement in function, maintenance of optimum function, or aslowing of its deterioration can be achieved it is not only the patientwho will benefit; family and carers could obtain much relief too.The difficulty in promoting the message that profoundly disabledpeople should be rehabilitated is that the evidence that somethingcan be done for them is at present only anecdotal; and it will remainso unless larger numbers are treated. The technology for aidingmobility and communication is there (although there is room forimprovement2), and innovations have been made in physiotherapy(such as the use of electrical biofeedback to teach new movements).The obstacles remain the usual ones of attracting staff to this kind ofwork and of ensuring that the resources required have not beenobtained at the expense of larger numbers of less severely disabledpeople.One means of raising funds for rehabilitation of disabled people is

    the scheme introduced in France in 1987, which obliges firms withstaff of 20 or more to allocate a proportion of their jobs to disabledpeople. Firms that do not comply have to pay a levy.


    DEPLETION of the stratospheric ozone layer is advancing twice asfast as was predicted only two years ago, and the 1987 Montrealproposals for a freeze on the production and use of ozone-damagingchlorofluorocarbons (CFCs) at 1986 levels by Jan 1, 1989, and a50% reduction by mid-1998 now seem too modest. TheGovernment of Finland, which hosted an international meeting onozone in Helsinki last week, has now proposed that CFCconsumption should be halved by 1995 and eliminated by the year2000.Dr Mostafa Tolba, executive director of the United Nations

    Environment Programme (UNEP), which convened the meeting,described how attitudes had changed since the Montreal meeting,which he described as a negotiating nightmare. But now there wasno need to plead or cajole, he said. "Governments are running, notwalking, to Helsinki", he added. "People get frightened when theyhear that a 1 % decrease in ozone is likely to cause a 4% increase inskin cancer."Dr Tolba suggested that the greatest need was to monitor what

    was happening to the ozone layer, especially in the southernhemisphere and the tropics. Since CFCs have been indicted as"greenhouse" gases, the interplay between ozone, carbon dioxide,and other gases also needed to be studied. Dr Tolba is aiming,through collaboration between UNEP and the WorldMeteorological Organisation, to establish a Climate WarmingConvention by 1992.Methods of measuring ultraviolet radiation need to be refined,

    said Dr Tolba. A delegate from the Caribbean told the meeting thatcrops in his region were very sensitive even to small variations inradiation. More research was needed into new crop varietiesresistant to ultraviolet light.One likely sticking point in achieving a ban on CFCs is who is to

    pay for the substitution of ozone friendly chemicals (and theassociated expensive technological changes) for the CFC used inrefrigeration in developing countries. India and China, which seeozone depletion as a problem created by the developed nations,appealed for financial assistance at an ozone conference in Londonin March. Such assistance was approved in principle at the Helsinkimeeting, but Dr Tolba had earlier reminded delegates that only 11of the 35 governments which ratified the Montreal protocol had sofar paid their dues.

    2. Mulley GPO. Standards of wheelchairs. Br Med J 1989; 298: 1198-99.

    Another issue raised at the meeting was the ozone depletingpotential of halons, which was said to need urgent investigation.Scientific knowledge of halons is less advanced than that of CFCs,but some halons, which are increasingly being used in fireextinguishers, are believed to be ten time more dangerous to theozone layer than CFCs.Dr Tolba is optimistic. "When ozone layer depletion affects

    people in their daily lives," he said, "they get very interested indoing something about it."


    A DIET of bran and skimmed milk is just as effective as anyproprietary very-low-calorie diet, according to the Drug andTherapeutics Bulletin,l and it is very much cheaper. Two pints ofskimmed milk a day for women (or three for men), with bran forbulk, unlimited calorie-free drinks, and iron and multivitamintablets to make up any deficiencies may help the severely obese tolose weight quickly, but such a diet will do little to improve eatinghabits. The benefits of weight reduction in obese patients-reduction of raised blood pressure, improvement in impairedcarbohydrate tolerance, lowered risk of osteoarthritis of weight-bearing joints, and increased life expectancy--can be reaped only ifbad habits are permanently changed. Overweight patients are mosteffectively managed in groups, says the bulletin, and many peoplefind the mutual learning and support gained from joining aslimning club helpful. Techniques aimed at recruiting the psycheseem to have the best chance of long-term success-behaviourtherapy, for instance, can achieve excellent weight loss (an averageof 17 kg in one year in one study, but the cost in time to patient andtherapist was enormous); however, such treatment is rarelyavailable within the National Health Service. Drug treatments(appetite suppressants, bulk-forming agents, and "starchblockers") are ineffective in the long term, says the bulletin, and soare surgical methods such as jaw-wiring, gastroplasty, andintragastric balloons. Regular aerobic exercise can contribute toweight maintenance by increasing resting metabolic rate, but thebulletin observes that obese people do not tolerate a weekly routineof 5 hours hard physical work.


    234 outbreaks of foodbome disease affecting 1825 people werereported to the Communicable Diseases (Scotland) Unit in 1987 2In 49 of these, the food was eaten outside Scotland. Incriminatedagents were species of Salmonella, Campylobacter, Shigella, andBacillus, Staphylococcus aureus, Clostridium perfringens, and viruses;in 15 outbreaks the cause was unknown. 77% of the episodes wereattributable to salmonellosis, S enteritidis phage type 4 (now afamiliar contaminant of poultry and eggs) being the strain mostfrequently found. Although the number of listeriosis cases has risenin Scotland (as in England and Wales), none has yet been traced toinfected food.The report also describes three outbreaks of hospital food-

    poisoning, which brings the total during 1978-87 to 48: meat andpoultry were the source of infection in over 90% of outbreaks wherea food vehicle was identified. Over the past 15 years, the overall

    frequency of outbreaks has fallen, but the number of people affectedper outbreak has increased. Have the removal of Crown Immunityfrom hospital kitchens in February, 1986, and the introduction ofcook-chill catering had any effect on hospital foodbome infection inScotland? Only time will tell.


    As the trend for community care for mentally handicapped adultsgrows, attention needs to be paid to contraceptive cover for theseindividuals. Men with Down syndrome are said to be infertile.However, a 29-year-old man with apparently non-mosaic trisomy21 was most probably the father in a pregnancy in an educationally

    1 Managing obesity successfully. Drug Ther Bull 1989; 27: no 9.2. Surveillance programme for foodborne infections and intoxications Scotland1987.

    Communicable Diseases (Scotland) Unit, Information and Statistics Division,Trinity Park House, South Trinity Road, Edinburgh EH5 3SQ. 1989. 1.50.ISSN 0263-8754.


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