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established during early childhood and those who feelthat atherosclerosis is a disease of adult life and that

dietary discretion should be taught as an essentialaspect of maturation during adolescence. Specificguidance is necessary on such a confusing issue.

Another area of concern relating to both reports isthe recommendation about "case finding". This termdescribes the search for symptoms of disease, otherthan the presenting symptom, at the time ofconsultation. Attempts to identify symptomless "riskfactors" must constitute screening, and it is importantthat an ineffective and disorganised populationscreening programme is not begun under the guise ofcase finding. If screening for high serum cholesterol isnecessary, it should be done systematically-even ifselectively or opportunistically-and the resourceimplications must be addressed. Screening tests mustbe paid for (the portable cholesterol meters

recommended for use in general practice cost 3000,plus 60 pence/test); protocols must be agreed (as forblood pressure measurement, more than one test maybe indicated); a system for collating information mustbe devised; and lipid clinics must be established to dealwith referrals. The accepted method of assessing thevalue of screening is by randomised controlled trial,although the situation is not exactly analogous tocervical or breast cancer screening and the end-pointof such a study could reasonably be taken as a

sustained reduction in serum cholesterol rather thandeath. However, although it is correct to argue thatscreening should not begin until its effectiveness hasbeen established and the cost assessed, it may bedifficult to hold back the tide.

Overall, both reports are welcome. They indicatemedical concern and medical consensus and providean accessible summary of the evidence for theprofession and for government agencies. They rightlystress the considerable agreement that exists on

appropriate action, which should not be obscured byareas of debate. Nevertheless, both reports emphasisethe important role of the doctor, particularly thecardiologist, in influencing opinion and initiatingchange. This is undoubtedly true with respect tovested interests such as the food and tobacco

industries, and also in relation to smoking habits inindividuals. However, it may be unwise to generaliseto other areas of concern such as diet, exercise, andstress. The COMA report was criticised for reflectinga very narrow view of social policy options.7 Similarly,pressure for the social changes necessary to make asignificant impact on the prevalence of disease may bereduced by the "medicalisation" of those at highestrisk in a high-risk society. This notion runs counter tothe argument presented in both reports that theindividual patient approach and the whole populationapproach to prevention are compatible and

complementary. The debate is not over.

7. Winkler JT The COMA report. what it left out. Br Med J 1985; 290: 685-87.

Geriatric Consultation Teams

THE growing number of socially isolated elderlypatients with multiple acute medical problems andfunctional disabilities has created the need for effectivecollaboration between geriatricians and other

physicians and surgeons. The contribution of thegeriatrician is partly medical and partly coordinator ofthe multidisciplinary team. Various arrangementshave developed informally, but occasionally the fruitsof collaboration have been sufficient to justify generalapplicability--eg, orthogeriatrics, pioneered in theUK at Hastings1 and subsequently promoted by aDHSS report.2 Coexistent physical and mental

disability has led to collaboration between

geriatricians and psychiatrists, exemplified by theestablishment of a joint department of health care ofthe elderly at Nottingham.

In the management of the medical problems of theelderly, however, the recognition of distinct butcomplementary skills of general physicians and

geriatricians has been rather slower to develop. Inmany districts, referral to a geriatrician is a request forthe provision of long-stay care; this outcome is bestprevented by early involvement of geriatricians andtheir associated multidisciplinary teams. Theundoubted improvement in hospital medical care ofelderly people during the emergence of geriatricmedicine as a specialty does not prevent the fiercedebate still generated by the suggestion that

geriatricians provide more effective care than theirgeneral medical colleagues.3-8 How might generalphysicians and geriatricians best combine their

complementary skills? One suggestion is that a

consultant geriatrician should combine with severalother consultants to integrate acute admissionresources while retaining charge of specialistrehabilitation, day hospital, and continuing-carefacilities.9 Another approach has been the

development of parallel acute admitting facilities withdivision of responsibilities being determined by thepatient’s age.10A more directly collaborative approach is that of the

geriatric consultants’ team providing advice to generalphysicians or other colleagues. In 1979, Burley et all’reported a scheme in which geriatric teams wereattached to the acute medical wards in a large teachinghospital. A weekly ward round identified all new

1. Devas M. Geriatric orthopaedics. London: 1977.2. Department of Health and Social Security. Orthopaedic services report of a working

party to the Secretary of State for Social Services. London: HM Stationery Office,1981.

3. Rai GS, Murphy P, Pluck RA. Who should provide hospital care of elderly people?Lancet 1985; i: 683-85.

4 Editorial Geriatrics for all? Lancet 1985; i: 674-75.5. Hoffbrand BI. Geriatrics and admission policies Lancet 1985; i: 984.6. Bums-Cox CJ, Harvey RF. Geriatrics and admission policies Lancet 1985, i: 984.7. Rai GS. Genatncs and admission policies Lancet 1985; i: 1334-358 Barker WH. Care of the elderly: is it a specialty? Lancet 1985; ii: 781.9. Evans JG. Integration of genatric with general medical services in Newcastle. Lancet

1983; i: 1430-33.

10. Bagnall WE, Datta SR, Knox J, Harrocks P. Geriatric medicine in Hull a

comprehensive service. Br Med J 1977; ii: 102-04.11. Burley LE, Currie CT, Smith RG, Williamson J. Contribution from geriatric

medicine within acute medical wards. Br Med J 1979; ii: 90-92.

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patients over the age of 65 and highlighted featuressuch as multiple disorders, social problems, mentaldisturbance, and impairments of mobility or

continence. The multidisciplinary team of

geriatricians, nurses, remedial therapists, and socialworkers devised suitable programmes for bothrehabilitation and planned discharges, with detailedarrangements for aftercare and community support;both patients and care plans were reviewed weekly.The effect was examined by comparing the outcomeof admissions during the two 8-month periodsimmediately preceding and during the attachment.Lengths of hospital stay were reduced, especially forwomen. Mean stay for all women over 65 fell from 25to 16 days and for those over 85 from 50 to 19 days.The proportion of patients discharged home rosefrom 45-4 to 59-1%, and from 19-4 to 40-7% forwomen over 85. This change was accompanied by adrop from 7-9 to 5-8% in the proportion of patientstransferred to geriatric department beds. The

apparent success of this scheme has led to thecontinued existence of the arrangement. A survey of

recently appointed consultants working in geriatricmedicine found that 51 % had regular plannedconsultative liaison with general medicine

departments, but very little has been published aboutsuch schemes.Two North American reports on the effect of

geriatric consultation teams are interesting for theirapparent differences. In a controlled trial of a geriatricconsultation service, the treatment and outcome of aconsecutive series of 46 acutely ill patients aged 75 orover admitted to a medical unit at MassachusettsGeneral Hospital were compared with those of twocontrol groups (n = 86) in the same hospital.12 Allpatients had important medical problems and/orfunctional disabilities. The intervention groupreceived three times as much remedial therapy(physiotherapy, and occupational and speechtherapy). There was no reduction in mean length ofstay (aproximately 10 days) and fewer patients weredischarged home in the intervention group (41 %compared with 69% and 80 % in the control groups).Hospital readmission- rates were high in all three

groups (approximately 40%), although the proportionreadmitted in the first month was lower in theintervention group. The patients who received

specialist intervention may have had a better quality ofservice (probably at considerable additional expense)but insufficient details were provided of post-discharge quality of life to be sure of this.

Barker et a113 studied the effect of a geriatricconsultation team on the management of a different

group of patients-those in acute medical wards butbelieved by their physicians to be no longer in need of

12. Campion EW, Jette A, Berkman B An interdisciplinary geriatric consultation service:a controlled trial J Am Geriatr Soc 1983, 31: 792-96.

13. Barker WH, Williams TF, Zimmer JG, et al Geriatric consultation teams in acute

hospitals. impact on back-up of elderly patients J Am Geriatr Soc 1985, 33: 422-28.

such facilities (often called "bed-blockers" in the

UK). Over a 6-month intervention period there was areduction in the lengths of stay as "bed-blockers" anda resultant decrease in the number of such patients.Better rehabilitation facilities or improved access toappropriate placement outside hospital for thoseindividuals with serious disability may have beenresponsible for the improvement. There is evidencethat prolonged lengths of stay in UK hospitals are theresult of continuing medical problems rather thansocial service or administrative delays,l4 and that theseverity of medical problems on admission to hospitalis a better predition of prolonged stay than socialfactors.lsA major factor in determining the effectiveness of

any consultation is compliance with the recommenda-tions. A report by Allen and colleagues has latelyexamined this question.16 Patients over 75 admitted tothe Durham (NC) Veterans Administration MedicalCenter were assessed by a multidisciplinary consulta-tion team and then randomly allocated to a group(n = 92) for whom a series of recommendations wasmade in writing and by follow-up thrice-weekly wardrounds, or to a control group of 93 patients for whomrecommendations were formulated but not com-municated to the medical team responsible. Themedical and functional states of the groups weresimilar. Overall compliance with the total 559recommendations (mean =6 1 per patient) in theintervention group was 71-7%. Compliance washighest with respect to instability and falls (95-0%)and discharge planning (94-3%) and lowest for drugtherapy (46-7%). Direct discussions with house staff,in addition to written notes, were strongly associatedwith compliance; there was also a trend towardsimproved compliance with longer duration of patientstay. In the control group, the rate of implementationof actions which would have been subject to

recommendations by the consultation team was27-1%. Actions commonly neglected involved

impairments of vision, hearing, or speech, confusion,depression, and drug therapy. Despite theconsiderable impact in terms of recommended

activity, the mean length of hospital stay was notreduced. This finding is open to several

interpretations. Did the intervention group receive abetter quality of care without this necessitatingprolonged hospital stay or, were the recommendationsirrelevant to the success of management?Although the proportion of the elderly population

who require specialist geriatric skills may be small,8 forthe patient who needs expert care the implications arevery great. Delay is a common feature of an

14. Seymour DG, Pringle R. Elderly patients in a general surgical unit: do they block beds?Br Med J 1982; 284: 1921-23.

15. Maguire PA, Taylor IC, Stout RW Elderly patients in acute medical wards: factorspredicting length of stay in hospital. Br Med J 1986; 292: 2151-53

16 Allen CM, Becker PM, McVey LJ, et al. A randomised, controlled clinical trial of ageriatric consultation team. JAMA 1986; 255: 2617-21.

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inadequate service and is generally disastrous in termsof a successful outcome. Where medical services

provided for elderly people are not age-related,further research is needed to evaluate various methodsof effective collaboration. Such evaluation, however,must assess effectiveness in terms of quality as

perceived by patients and their families, as well asefficiency as perceived by managers.

THALLIUM POISONING IN GUYANA—A NATIONAL CRISIS

As the thallium story in Guyana unfolds, it is already clearthat use of this toxin as a pesticide should be bannedworldwide.The toxicity of thallium was quickly recognised by its

discoverer, Sir William Crookes. He and his assistant,Lawy, both suffered from symptoms of mild thalliumpoisoning in 1861, and Lawy demonstrated its lethal toxicityfor dogs, hens, and ducks.1 Despite its early reputation fortoxicity thallium was used, but soon discarded, as a

treatment for syphilis, gonorrhoea, gout, dysentery, andtuberculosis. It was also widely used as a depilatory for thetreatment of ringworm of the scalp, but the dose of 8 mg/kgthallium acetate was toxic, and there were many fatalities.The last such case in the UK was in 1949. The extreme

toxicity of thallium, plus the fact that it is odourless andtasteless, has led to its use as a homicidal poison, and as suchit has been said to be 100% fatal.2 Symptoms of toxicityinclude gastrointestinal disturbances, neuropathy with

pains in the limbs, ptosis, facial paralysis, and retrobulbarneuritis. Deposition of thallium in the brain may lead topsychological disturbances, convulsions, and coma, anddeath may occur from cardiac arrest or respiratory failure. 3The most notable feature of poisoning is alopecia, whichcharacteristically occurs 15-20 days after ingestion.4 Asingle dose can be fatal within 1-2 days, but smaller repeateddoses are cumulatively toxic, with symptoms appearing overseveral weeks.

Thallium has a number of industrial uses, for example inlens manufacture, photography, and scintillation counters.Radioisotope thallium-201 scanning is a well-recognisedtechnique in the diagnosis of myocardial ischaemia.Thallium sulphate has also been widely used for killingsmall mammals. However, although long banned as apesticide in the UK and the USA, it is still used in manycountries as a rodenticide, despite the World Health

Organisation’s recommendation against such use.5 In

Guyana, the Guyana Sugar Corporation imports at least500 kg of thallium sulphate a year to kill rats in the sugarplantations.6 Since the lethal dose for man is 0-8-1-0 g,2,7poisoning could occur on a wide scale unless the use ofthallium is closely controlled. Over the past year there havebeen several sporadic cases of fatal thallium poisoning inGuyana. However, it is now clear that it is not a question ofisolated incidents-a large proportion of the population may

1. Reed D, Crawley J, Faro S, Pieper S, Kurland L. Thallotoxicosis: acute manifestationsand sequelae. JAMA 1963; 183: 516-22.

2. Hausman R, Wilson J. Thallotoxicosis: a social menace. J Forens Sci 1964, 9: 72-88.3. Roby DS, Fein AM, Bennett RH, Morgan LS, Zatuchni J, Lippmann ML.

Cardiopulmonary effects of thallium poisoning. Chest 1984; 85: 236-40.4. Saddique A, Peterson CD. Thallium poisoning: a review. Vet Hum Toxicol 1983; 25:

16-22.5. Safe use of pesticides 20th report of WHO expert committee on insecticides. WHO

Tech Rep Ser 1973; 513.6. Catholic Standard (Guyana) Aug 31, 1986 1-4.

7. Moeschlin S Thallium poisoning. Clin Toxicol 1980; 17: 133-46.

have a potentially toxic body burden. The Guyanesegovernment reacted by banning the import of thallium onJan 20, setting up a screening centre, and asking for helpfrom international organisations. Presumably water or foodsupplies are contaminated; the most urgent problem is toidentify the extent of contamination and contain it.What can be done for those who may be contaminated?

People who are symptom-free and have undetectable bloodor urine thallium levels are unlikely to be at risk, and, oncescreened, should be reassured. Those who have increasedthallium levels with or without symptoms of chronicthallium poisoning, such as hair loss, stomatitis, wasting,emotional disturbance, tremor, weakness, numbness, orpains in the limbs,8 can be treated with Berlin blue (Prussianblue, potassium ferric hexacyanoferrate), which trapsthallium atoms in its crystal lattice and can reduce the bodyburden by interrupting enterohepatic circulation of themetal. 9-11 Other proposed treatments, such as potassiumsupplementation, dithiocarb, or haemodialysis have notbeen shown to be effective, particularly in chronic

poisoning, and their use should not be contemplated.Forced diuresis is effective,!1 but it is a practical procedureonly in the more severely poisoned patients. General adviceshould be given to drink plenty of fluid (provided it is notcontaminated), and maintain regular bowel habits.

THE SOLITARY BRAIN TUMOUR

THE aims of neurosurgery for intracranial tumours are

(and have been for over 100 years1) to make a definitehistological tissue diagnosis; to cure by excision whenpossible; or if curative surgical resection is not possible toallow adjuvant therapy to proceed or in other selected casesto palliate symptoms of raised intracranial pressure andneurological deficit. The introduction of computedtomographic (CT) scanning improved dramatically the easeand accuracy of diagnosis of intracranial lesions. However,the spread of CT scanning to general radiologicaldepartments has meant that initial differential diagnosis ofintracranial mass lesions is now often made by non-neurological specialists. It is becoming increasinglyimportant not to lose sight of the aims and potential-pitfallsin the management of presumed solitary brain tumours(SBT) diagnosed on CT scan.

In the UK management of many patients with malignantbrain tumours is suboptimal; it will surprise neurologistsand neurosurgeons in western Europe and the USA thatvery often no attempt is made to confirm the radiologicaldiagnosis of malignant glioma. The potential error of relyingsolely on CT scan evidence is now becoming apparent. Inthis issue (p 611) Mr Todd and his colleagues address thisimportant topic. Of 70 patients in whom a CT diagnosis ofglioma was made 60% underwent a surgical procedure andin 7% the diagnosis was shown to be incorrect. Thusreliance on CT appearance for diagnosis may mean that anon-malignant and potentially curable lesion, such as anabscess or a meningioma, is overlooked in some cases. The

8. Paulson G, Vergara G, Young J, Bird M. Thallium intoxication treated with dithizoneand haemodialysis. Arch Intern Med 1972; 129: 100-03.

9. Heydlauf H. Ferric-cyanoferrate (II): an effective antidote in thallium poisoning. Eur JPharmacol 1969; 6: 340-44.

10. Kamerbeck HH, Rauws AG, ten Ham M, van Heijst ANP. Prussian blue in thetherapy of thallotoxicosis. Acta Med Scand 1971; 189: 321-24.

11. Thompson DF Management of thallium poisoning. Clin Toxicol 1981; 18: 979-901. Davis CH, Bradford R. A surgical history of Maida Vale Hospital. In Walker MD,

Thomas DGT, eds. The biology of brain tumour. Boston: Martinus Nijhoff, 1986245-49.