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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on thebmj.com. Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

Re: Oral treatment for hepatitis B gets approval in United States Deborah Josefson. 317:doi 10.1136/bmj.317.7165.1034b

Dear Dr Smith,

I am sorry that the news item on the prevalence of hepatitis B
infection (page 1034) is incorrect and that the accompanying artificially
coloured photograph is misleading. A negatively stained electron
micrograph has been sent under separate cover (magnification x 252,000).

It is important that the following information be provided to the
readers of the British Medical Journal:
1. More than a third of the world's population had been infected with
hepatitis B virus (WHO/12:21 February 1992)
2. It is estimated (conservatively) that there are 350 million chronic
carriers of hepatitis B virus worldwide i.e. persistently infected
individuals (WHO/12, 1992). Many are lifelong carriers, although not all
are infectious, and some clear the virus after varying intervals of many
months or years.
3. About 25% of carriers will develop serious liver disease as a result
of the infection, including chronic hepatitis, cirrhosis and primary liver
cancer.
4. WHO estimates that hepatitis B results in 1-2 million deaths every
year worldwide.
5. The WHO (European Regional Office) estimates that 1 million people are
infected in the Region each year. Of these, about 90,000 will become
chronically infected and about 22,000 will eventually die from cirrhosis
or liver cancer.
6. The sexual route is the most common means of spread of HBV in Europe
and North America. Those aged 15-24 are at the highest risk.
7. The World Health Assembly recommended in 1992 that all countries
introduce hepatitis B vaccination into national immunisation programmes by
1997. Low prevalence regions such as Europe, North America and Australia
should consider immunisation of all adolescents as an addition or
alternative to infant immunisation. This policy has been implemented by
over 85 countries and most European countries.
Yours sincerely,
Professor A.J. Zuckerman
Director of the WHO Centre and Principal and Dean of the Royal Free and
University College Medical School

Competing interests: No competing interests

21 October 1998
A J Zuckerman
Director of the WHO Centre and Principal and Dean of the Royal Free and University College Med Sch
Royal Free and University College Medical School
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Re: Chiropractic treatment is of limited benefit Scott Gottlieb. 317:doi 10.1136/bmj.317.7165.1036

As a Chiropractor i am pleased to see the intrest in chiropractic as
shown by the publications in this journal.
I would like to thank all the people who puts down time and effort to
bring scientific light to the difficult field of treating low back pain,

I first learned about the paper" A comparison of Physical
therapy,chiropractic manipulation,and provision of an educational booklet
for the tratment of patients with low back pain" in a popular science
program on the swedish radio. It was announced as a study that proved
chiropractic to be more efficient than physiotherapy for treating low back
pain "The difference is in the hands of the chiropractor"

Thus the study can be seen as an argument for chiropracic if one
wants to.

The difficulty with a control group in a place where chiropractic is
so common as in the US is:

1. Patients who seek help in a medical setting for low back pain has
actively chosen not to go to a chiropractor(I assume there where no
Chiropractors as primary care physicians i n the health center).
And thus may have previously tried chiropractic with not so good results
ie be resistant to treatment, or may have negative opinions on
chiropractors.

Patients with good experiences of chiropractic may have sought
chiropractic instead and thereby excluded themselves from this study.

This may cause a bias in the outcome.

2.Many patients in the control group consulted for low back pain with
other health care providers(18% admitted to) during the study.

It is known that a large percentage of LBP patients who have
consulted MD`s for their problem later seek chiropractic help,and many
wont tell their MD about it.

This may have contaminated the control group.

The only reliable control group would be in an area where
chiropractic was totally unknown and nobody in the study group had had any
form of manipulative treatment.

As I see it this study indicates that the chiropractic and
physiotherapy treatments was of limited benefit for the population
studied,but the conclusion that chiropractic or physiotherapy is of limted
benefit for any other population cannot be drawn from this study.

Competing interests: No competing interests

21 October 1998
Erik Rudberg
Chiropractor in private practice
Sollentuna sweden
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Re: Mouth care and skin care in palliative medicine Claud Regnard, Sarah Allport, Lydia Stephenson. 317:doi 10.1136/bmj.317.7164.1013

It is apparent that the results with systemic pilocarpine are
variable. While some patients are reported to have no significant
improvement in saliva production, others encounter side effects such as
sweating and nausea.

I find pilocarpine to be invaluable in the management of a range of
salivary disorders, including hypofunction following radiation or
chemotherapy. However, the dose for each individual is variable and I
believe this to be a most important factor in its successful use.

My practice has been to start with a dose of 2.5mg taken four times
daily and to increase this weekly in steps of 2.5mg until a therapeutic
response is obtained. This may be between 2.5mg and 15mg. Once this dose
is established, patients do not appear to develop tolerance.

Competing interests: No competing interests

21 October 1998
M M Ferguson
Professor of Oral Medicine & Oral Surgery
University of Otago, Dunedin. New Zealand
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Re: Minerva . 317:doi 10.1136/bmj.317.7162.894

Editor - Minerva does well to highlight the importance of protecting
latex-allergic patients undergoing surgery from latex containing
products(1).

Natural rubber latex, derived from the Hevea brasiliensis tree, is
used to manufacture many products, both medical and household.
Hypersensitivity to latex can occur in two forms. Type I (immediate)
reactions, are mediated via an IgE antibody formed on previous exposure to
small proteins which are natural components of latex. Type IV (delayed)
reactions are T-cell mediated, and occur against additives introduced
during the manufacturing process, rather than to latex proteins
themselves(2). Type I reactions can range between urticaria and
anaphylaxis, whereas Type IV present typically with contact dermatitis.

Latex allergy is an increasingly common problem, particularly amongst
medical personnel(3), and patients with meningomyelcoele(4). This second
group maybe repeatedly exposed to latex-containing medical products from
soon after birth, resulting in specific IgE antibodies being formed. Many
units now routinely perform surgery on such patients in a latex-free
environment, to reduce the chance of sensitisation, and hence to lessen
the risk of subsequent type I reactions.

In its extreme form, a type I hypersensitivity reaction can present
as anaphylaxis, with fatal consequences. It is therefore of utmost
importance that patients known to be latex-allergic are protected from
contact with the allergen, applying particularly to the environment of the
operating theatre. To this effect, the recent article by Dakin and
Yentis(5) outlines a protocol for treatment of those known to be, or
suspected of being, latex-allergic. They helpfully list a selection of
latex-free products that can safely be used in such an instance.

Recent personal experience has revealed the problems that can arise
when emergency surgery is required in such a case. The operating
department had not encountered the problem of latex allergy before, and no
measures had been taken to enable a latex-free procedure to be performed.
In this instance, no latex-free gloves were available in the hospital, and
a delay ensued whilst gloves were summoned from another centre.
Fortunately, the delay caused no detriment to the patient's final outcome.
I would recommend, therefore, that Dakin and Yentis's article be made
available in each operating department, particularly in view of its list
of latex-free products. Each unit should, in addition, ensure that it has
the necessary latex-free materials available should such a problem be
encountered.

Yours sincerely

Andrew Hockey.

References

1. Minerva. British Medical Journal 1998;317:894 26 September

2. Warshaw EM. Latex allergy. Journal of The American Acadamy of
Dermatology 1998;39(1):1-24 July

3. Handfield-Jones SE. Latex allergy in health-care workers in an English
district general hospital. British Journal of Dermatology 1998; 138:273-
276 February

4. Shah S, Cawley M, Gleeson R, O'Connor J, McGeady S. Latex allergy and
latex sensitisation in children and adolescents with meningomyelocoele.
Journal of Allergy and Clinical Immunology. 1998; 101(6 Pt1):741-746 June

5. Dakin MJ, Yentis SM. Latex allergy: a strategy for management.
Anaesthesia 1998; 53(8):774-781 August

Competing interests: No competing interests

21 October 1998
Andrew Hockey
Specialist Registrar in General Surgery, North Thames (E) Rotation
Currently reading MSc Degree at University College London
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Re: Long term relative survival after surgery for abdominal aortic aneurysm in Western Australia: population based study Paul E Norman, James B Semmens, Michael M D Lawrence-Brown, C D'Arcy J Holman. 317:doi 10.1136/bmj.317.7162.852

During my recent surgery for "AAA" (Abdominal Aortic Aneurysm), a
clamp slipped off the iliac artery and was not detected until after the
aneurysm was incised. This resulted in blood fluid replacement of 11
units during the procedure. I did not see any reference in the Norman
article to "surgical complications" in considering variables for 5 year
survival rate of "AAA" patients. Are the authors or other readers aware
of studies which have considered "surgical complications" as a variable.
In reflecting on this question, I considered factors such as anoxia and
interrupted blood flow to vital organs and the neuromuscular system, lapse
of time while the anomaly was corrected, and effect on total elapsed time
required to complete the procedure. My only "competing interest" is that I
am a patient.

Competing interests: No competing interests

21 October 1998
Jack Grogan
Self employed
Semi-Retired
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Re: Acute oxygen therapy N T Bateman, R M Leach. 317:doi 10.1136/bmj.317.7161.798

EDITOR - Bateman and Leach have commendably drawn attention to the
common reluctance to supply a high enough concentration of oxygen to some
hypoxic patients for fear of causing carbon dioxide retention. (1) There
are, however, some aspects in their section on Oxygen delivery systems
which are inconsistent and misleading:

1) Line 3 of the section carries a misprint :- 24-90% is the same as
Fio2 0.24-0.90, not 0.26-0.90 as printed.
2) It is not true to say that High flow masks deliver only 24-35% oxygen.
They in fact go up to 60%, as shown in the illustration of the venturi
series on the same page!
3) The whole point of High flow masks has been missed: it is not just
that rebreathing is abolished (it is actually insignificant even with
shell masks), it is the fact that the flow rate of the constant oxygen/air
mixture coming to the patient exceeds the peak inspiratory flow rate.
This means that we can be completely sure of the Fio2, there being no
possibility that air can be indrawn, since the flow is always outwards
through the mask.
4) With Low flow masks it is invidious and extremely misleading to attempt
any calculation on the likely resulting Fio2. The calculations shown
here, in addition, fail to take into account the fact that the patient is
actually breathing out for between half and two thirds of the time. The
oxygen that is being supplied through the mask during these periods is
lost to the patient, so that the improvement in Fio2 will be
proportionately less than
that depicted by this misleadingly quasi-accurate calculation. The most
that should be said about Low flow masks is that the higher the tidal
volume and inspiratory flow rate of the patient, the more air dilution can
be
expected. The converse is also true, the most common example being
asthma. Any calculated Fio2 is thus approximate, as the authors have
quoted in the text under the picture of a Low flow mask.

Anthony M.Hewlett. Consultant Anaesthetist.
Northwick Park Hospital
Watford Road, Harrow
Middlesex. HA1 3UJ.

1. Bateman NT, Leach RM. Acute Oxygen Therapy. BMJ 1998;317:798-
801. (19 September.)

Competing interests: No competing interests

21 October 1998
Anthony M Hewlett
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Re: Withdrawal reaction associated with venlafaxine H Johnson, W P Bouman, J Lawton. 317:doi 10.1136/bmj.317.7161.787a

Dear Sir,

Johnson etal. (1) report a withdrawal reaction associated with
venlafaxine at low dose . I have personally experienced a withdrawal
reaction after taking 37.5mg. twice a day for two weeks. The reaction was
identical to that experienced with paroxetine in the past and consisted of
insomnia, vivid dreams and sweating. The symptoms subsided immediately on
reintroduction of medication. Previous experience with paroxetine would
suggest that such symptoms can take up to a week to subside.

Competing interests: No competing interests

21 October 1998
Sarah Newth
Consultant child psychiatrist
Solihull Healthcare NHS Trust
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Re: Doctor demands payment for helping airline passenger Clare Dyer. 317:doi 10.1136/bmj.317.7160.701

October 18, 1998

Letters to the Editor
British Medical Journal
www.bmj.com

To the Editor

We are troubled by Dr. John Stevens’ lawsuit against American
Airlines for services rendered to an acutely ill passenger. Apparently he
is bitter about his meager compensation of a bottle of “cheap champagne”
and a $50 travel certificate for his 4 1/2 hours of service and exposure
to malpractice. (1)

Although liability is a concern for physicians, there have not been
any lawsuits brought against physicians treating in-flight emergencies. In
the United States, the Aviation Medical Assistance Act of 1998 was passed
into law on April 24, 1998. This law includes provisions to evaluate the
adequacy of on-board emergency kits, the need for automatic external
defibrillators, monitoring of deaths aboard airlines, and includes
language to protect airlines and physicians who come to the assistance of
patients (2).

Physicians have been granted special status by the public, which has
seen fit to publicly fund the education of doctors, subsidize hospitals,
and grant monopolies of practice via the licensure process. This is in
addition to their special status as healers, as those entrusted with
healing knowledge and privileged to intensely personal information (3). As
a result, do physicians not have a debt to the public? Is there not a
moral obligation to respond to a request for help, and not expect
compensation?

We believe that Dr. Stevens’ action sets an unfavoarble precedent for
Good Samaritans. Further, he has tarnished the image of physicians and
strengthened the public perception that physicians are an elitist, greedy
and selfish group. He neglects the hundreds of other passengers who also
were inconvenienced by his call to divert the plane. Perhaps all those
passengers can send him a bill for their trouble.

John Cheng, M.D., Assistant Professor
Patrick Dowling, M.D., Chairman
Department of Family Medicine
Harbor-UCLA Medical Center
Torrance, California
U.S.A.
1001 W. Carson St.
Suite I
Torrance, CA 90502
(310) 222-5205
fax: (310) 782-0752
email: jccheng3@yahoo.com

References
(1). Dyer C. Doctor demands payment for helping airline passenger. BMJ.
1998:317;701.
(2) Aviation Medical Assistance Act of 1998 (H.R. 2843). Available at:
http://thomas.loc.gov. (search for “aviation medical assistance act”)
Accessed October 14, 1998.
(3) Dowling PD. Access to medical care: do physicians and academic medical
centers have a societal responsibility?, in “It Just Ain’t Fair: The
Ethics of Health Care for African Americans”, edited by Annette Dula and
Sara Goering. Connecticut, Praeger, 1994. pp. 134-144.

Competing interests: No competing interests

21 October 1998
John Cheng
assistant professor
Department of Family Medicine, Harbor-UCLA Medical Center
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Re: Cost effectiveness of shortening screening interval or extending age range of NHS breast screening programme: computer simulation study Andrew Street, Ellis Friedman, Ciaran Woodman, et al. 317:doi 10.1136/bmj.317.7155.376

The Editor

Dear Sir

Boer and his colleagues (1) present the results of a simulation
exercise in which they investigate the cost effectiveness of changing the
parameters of the national breast screening programme. In particular, they
compare a two year screening interval in place of the current three year
interval. Their results should not pass without comment.

Firstly, their simulation model uses values for the natural history
of early breast cancer and the sensitivity of breast screening taken from
the Utrecht and Nijimegen programmes both of which started in the mid
1970's. The relevance for breast screening in the UK in the late 1990's is
not clear, bearing in mind that there is considerable between programme
variation in such basic parameters as the interval cancer rate and the
screening detection rate of small (<_10 mms="mms" invasive="invasive" cancers="cancers" _2.="_2." p="p"/> Secondly, their model fits the NW England results for the second
screening round badly, even though they have made some adjustment to the
assumed natural history values (doubling the sojourn time of T1a and T1b
cancers) to ensure that the NW England first round screening data are well
fitted. Their model predicts that at the second screening test after on
interval of three years, more than 60% of invasive cancers will be less
than or equal to 10 mms in diameter, and 9% greater than 20 mms. The
corresponding observed frequencies are 40% and 19%. Since the effect of
screening on breast cancer mortality is determined largely by the
reduction in T2+ cancers and the corresponding increase in T1a and T1b
cancers, the effect of gross inaccuracy in modelling these two quantities
is likely to be substantial. Reducing the screening interval will increase
the proportion of cancers that are screen detected, and among screen
detected should both increase the proportion of small cancers and decrease
the proportion of large cancers. The effect on predicted mortality of
poorly modelling the stage distribution of cancers detected at the second
or later screen, is thus likely to be even greater, with a two year
interval than a three year interval. The estimated marginal effect of
reducing the screening interval will then be unreliable to an unknown
extent.

Thirdly, no indication whatever is given of the uncertainty
surrounding the various estimates. The authors claim that the marginal
cost per life year gained of shortening the screening interval from three
to two years is £3545. This is a clear example of spurious precision, but
more seriously is likely to be highly misleading. Given the uncertainties
over the parameter values and the poor fit of the model itself, one would
have expected some sensitivity analyses at the very least. Quite plausible
alternative parameter values might well generate marginal cost values
several times greater than the quoted estimated of £3545. In most
situations the British Medical Journal quite rightly insists on
uncertainty estimates, usually in the form of confidence intervals. For an
article which the authors hope will make an impact on policy, omission of
uncertainty bounds renders it almost valueless.

One expects policy for the national breast screening programme to be
evidence based. The modelling presented by Boer and his colleagues uses
only a small portion of the available evidence on breast screening, and
none of the evidence from randomised trials or from relevant screening in
the UK. It fits the relevant parts of the NW region screening data badly,
and the resulting estimates are of unknown reliability. Future policy
decisions should be based on evidence directly related to the UK programme
itself. Such evidence will shortly be available from the results of the
multi centre randomised trial of different breast screening frequencies,
undertaken in Britain under the auspices of the UKCCCR.

N E Day PhD
Director of the Unit

1 Boer R, de Koning H, Threlfall A, Warmerdam P, Street A, Friedman E
and Woodman C. Cost effectiveness of shortening screening interval or
extending age range of NHS breast screening programme: computer
simulation study. British Medical Journal 1998; 317: 376-379.

2 Day N E, McCann J, Camilleri-Ferrante CC et al. Monitoring interval
cancers in breast screening programmes: the East Anglian experience. J
Med Screen 1995; 2: 180-5.

Competing interests: No competing interests

21 October 1998
N E Day
Director
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Re: Crude rates, without standardisation for age, are always misleading Hugh Tunstall-Pedoe. 317:doi 10.1136/bmj.317.7156.475b

We concur with Prof. Tunstall-Pedoe's opinion that crude death rates
are misleading for the purpose of comparison 1). However, our experience
is introduced to illustrate different viewpoints between clinicians and
epidemiologists towards these health indicators.
It is well known that mortality from ischemic heart disease (IHD) has been
very low in Japan 2). Nonetheless, its recent trends were interpreted
differently by clinicians and epidemiologists: Based on their experience,
clinicians believed that IHD mortality was on the rise. Trends in crude
rates were compatible with their belief. Epidemiologists stated that
seeing the secular trend required age-adjustment, which reduced the
resultant rates. There had been no simple answer as to the validity of the
two interpretations 3). Which was really true?
If one population exhibits age-adjusted mortality that is higher than the
others, discovering the cause is a concern of public health. However, age-
adjusted mortality differs from the crude mortality that directly reflects
that real number of deaths because it is a hypothetical value. Crude rates
may be used to estimate the extent of the needs for health services. The
difference between these two indices may be illustrated by a community
with a high aged population yet a low age-adjusted mortality.
IHD mortality has been increasing in Japan, while age-adjusted mortality
has been decreasing. Therefore, the assumption that an individual is
exposed to a higher risk of dying from IHD cannot be validated. On the
other hand, the need for improving medical facilities to serve a growing
patient population is justifiable because the actual number of patients is
increasing as clinical practitioners noted. An emeritus president of the
National Cancer Center expressed his impression as a clinician: "Age-
adjusted mortality is overused; an estimated incidence is more important
for health care planning." 4)
In Japan, the 1985 population was used to replace that of 1935 for the
reference for age-adjustment in 1990. Because the aged population was
small in 1935, the age-adjusted mortality on this basis tends to be
unrealistically small 5). The age-adjusted mortality may be misleading if
it is used to plan for present and future health care because it markedly
differs from the actual situation.
Measuring disease frequency in an aged society is not only for estimating
health risks but is indispensable for allocating health services. Both age
-adjusted and crude rates, with actual numbers, have significance. With
the collaboration of clinicians, epidemiologists must convey the true
significance of these indices and use them as appropriate.

References

1. Tunstall-Pedoe H. Crude rates, without standardisation for age,
are always misleading. BMJ 1998;317:475-476. (15 August.)

2. Nakayama T, Yokoyama T, Yoshiike N, Iwaoka H, Zaman MM, Chowdhury AH,
et al. Secular trends in death rates from ischemic heart diseases and
cerebrovascular diseases in selected countries. J Epidemiol.
1996;6(supple):S189-S196.

3. Shimamoto T, Komachi Y. Epidemiology and etiology of coronary disease.
Nippon Naika Gakkai Zasshi 1990;79:1485-1490. (in Japanese)

4. Ichikawa H. Invited commentary: Re-evaluation of cancer mass screening
in Japan. J Jpn Med Assoc. 1992;107:622-625. (in Japanese)

5. Abe Y, Kamiya K, Onodera M, Saito F. Reconsideration on the reference
population for age-adjusted death rates. J Health Welfare Stat. 1990;37:28
-33. (in Japanese)

Nobuo Yoshiike (epidemiologisit with the National Institute of Health
and Nutrition, Japan) and Tetsuji Yokoyama (epidemiologist with Medical
Research Institute, Tokyo Medical and Dental University, Japan) are co-
authors.

Competing interests: No competing interests

21 October 1998
Takeo Nakayama
postdoctral fellow
UCLA School of Public Health, Department of Epidemiology
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