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enable implementation of the key proposals set out in the legislation.Money is guaranteed only for the guardian-ad-litem programme,which appoints an independent social worker to represent thechild’s interests in court. Social service departments claim that thereare too few social workers to allow for the Act’s ideals to be met

effectively.Moreover, interpretation of the new law is left to individual local

authorities, with no clear policy on the minimum requirements thatmust be provided. Although the Act’s success or failure will bemonitored by the Children Act Advisory Committee, which willreceive information from 104 regional committees, there is noindication of how difficulties will be solved or what powers this

monitoring body will have to enforce improvements. A laissez-faireapproach may be inappropriate for a service already hard-pressedfor cash; new funds do not have to be channelled into the schemesproposed by the Act; and local authorities may choose to directmoney into other, specifically local needs.

Children who have been placed for adoption now have newopportunities for identifying their natural parents. An AdoptionContact Register was established in May, 1991, which allowsnatural parents to assure an adopted person that communicationwould be welcome. Responsibility for initiating contact remainswith the adoptee, who may obtain application forms from the Officeof Population Censuses and Surveys, General Register Office,Adoption Section, Smedley Hydro, Trafalgar Road, Birkdale,Southport PR8 2HH, UK.

Action against asthmaThe management of asthma has undergone a minor revolution in

the past five years, from treatment of symptoms as they occur toprevention of symptoms by treating the underlying disorder.Morbidity and mortality, however, remain unacceptably high, andthe British Thoracic Society, which last year set guidelines forasthma management, identified inadequate supervision as a

contributory factor. A continuing concern is that preventablefactors play a part in 80% of asthma deaths. Action Asthma, apressure group formed a year ago by hospital doctors and generalpractitioners, has submitted to the Department of Health sevenproposals for improving the management of asthma.The group recommends that all asthma patients be reviewed

clinically every year and that GPs keep a register of their asthmaticpatients. And it wants hospitals and GPs in every health district toestablish protocols for hospital admission and discharge of suchpatients. The lives of asthma patients are unacceptably restricted,says the group, and their illness imposes a considerable burden onthe National Health Service. Both diagnosis and management needto be improved.

Action Asthma’s seven-point plan is a response to theGovernment’s discussion document, The Health of the Nation,which invited interested parties to identify key areas of action topromote good health. The group asks the Department of Health todirect family health service authorities to approve asthma clinics ashealth promotion activities. In its submission the group calls on theGovernment to publish annual data relating to time off work andschool caused by asthma and to set up an inquiry into asthmadeaths.As a way to cut passive smoking, which is high on its list of targets,

Action Asthma wants the Government to ban smoking in all publicplaces. In a national survey carried out by the group 57% of 61 000asthmatics said that they were significantly affected by smokyatmospheres, 32% being affected a great deal.

Helping patients to understand their illness is an essential elementof Action Asthma’s plan, and the group has produced a checklist often questions for patients to ask their doctors-what, for instance,they can do to control an attack; how to monitor their symptoms;and what peak flow readings to aim for. "Asthma patients sadlyadapt their lifestyles to their condition", said a spokesman for thegroup earlier this week, "and too easily accept the restrictions whichit imposes". Instead, he said, they "should be discussing theirasthma fully with their doctor and together they should aim to attaina life free from symptoms".

Infertility in cystic fibrosis

One of the many puzzling features of cystic fibrosis (CF) is why itis so often associated with infertility. The disease is caused by amutation in the gene encoding a protein known as cystic fibrosistransmembrane conductance regulator (CFTR), and studies ofth§tissue distribution of CFTR are beginning to throw some light’onthe relation between cell-specific expression of the protein and CFpathology. In male CF patients obstruction or absence of the vasdeferens is one common cause of infertility; another is dysmorphicsperm, which result from a disturbance of spermatogenesis. Treziseand Buchwald have now shown that expression of the CFTR genein rats is regulated during the cycle of the seminiferous tubule and isnormally maximum in round spermatid stages VII and VIII, withlittle expression in germ cells at other stages of maturation.1 Thisfinding, the authors suggest, indicates that CFTR has a critical rolein spermatogenesis and that a deficiency of this function contributesto male infertility in CF. CFTR is not expressed in Sertoli or Leydigcells, the somatic cells of the testis. A raised concentration ofchloride ion in exocrine gland secretions is another primarymanifestation of CF, and there is evidence that in some tissuesCFTR functions as a regulated chloride channel. Trezise andBuchwald suggest that stage-specific expression of CFTR mayindicate either a critical requirement for a regulated chloridechannel during normal spermatogenesis or involvement of CFTRin the transport of some other substrate important for spermmaturation. Abnormal sperm maturation presents an unusuallydifficult obstacle in the treatment of infertile CF patients, since itwill generally preclude in-vitro fertilisation as an option.

1. Trezise AEO, Buchwald M. In vivo cell-specific expression of the cystic fibrosistransmembrane conductance regulator. Nature 1991; 353: 434-37.

Tuberous sclerosis

The first clear description of tuberous sclerosis (TS) is usuallyattributed to Desire-Magloire Bournville, who in 1880 noted white"tubers" and cerebral sclerosis at necropsy in the brains of patientswith mental retardation and epilepsy. In 1908 Vogt described theclassical triad of seizures, mental retardation, and a facial rash.Diagnosis is not, however, always clear cut, because themanifestations of the disease are protean, and 50% of peopleaffected are of normal intelligence. Absolute certainty of diagnosisin all cases will not be possible until a genetic test becomes available,and even then the procedure is unlikely to be straightforward,because at least two gene loci (one on chromosome 9) are thought toproduce the TS phenotype. The Tuberous Sclerosis Associationhas produced a booklet1 to guide medical readers through thecertainties and uncertainties of TS, its clinical features, diagnosis,and treatment. A section on genetic advice recommends that bloodsamples should be collected, for future analysis, from patients’relevant family members. However, family studies will be helpful inonly a minority of cases, since 75% appear to arise from

spontaneous mutations.

1. Tuberous sclerosis ... more than just skin deep. Available free of charge from theTuberous Sclerosis Association, Little Barnsley Farm, Catshill, Bromsgrove,Worcestershire B61 0NQ (telephone 0527 71898).

Medical Art SocietyAs Big Ben struck 6 o’clock last Tuesday evening, members of the

Medical Art Society gathered a stone’s throw away in theWestminster Gallery for their annual exhibition. 141 paintings anddrawings and 11 sculptures competed for this year’s Baron verHeyden de Lancey prizes. The prize for sculpture went to Dr MaryWood for her two seated figures carved in mahogany, Difference ofOpinion. The prize for painting/drawing was shared by Dr HaroldHewitt for Disjecta Memoria, Marlow and Dr Myrna Guest forHead of Auzalia. Each prize is worth £ 150, to be used to further thelink between art and medicine. Details of membership of the societymay be obtained from Claire Hunter, Medical Art Society, 1

Wimpole Street, London WIM 8AE, UK.