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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: Why I went to Oxford, not Cambridge Jeremy Hugh Baron. 316:doi 10.1136/bmj.316.7141.1354a

Medicine today is prosaic and frequently defies logic.

Competing interests: No competing interests

04 May 1998
David N Chorley
Family Medicine Resident, OSU Tulsa
OSUCOM Tulsa Oklahoma
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Re: The morbidity of rich and poor . 316:doi 10.1136/bmj.316.7139.0

Editor, I originally come from Bihar (India), and I would like to comment on the article "The morbidity of rich and poor."

I agree with Amartya Sen in that mortality ia a better indicator of economic status of society than morbidity. Even in Bihar, mortality varies between rich and poor.However, I do not agree with Sen's comment that people who have not had the privilege of medical care have a low perception of illness. People in Bihar ('Biharis') may report less medical problems because they are likely to seek various forms of alternative therapies ranging from herbal / homeopathy to ancient withcraft! Some Biharis are also likely to accept ill health as their destiny probably due to poverty and ignorance.Poverty determines many peoples' belief, faith,lifestyle and expectations.On the other hand, people in general have a very optimistic attitude, sometimes to an unrealistic extent.

In Bihar, the health service is mainly provided by privately run hospitals, surgeries and pharmacies. Government hospitals are few and far between and even in these hospitals patients have to pay for the cost of treatment, investigations and even their meals.The main differences between Bihar and America are that whereas many people in Bihar cannot afford treatment for curable diseases, the western world invests hugely not only in treatment but also in prevention and palliation.

Pain is felt by Biharis as much as by Americans.

Competing interests: No competing interests

04 May 1998
Ranjana Rani Jarvis
Senior Registrar in Genitourinary Medicine
Royal Bolton Hospital, UK.
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Re: Outcome of low back pain in general practice: a prospective study Alan J Silman, et al. 316:doi 10.1136/bmj.316.7141.1356

I find it hard to work out what the conditions were that underlay the complaint that this paper studies. Metastatic disease, tuberculosis, and osteoporosis for example are all causes of back pain with more or less forseeable but different outcomes in time. On the other hand people who have undoubted secondary gain in the form of money, love, or avoidance of unpleasant duties through a pain that the doctors cannot cure are not likely to give up their pain. Those on Disability Benefit or other recompense for example would be much worse off if they were to recover and become unemployed instead. Without knowing something about the case mix this study does little mor than tell us that back pain is a big and chronic problem to a lot of people. I suppose that we should be glad to have our intuition supported by factual information but harder facts are needed.

Competing interests: No competing interests

03 May 1998
George J Addis
Consultant Physician
49 Whittingehame Court Glasgow, G12 0BQ
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Re: Lithium James W Jefferson. 316:doi 10.1136/bmj.316.7141.1330

EDITOR-Jefferson's justification of lithium as a "tried remedy" requires scrutiny.1 Impeaching clinical trials because of methodological problems is easy game, but Moncrieff's determined scepticism is refreshing,2 and a counterbalance to the bias of proving that psychotropic medication is effective.

Jefferson does not mention that doubts have also been raised about the value of lithium from evidence in routine clinical practice.3 A meta-analysis of more recent placebo controlled lithium discontinuation studies did not find as great a difference between relapse rates on lithium and placebo (37.5%-53.5%) as previous reviews.4 Rapid withdrawal is associated with higher relapse than gradual withdrawal (62%-29%).4 The finding of such a difference suggests that nonspecific factors are important. Unblinding can occur in clinical trials of lithium, compromising their results.5

Despite Jefferson, the issue of the effectiveness of lithium prophylaxis has not been foreclosed. No withdrawal study has included a no drug control group as an addition to the standard double-blind placebo design, so that withdrawal to placebo and no drug can be compared, giving an estimation of the placebo effect of withdrawal of medication when the primary treatment is merely tablet taking. Nor has any study of the discontinuation of lithium attempted to measure whether the blind has been broken. Correlation can be made with relapse and symptom ratings to determine whether degree of unblinding is associated with measured efficacy.

This improved design should provide more data to evaluate the evidence for the effectiveness of lithium, even if it does not give the certainty that Jefferson would like. Denial of the extent to which lithium is a placebo effect in clinical practice does not serve the interests of the many patients who are reliant on this medication. Jefferson quotes Ambroise Paré who readily discarded ineffective remedies and was also critical of remedies that were highly esteemed by others.

D B Double, Consultant Psychiatrist, Norfolk Mental Health Care, Hellesdon Hospital, Drayton High Road, Norwich NR2 2AE. (Duncan_Double@bigfoot.com)

1. Jefferson JW. Lithium. Still effective despite its detractors. BMJ 1998;316:1330-1

2. Moncrieff J. Lithium: evidence reconsidered. Br J Psychiatry 1997;171:113-9

3. Greenberg RP, Fisher S. Mood-mending medicines: Probing drug, psychotherapy, and placebo solutions. In: Fisher S, Greenberg RP, ed. From placebo to panacea - Putting psychiatric drugs to the test. New York: Wiley, 1997:115-172

4. Baker JP. Outcomes of lithium discontinuation: a meta-analysis. Lithium 1994;5:187-192

5. Double DB. Lithium revisited. [letter] Br J Psychiatry 1996; 168: 381-2

Competing interests: No competing interests

03 May 1998
D B Double
Consultant Psychiatrist, Norfolk mental Health Care NHS Trust
Hellesdon Hospital, Norwich NR6 5BE
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Re: Fortnightly review: Plantar fasciitis Dishan Singh, John Angel, George Bentley, Saul G Trevino. 315:doi 10.1136/bmj.315.7101.172

Dear Sir,
In the article the authors had claimed the plater fasica is the most common cause of inferior heel pain and they have suggested some treatment for it. In my practice I have noticed than planter fasciitis is not the common cause of heel pain but the most common cause is the referred pain from the calf muscles particularly the medial head of gastronemius, althogh the later can be itself due to lumo-sacral pathology.
First of all the there is not aetiology mentioned for the common planter faciitis but certain predisposing factors and the mostly the local treatment that is stretching the Achiles tendon is illogical to treat the plater fascia. The stretching techniques mentioned in the article further over stretch the inflammed planter fascia. In fact the stretching technique relieves the Trigger Point in the medial head of gastronemius.Any practioner in back pain knows that while treating the back pain also relieves the heel pain in significant number of people.
Lastly the symptoms of most common heel pain is the sever pain at the commencement of walking after some rest and the pain deccreases on movement also negate any local planter fascia pathology. In fact there are some patients who have local panter fascia pathology and they become worse after stretching therapy.
The second most common cause after gastronemius muscle is the lesion(Trigger Point) at the quadratus plantae muscle which can be relived by local stretching.
The most evident proof of involvement of medial head of gastronemius is the stretching after cold application or injecting the trigger point with lignocaine with or without steroid immediately relives the heel pain in more than 90% of the patients. And only one or two therapies are required to get a permanent cure.

Competing interests: No competing interests

03 May 1998
Tariq Maqsood Khan
private practice in manipulative therapy
Lahore
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Re: Impact of surgery for stress incontinence on morbidity: cohort study Paul Abel, et al. 315:doi 10.1136/bmj.315.7121.1493
I am astonished that six months have gone by without any response to the article by Black et al [1] being published. The paper makes some challenging assertions. The authors state that previous studies have been of poor quality yet themselves report data from patients on the basis of symptoms alone. It is well established that urinary symptoms alone are of little value in reaching a diagnosis of either genuine stress incontinence (GSI) or detrusor instability (DI) [2]. Thus the patients included will contain a mixture of those with GSI, DI and other conditons and since roughly 65% of patients have GS the proportion of patients in the improved or not improved groups may well be different. The resulting bias will distort the results of both surgery and of the study, and therefore perhaps mask the risks of surgery in patients with DI.
The authors continue by stating on the basis of this data that urgency is not a contraindication to surgery, and conclude by questioning the value of cystometry. We would argue strongly against these two assertions based upon data from such a poorly defined study, particularly where the authors show themselves to be unfamiliar with the difficulties of reaching diagnoses in these patients. We agree that the symptoms of urgency and urge incontinence are not contraindications to surgery since many patients with GSI will complain of these. However, a diagnosis of DI is certainly a relative contraindication to surgery [3] and, as previously stated, this cannot be diagnosed on history alone [2]. Cystometry will exclude instability in addition to providing important information on voiding flow rates and pressures, which is importance when trying to minimise postoperative retention. The benefit of reaching a proper diagnosis and of identifying potential voiding disturbances mean that preoperative cystometry is and should remain an essential investigation in the management of women with urinary complaints.

1. Black N, Griffiths J, Pope C, Bowling A, Abel P. Impact of surgery for stress incontinence on morbidity: cohort study. Br Med J 1997;315:1493-1498.

2. Sand PK, Hill RC, Ostergard DR. Incontinence history as a predictor of detrusor instability. Obstet Gynecol 1988;71:257-259.

3. Cardozo LD, Stanton SL. Genuine stress incontinence and detrusor instability: a review of 200 patients. Br J Obstet Gynaecol 1980;87:184-190.

Douglas Tincello

Competing interests: No competing interests

02 May 1998
Douglas G Tincello
Specialist Registrar (Year 4)
Urodynamic Department, Liverpool Women's Hospital, Crown Street, Liverpool L8 7SS
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Re: Why I went to Oxford, not Cambridge Jeremy Hugh Baron. 316:doi 10.1136/bmj.316.7141.1354a

The writer asks a question. The answer is No! the world has changed.

Competing interests: No competing interests

01 May 1998
Colin Mackenzie
Family Physician in Private Practice
Santa Cruz, California
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Re: Care for the growing number of elderly people in developing countries needs to be addressed Debashis Dutt. 316:doi 10.1136/bmj.316.7141.1387a
D.Dutt's article brings to light a very relevant issue
plaguing the middle-class society in developing countries.
Geriatrics is a non-existent speciality - either at
hospital/community level. Probably the awareness
that the elderly can have a good quality of life
and continue to be useful members of society needs
to be communicated to people in these countries as
a whole.

Competing interests: No competing interests

01 May 1998
Thadi Mohan
SHO-Orthopaedics
Southend Hospital
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Re: An unusual use of a stethoscope Bela Vadodaria. 316:doi 10.1136/bmj.316.7141.1382

The use of a stethoscope to help hearing impaired patients is not new. In fact an episode of the TV serial ER showed this almost a year ago.
Sajeev

Competing interests: No competing interests

01 May 1998
Sajeev
Pediatrician
Barbados
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Re: Antidepressant discontinuation reactions Peter Haddad, Michel Lejoyeux, Allan Young. 316:doi 10.1136/bmj.316.7138.1105

(Copy of letter sent a few weeks ago to 100730.1250@compuserve.com - before online letters feature available - to which I have not yet had reply, nor am I sure whether is being considered for publication)

Haddad et al minimise the problems caused by discontinuing antidepressant treatment, claiming without evidence that antidepressants are not drugs of dependence.1 The dependence potential of drugs has regularly been denied in history, until eventually accepted for drugs such as opiates, barbiturates and most recently benzodiazepines.2 Discontinuation symptoms were regarded as evidence of benzodiazepine dependence, but this clinical condition would now hardly meet the modern DSM-IV criteria for substance dependence.3 Recognition of the withdrawal effects of benzodiazepines caused a collapse in their market. It may be suspicious that Haddad et al prefer the term discontinuation reaction rather than withdrawal reaction, but it is difficult to assess their bias as they do not declare a conflict of interest.

Semantic confusion about discontinuation, withdrawal and relapse can be traced to dissatisfaction with the definitions of addiction and habituation, leading to the introduction of the single term drug dependence by a WHO Expert Committee in 1964. Since then there have been varying shades of meaning of dependence. The Diagnostic and Statistical Manual of the American Psychiatric Association made tolerance or withdrawal a required criterion in DSM-III, but in DSM-IIIR dependence was redefined as the antisocial syndrome of clinically significant behaviours and symptoms indicating loss of control of substance use and continued use despite adverse consequences.

The former distinction between physical and psychological dependence may still have some relevance in clinical practice. Haddad et al leave open the question of the nature of antidepressant discontinuation reactions. They may be nonspecific effects. More worryingly though are the few reports of suspected neonatal withdrawal reactions resulting from maternal SSRI use in pregnancy.4 Nonetheless it is disingenuous to criticise the public for their commonsense belief that people can become dependent on medication which is regarded as improving mood.5 High placebo response rate of antidepressants is recognised and suggestion can play an important part in initial response to treatment, so expectations are as likely to play a role in withdrawal. Although discontinuation reactions may be minimal, placebo effects can be powerful. Evidence for the value of continuation treatment means patients are likely to remain on antidepressants for some time, increasing the risk of discontinuation reactions. This reliance on medication is significant and is present with other psychotropic medication such as neuroleptics and lithium. Simplistic, dismissive views such as Haddad et al will not help the recognition of these difficulties.

Yours faithfully

D B Double, Consultant Psychiatrist, Norfolk Mental Health Care, Hellesdon Hospital, Drayton High Road, Norwich NR2 2AE. (Duncan_Double@bigfoot.com)

1. Haddad P, Lejoyeux M, Young A. Antidepressant discontinuation reactions. Are preventable and simple to treat. BMJ 1998;316:1105-6 (11 April).

2. Medawar C. Power and dependence. Social audit on the safety of medicines. London: Social Audit, 1992

3. Medawar C. The antidepressant web. International Journal of Risk and Safety in Medicine 1997;10:75-126 and http://www.socialaudit.org.uk

4. Kent LSW and Laidlaw JDD. Suspected congenital sertraline dependence. British Journal of Psychiatry 1995;167:412-3

5. Double DB. Prescribing antidepressants in general practice. People may become psychologically dependent on antidepressants. [letter] BMJ 1997;314:829

Competing interests: No competing interests

01 May 1998
D B Double
Consultant Psychiatrist, Norfolk Mental Health Care NHS Trust
Hellesdon Hospital, Norwich NR6 5BE
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