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commonly accepted as the lower limit. The high non-renalmorbidity and mortality make careful preoperativeassessment very important.

Preliminary data from 40 patients in the Cleveland

group’s randomised study comparing medical and surgicaltreatment in patients with renal impairment secondary toARAS suggest that event-free survival after 18 months isbetter in the surgical group (74% vs 44%), although renalfunction at 12 months was similar in the two groups (datapresented at American Society of Nephrology, Nov 1991).No formal consensus was achieved, but most of those

present at the meeting accepted that intervention in ARASis worthwhile when renal function is impaired (probably aplasma creatinine of > 150 umol/1), particularly if it is

deteriorating, and when there is a prospect of recovery orstabilisation of function. Results from uncontrolled studies

support such optimism, although these may reflect a

reporting bias. PTRA, with its lower mortality andmorbidity, is the treatment of choice in most patients, butcomplete arterial occlusion or a severely diseased aorta (quitecommon) may preclude angioplasty. Surgery of the renalartery is complex and the argument for specialist centres wasdiscussed--certainly Dr Novick’s and Dr Bergentz’sexpertise supports such an approach.Department of Nephrology,Middlesex Hospital, London, UK Hugh S. Cairns

1. Debatin JF, Spritzer CE, Grist TM, et al. Imaging of the renal arteries:value of MR angiography. AJR 1991; 57: 981-90.

Noticeboard

Wellcome boost to research

The Wellcome Trust’s sale of part of its stake in Well come plc hasraised about C2 billion instead of the C4 billion hoped for. Still, fornext year, this amount means a doubling of the Trust’s income to220 million, from 110 million this year. A main feature of theTrust’s plans is to increase long-term funding of research-to fundcareers of whole teams of scientists and not just of its stars, and tofund purpose-built centres of excellence. The importance thatresearchers need to have adequate time for research and not beoverwhelmed by other commitments is recognised. So is the need toupgrade existing equipment, and to this end a working party hasbeen set up to consider how to fund equipment in universities.Another working party has been set up to look into how to developthe Trust’s long-standing commitment to tropical medicine. TheTrust will also be developing its interest in areas that it considersimportant but neglected-eg, clinical epidemiology, mathematicalbiology, and taxonomy. The training of clinicians in research isanother important focus of the Trust’s plans.Two announcements made this week exemplify the Trust’s new

approach to funding. The Trust is setting up, jointly with theMedical Research Council, a genetic research centre, the SangerCenter, whose location has yet to be decided. The centre will housea staff of 300 led by Dr John Sulston, whose team at Cambridgehave been sequencing the genome of the nematode wormCaenorhabditis elegans and whose emigration had been speculatedabout before discussion on the new centre started. The Trust will be

providing more than 50 million for the first 5 years for this centre,for stepping up research on the nematode genome and on

sequencing selected regions of the human genome.The Trust also announced that it is providing nearly [,3 million to

enable immunologist Prof Douglas Fearon and his team from thedivision of molecular and clinical rheumatology at Johns HopkinsSchool of Medicine in Baltimore to move to Cambridge, where theywill work closely with Prof Herman Waldmann, who holds the chairin therapeutic immunology. The team’s area of interest is in thecontrol of unwanted immune responses. Fearon’s work has been on

the physiology and pathology of the alternative pathway ofcomplement activation and in the characterisation and function ofseveral complement receptors. SmithKline Beecham are

developing for clinical use Fearon’s work on the use of solubilisedCR1 as a means for controlling complement-dependentinflammation. Fearon has also shown that CR2 is the receptor used

by human B lymphocytes for Epstein Barr virus. His present work,based on the possibility that complement receptors and relatedmembrane proteins act as "on/off ’ switches for production ofantibodies by B cells raises prospects of how diseases mediated byautoantibodies may be controlled. In the longer term, there may bespin-offs for xenografting.

X-rays from CT scans

A report by the National Radiological Protection Board (NRPB)lshows that 850 000 computed tomography (CT) examinations,involving 600 000 patient attendances, were made with the 200machines in operation in the UK in 1989; this corresponds to about15 CT examinations per 1000 inhabitants. Although CT scansrepresented only 2% of the annual total of all X-ray examinations,they accounted for about 20% of the collective dose, and were thusthe largest single source of exposure from diagnostic X-raytechniques. The contribution to diagnostic X-ray exposure fromCT may be even greater in other countries: in Japan, for example,123 CT examinations per 1000 population were reported as far backas 1979. Patients having CT examinations in the UK tended to beelderly. About half of all scans involved imaging the head; scans ofthe abdomen were less common (20%) but contributed to a greaterproportion of the collective X-ray dose than CT of the head. Thereport states that "the typical levels of patient dose from CT arerelatively large compared with those from many conventional X-rayexaminations of similar regions of the body", and recommends that,when clinically appropriate, non-ionising techniques (eg,ultrasonography and magnetic resonance imaging) or low-doseX-ray techniques should be used. When surveyed by the NRPB,only 7% of CT operators reported any periodic dose assessment, sothe report also recommends comprehensive quality assuranceprogrammes for all CT scanners in clinical use.

1. Protection of the patient in X-ray computed tomography. Documents of the NRPB,vol 3, no 4. London: HM Stationery Office, 1992. £5.00. ISBN 0 85951 354 8.

Migrants in the global villageMainstream health services in the richer countries of Europe are

quite unprepared to cope with the sharp increase in the number oflong-term migrants worldwide. The official world figure for

migrants of 70 million today does not take into account the

consequences of the free movement within the EuropeanCommunity and the pressure building up from Eastern Europe.Contrary to popular belief the main pressure comes not fromrefugees, who number only about 15 million worldwide, but fromthe general movement of ordinary people. The developing world’sworkforce is also predicted to increase by 733 million by 2002 and,unless there is a mass redistribution of resources, many will

emigrate in search of work.This warning of ill-preparedness comes from the second

International Conference on Migration and Health held in Brusselslast month, where the 300 participants from more than 40 countriesbacked the controversial principle of ethnic monitoring. The UKalready includes a question on ethnic background in the nationalcensus, and ethnicity data on patients is to be included for healthauthorities’ management information.The mental health services are going to be overwhelmed by the

political turmoil in Europe. They are already trying to cope with upto three million war-traumatised migrants from the former

Yugoslavia. Speakers from Dubrovnik said that four out of everyfive inhabitants showed psychological and somatic symptomsneeding treatment, with the very old being especially susceptible tosuch trauma. With the East European migrants, the problem iscompounded by serious alcoholism endemic in their country oforigin.

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Research by Dr Paola Bollini, of the Geneva-based InternationalOrganisation for Migration, showed that most rich Europeancountries have no decent structure for coping with long-termforeign migrants. Britain, Canada, and Sweden were magnetsbecause they provided free health care for migrants. France had amillion uninsured migrants, and the USA 35 million. Dr HaraldSiem, director of the IOM and conference convenor, pointed outthat illegal immigrants often did not approach health services forfear of discovery by the authorities. Lead poisoning was also ahazard that migrants faced, said Dr Esmerelda Luciolli of MedecinsSans Frontieres and Dr Francois Bourdillon of Migration Sante inParis. The extent of childhood poisoning in France from lead-basedpaint had not been appreciated until two children died of acute leadpoisoning in Paris. The lead had come from deteriorating paintpeeling off walls and banisters in run-down housing. Subsequentscreening in three Paris districts has identified 1500 children,mostly immigrants, with high blood lead concentrations.

Prof Shah Ebrahim of the Royal London Hospital said thatmigrants, especially the elderly, whose tuberculosis had beencontrolled in their country of origin, often experience relapsesbrought on by poor social conditions in their host countries. Moredisturbing is the spread of drug-resistant TB-for example, thatwhich Dr Robyn McDermott of Australia, working out of IOM’sPhilippines office, has noted among Vietnamese migrants.Migrants in the pre-departure camps are comparatively wellserviced medically by the IOM, the main governmental body sincethe 1939-45 war for assisting refugee placement.

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"Novel" foods

Genetically modified mushrooms and potatoes, developed toimprove resistance to viruses, are among the examples of "novelfoods" justifying introduction of new Community legislation onfood health checks. The Commission is suggesting that it should benotified of any "novel" food or ingredient. It would then be open forthe Commission or any one member state to initiate studies by theCommission’s Scientific Committee on Food. The reasoning is thatit is illogical for the Community to have extensive legislation on foodadditives, without similar rules on food ingredients likely to bepresent in food in much larger proportions than additives. But theGreens claim that the safety of genetically modified foods cannot bedetermined by current methods. They point to the admission by theUS Food and Drug Administration, which promulgated similarregulations in May, that there is no adequate means by which topredict what effect such foods might have on people with certainallergies_ ‘

The UK’s Advisory Committee on Novel Foods and Processes(ACNFP) published its 1991 annual report last week.’ TheCommittee is satisfied that sterilisation by ohmic heating shouldcause no adverse effects on health provided that certain guidelinesare followed. The report also contains draft guidelines on theconduct of taste trials of novel foods. The Committee points outthat, if the conditions of the guidelines are met, there is no need fortaste trials to be referred to it for consideration.

1. Advisory Committee on Novel Foods and Processes, annual report, 1991. Availablefrom ACNFP Secretariat, Rm 604, Department of Health, Eileen House, 80-94Newington Causeway, London SE1 6EF.

Organ transplantationIslamic rules on the obligation to bury the whole or any part of a

deceased person’s body has been a stumbling block to obtainingsufficient organs for transplantation in Moslem countries. TheNational Committee of Transplantation in Iran, which has beenlooking into ways of encouraging organ donation, has takenadvantage of Shi’ite rules that allow clarification on ambiguousreligious’issues to be sought from a senior religious leader. TheCommittee has obtained written confirmation from the late and thepresent Ayatollahs that any organ from a brain-dead person may beused for transplantation. ,

The global increase in demand for transplantable human organshas been paralleled by worrying reports of commercial enterprise

and the use of living donors. The WHO response to the moral andethical difficulties raised by organ transplantation are set out in anew two-part booklet. The first part contains a set of nine

guidelines for the regulation of procurement and transplantation ofhuman organs-preferably from the bodies of deceased persons.The second half summarises the results of a WHO study into theresponses of more than fifty countries to trade in human organs.

1. Human Organ Transplantation. A report on the developments under the auspices ofWHO (1987-1991) Geneva: World Health Organisation. 1991 Pp 28 Sw Fr 8(5 60 for developing countries). ISBN 92 4 1693045.

Medical school damaged by fire

A fire has caused substantial damage to the library and teachingfacilities at the United Arab Emirates University’s medical school.The medical faculty, the only one in the emirates, was set up in 1986,and is based essentially -on the British system. There is now anenrolment of 194, with a female to male sex ratio of 2:1. Only malesare allowed to study abroad, and there are separate classrooms forthe two sexes. Even the library facilities have to be duplicated. Noeffort is being spared to restore the facilities by September, the startof the next academic year, which will be the final year for thefaculty’s first batch of students. Restoration is expected to costabout ,C1.2 million.

End of the line for Tommy’s?Hot on the heels of news of the planned merger between King’s

College London and the United Medical and Dental Schools ofGuy’s and St Thomas’s Hospitals (UMDS) (Lancet July 11, p 111)comes a leak on a recommendation that either Guy’s or St Thomas’sshould close down. The leaked draft submission from the SouthEast Thames Health Authority to Sir Bernard Tomlinson, who isheading an inquiry into London’s health services, recommended acritical look at the split in services between Guy’s and St Thomas’s.Although the official response from Guy’s concluded that ."Anyspeculation as to which hospitals may be closed at this stage ispremature", the report has been widely interpreted as the beginningof the end for St Thomas’s.

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Rational choices in health care in EnglishThe report of the Dunning committee (Lancet, July 25, p 228),

which contains recommendations for effective and cost-effectivehealth-care choices, is now available in English.l Although thereport deals with health care in the Netherlands, the conclusionsshould be applicable to other countries. The authors welcomecomments from readers in any country.

1. Choices in health care. Available from Ministry of Welfare, Health, and CulturalAffairs, PO Box 5406, 2280 HK Rijswijk, Netherlands. 1992. Pp 160. ISBN90 346 2840X

Close encounter of the owl kind

Outdoor-loving Kojak lookalikes beware, lest the great homedowl takes a fancy to your shiny pate. A midnight encounter with onesuch winged creature left an unfortunate diabetic man withlacerations to his scalp.’ (Although he did not see the assailant,which had knocked his 100 kg frame from his lawn chair, he "sawfeathers fly" and was adamant that the culprit was an owl.) Thelesions turned septic, so the man was given ciprofloxacin since hewas allergic to penicillin and sulphonamides, but treatment wasunsuccessful. Eventually foul-smelling pus yielded two

unidentified Bacteroides spp, for which clil1damycin did the trick.Future attacks might best be avoided by head protection. When anattack has occurred, empirical treatment with antibiotics effectiveagainst anaerobes is justified because a wound inflicted by an owl’stalons may be seeded with enteric organisms from a recent kill.

1. Davis B, Wenzel RP. Striges scalp Bacteroides infection after an owl attack J Infect Dis1992, 165: 975-76