Search all rapid responses

All rapid responses

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: Trial is needed of ACE inhibitors plus β blockers in survivors of myocardial infarction Finlay A McAlister. 317:doi 10.1136/bmj.317.7160.751a

I am mystified by the data calculations in the table accompanying
Finlay McAlister's letter regarding needed trials of ACE inhibitors plus
Beta Blockers in survivors of myocardial infarction (BMJ 1998;317:751[12
September]).

Using the data given, I believe the Odds Ratio for the TRACE study
should be 0.64, not 0.56 as indicated. For the Total, the OR calculates to
0.93, not 0.86. It does not appear such discrepancies would be the result
of number rounding.

While the apparent errors in simple calculations would not alter
McAlister's conclusions, this unfortunate situation does tend to shake
one's faith in the accuracy and reliability of reporting in BMJ.

Competing interests: No competing interests

14 September 1998
Stewart B Leavitt
Principle Researcher/Writer
Leavitt MedCom; Glenview IL USA
Click to like:
0
Re: Childhood Cushing's syndrome induced by betamethasone nose drops, and repeat prescriptions M D C Donaldson, et al. 317:doi 10.1136/bmj.317.7160.739

It is stated that nasal steroid drops are important in treating ear,
nose, and throat complaints in children. At our clinic we see a lot of
children but hardly use nasal steroid drops in children--at least, not
under the age of 14 years.
Many children suffer from nasal discharge in terms of blockage, enhanced
secretion and snoring while asleep, and consequent effusion of the middle
ear. The most common events leading to these symptoms are enlarged
adenoids and/or enlarged tonsils and occasionally an allergic nasal
hyperreactivity. After a complete examination including inspection of the
epipharynx the first step in these patients is usually a conservative
treatment consisting of decongesting nose drops for two weeks and a
systemic decongestant +/- and antihistaminic for four weeks. The children
are supposed to return after the treatment course for a control
examination. If the symptoms have not improved, an allergy test is
performed. If an antiallergic therapy with a topical and systemic
antihistamine has not improved the state of the patient, and adenoids are
present, we perform an adenoidectomy. Usually this treatment regime works very
well.
Nasal steroids are only used in children with nasal polyps and chronic
sinusitis; both are very uncommon in children under the age of 14.

Competing interests: No competing interests

11 September 1998
Andreas F P Temmel
Registrar
Christian Quint
University of Vienna, Department of Otolaryngology, Head and Neck Surgery
Click to like:
1
Re: Medicine may become “domain of the privileged” Alex Brooks. 317:doi 10.1136/bmj.317.7158.558d

I am a student enrolled in one of Australia's new Graduate Medical
Courses (4 years in length, must have a successfully complete bachelor
degree to enter) and some of you might be interested to know how much our
course costs. HECS fees (Higher Education Contribution Scheme) approx
$AUD 20,000 once we have completed the four year course. This is in
addition to fees already charged for undergraduate degrees (in my case add
another $7,000). Medicine attracts the highest HECS debt in Australia.
The additonal charges to participate in the University of Queensland course
are: Computers $135 per month, living expenses, petrol and car (all
locations are spread out and impossible to get to without a car -
unreliable public transport) and basic medical equipment and text books.
The next two years are spent on continual rotations around the state (so
there will be extra accomodation and travel money needed). So a rough
estimate of expenses (which does not include my mortage, school fees,
vehicle or babysitter's or all of the other things like textbooks etc) is
about $AUD 50,000 over the four years. Given the rules on student grants
in Australia (called Austudy - generally allowable for one degree only)
most of my fellow students have to work, despite 4 weeks holiday during
the year and 40 weeks of "classtime" work, and additional assessment
weeks (2). Some are still supported by their parents, but the average age
of our intake is about 27 and are not many are living at home.

Competing interests: No competing interests

11 September 1998
Gabi Caswell
Medical Student - MBBS UQ
University of Queensland
Click to like:
0
Re: Doctor demands payment for helping airline passenger Clare Dyer. 317:doi 10.1136/bmj.317.7160.701

I have considerable sympathy for any doctor who takes on the
responsibility of providing medical care for airline passengers who become
ill on-board. Not only are they working in a strange environment but
their equipment and the drugs available may also be strange to them.

It was as a result of my own experience on 20th May 1995 that I tried
to get British Airways interested in supporting courses for volunteer
doctors in providing emergency medical care for airline passengers.
Despite a carefully evaluated programme, submitted to Bob Ayling in
writing over 18 months ago, I was informed that such emergencies were so
uncommon that helping doctors to obtain training and gain a knowledge of
the medical kits carried by British Airways was not an appropriate
activity for the airlines to support.

In this American Airlines incident the law, as I understand it, is
quite clear - if the doctor spontaneously offers help to an ill passenger
they are completely responsible for their actions and the consequences of
their treatment. However if a call is put out by the Captain of the
aircraft for a doctor to help with the management of an ill patient then
the Captain and the airline are as responsible as the doctor for the
medical treatment. If your report is accurate then the airline is quite
wrong in believing that it has no responsibility to the doctor.

On the other hand I would have concerns about the type of doctor who
bills an airline for £540 for a "Good Samaritan" act.

I note that the BMA, which wants to clarify the position of doctors
who give in-flight help, hopes to raise the issue with an international
aviation advisory body but unfortunately there is no international body
which carries as much weight as a Court of Law.

I hope this case goes to court because it will clarify the law but I
fear both parties will come out of this action badly.

Professor W Angus Wallace.

Competing interests: No competing interests

11 September 1998
W Angus Wallace
Professor of Orthopaedic & Accident Surgery
Queen's Medical Centre, Nottingham
Click to like:
0
Re: Some experience necessary Trisha Greenhalgh. 317:doi 10.1136/bmj.317.7159.687

Editor

I usually enjoy Trish Greenhalgh's contributions to the BMJ, but I
find her description of detained people with mental disorder as 'menaces
to society'1 upsetting. Acknowledging that the article was humorous and
that Dr Greenhalgh would not, I imagine, use such language clinically,
such comments cause distress to patients and their relatives. Bad enough
for a doctor to make the comment, but even worse for one of the Journal's
Editorial Advisors. I'm sure that similarly insensitive and outdated
sexist or racist remarks would be identified by editorial policy and
weeded out. I do not think it too politically correct to ask the Journal
to take greater care.

J H M Crichton Lecturer in Forensic Psychiatry
Royal Edinburgh Hospital, Edinburgh, EH10 5HF

1Greenhalgh T. Some Experience Necessary BMJ 1998;687.(5 Sept)

Competing interests: No competing interests

11 September 1998
J H M Crichton
Click to like:
0
Re: Understanding the culture of prescribing: qualitative study of general practitioners' and patients' perceptions of antibiotics for sore throats Nigel Stott, et al. 317:doi 10.1136/bmj.317.7159.637

Dear Sir

Butler et.al. did not report a procedure that I use when I am faced
with either a sore throat about which I am unsure or where the patient has
asked for antibiotics. I tell the patient that I think that it is viral,
but take a throat swab, with the promise that if the throat is still
sore and the swab is positive, then I will prescribe the antibiotic
suggested by the swab result. Most seem happy - at least I don't see many
again.

Yours Sincerely

Andrew Sanderson

Ref :- Butler, C.C.,Rollnick, S., Maggs-Rapport, F.,Stott, N.
Understanding the culture of prescribing: qualitative study of general
practitioners' and patients' perceptions of antibiotics for sore throats.
BMJ 1998;317:637-642

No conflict of interest

Competing interests: No competing interests

11 September 1998
Andrew Sanderson
Click to like:
7
Re: Call to needle times after acute myocardial infarction in urban and rural areas in northeast Scotland: prospective observational study Norman Waugh, et al. 317:doi 10.1136/bmj.317.7158.576

Sir-the article by Rawles et al highlights the difficulties
experienced by many rural GPs who aim to provide optimal care for patients
with suspected acute myocardial infarction.1 The advantages of immediate
thrombolysis must always be balanced with the risks encountered in a
location remote to resuscitation facilities. The risk to benefit ratio can
only be optimised if acute myocardial ischaemia is accurately diagnosed,
early treatment instituted and the complications of such treatments
minimised. Whilst early thrombolysis is clearly important, patients remote
from inpatient hospital facilities may be disadvantaged by deficiencies in
any three of these criteria.

In Southampton, we are aware that cruise-ship passengers are
frequently remote from shore-based hospital facilities. As the popularity
of cruising increases and with the predominance of an older passenger
population, the incidence of acute-onset chest pain at sea is increasing.
A large cruise-ship with a passenger population of 2000 may expect to see
15 patients with suspected acute myocardial infarction per year. The
management of these passengers provides a further challenge to the ship's
medical team.

The proximity of on-board medical services may afford early
thrombolysis, (passengers with chest-pain are typically seen within 10
minutes by a medical officer) yet the remoteness of the ship to full shore
-based hospital facilities may add to the morbidity associated with the
complications of thrombolysis. Some of the larger cruise ship companies
have already addressed this problem. By developing a strategy based on
rapid confirmation of diagnosis and a strict protocol recognising
indications and contraindications to thrombolysis, the risk to benefit
ratio of treatment in this remote location can be optimised.

Technology such as satellite-fax enables ECG analysis by a consultant
cardiologist within 30 minutes. Routine on-board testing for troponin-I,
CK-MB and transaminases is performed on some ships, with results again
available in 30 minutes. This rapidly acquired knowledge enables prompt
diagnosis and commencement of thrombolysis in less than 60 minutes.

The opportunity to thrombolyse patients in these circumstances can
now occur within the guidelines recommended by the British Heart
Foundation.2 The advantages of a diagnosis supported by rapidly obtained
investigations, and with good resuscitation facilities means that
thrombolysis aboard ship minimises any dangers implicit to its remote
location. This management may exceed the standards of many less remote
locations.

Dr Matthew Hough MRCP FRCA
Specialist Registrar in Anaesthesia
Southampton University Hospital Trust, Tremona Rd., Southampton SO16 6YD

Dr John Knighton MRCP FRCA
Specialist Registrar in Anaesthesia
Salisbury District Hospital, Salisbury, Wiltshire. SP2 8BJ.
References

1 Rawles J, Sinclair C, Jennings K, Ritchie L,Waugh N. Call to needle
times after acute myocardial infarction in urban and rural areas in
northeast Scotland: prospective observational study. BMJ 1998;317:576-578

2 Weston CFM, Penny WJ, Julian DG on behalf of the British Heart
Foundation Working Group. Guidelines to the early management of patients
with myocardial infarction. BMJ 1994;308:767-71

Conflict of interest: None

Competing interests: No competing interests

11 September 1998
John Knighton
Click to like:
0
Re: Diabetes care in general practice: meta-analysis of randomised control trialsCommentary: Meta-analysis is a blunt and potentially misleading instrument for analysing models of service delivery Simon Griffin, Trisha Greenhalgh. 317:doi 10.1136/bmj.317.7155.390

Editor

General practitioners are now playing a greater role in the
management of patients with diabetes. However, there are wide variations
in performance between general practitioners. The effectiveness of systems
of care in general practice is of great interest and Simon Griffin’s meta-
analysis of diabetes care in general practice(1) is therefore timely.
However, like Trish Greenhalgh (Commentary(2)), I have considerable
concerns about some of the conclusions of Griffin’s meta-analysis.

Only five studies met the inclusion criteria for the meta-analysis
and all patients were receiving care from hospital. Griffin recommends
that prompted care should be provided to a selected group of diabetics.
However, this type of prompting would need to be delivered to all the
diabetics in the practice as it would be difficult to organise it for a
small select proportion of diabetic people. Our recent study has shown
that just over half of diabetic people are under general practice care,
19% under hospital care and approximately 30% are under shared care(3),
although I agree with Griffin that the taxonomy of shared care is not
fully developed(1).

To make valid conclusions of a meta-analysis, like must be compared
with like. Other factors such as the practice population and practice
organisation (besides a recall system) may also be associated with the
quality of care.
Although the proportion of local practices involved did not explain
interstudy heterogeneity(1), the size of the practice was only reported in
two trials(4),(5). Only one study reported whether the practices ran
diabetic mini-clinics(5). Furthermore, as Greenhalgh comments(2), the
population in the studies included in the meta-analysis are subject to
selection bias and cannot
therefore be representative of the general population. The care of
patients is very complex and many potential confounders are not taken into
account in the
meta-analysis. I recently conducted a literature search focused on quality
of care of patients with diabets in primary care and found over 37
potential factors. It was therefore inappropriate to use meta-analytical
techniques for such a complex and varied group of practices.

I am currently involved in a study to determine which factors are
related to good diabetic care. The study involves data from 169 practices
(639 general
practitioners) in three different health authorities that had conducted an
audit of patients with diabetes. Preliminary results show that there are
wide variations in the process and outcome measures. Regression analysis
indicates that having a recall system is not related to the process or
outcome of care of patients with diabetes.

Basing our decisions on evidence from randomised controlled trials is
becoming increasingly acceptable in general practice. A randomised
controlled trial with randomisation at practice level is required to
assess the effectiveness
of structured care with a prompted recall system. In the meantime the
debate over who should deliver care to a selected group of diabetic
patients will continue.

Yours sincerely

Dr Kamlesh Khunti
Clinical Lecturer
Department of General Practice and Primary Health Care
Leicester General Hospital
Gwendolen Road
Leicester LE5 4PW

Conflict of interest None

References

(1) Griffin S. Diabetes care in general practice: meta-analysis of
randomised
control trials. BMJ 1998;317:390-5.

(2)Greenhalgh T. Commentary: Meta-analysis is a blunt and potentially
misleading instrument for analysing models of service delivery. BMJ
1998;317:395-6.

(3) Hurwitz B, Goodman C, Yudkin J. Prompting the clinical care of
non-insulin
dependent (type II) diabetic patients in an inner city area: one model of
community care. BMJ 1993;306:624-30.

(4) Diabetes Integrated Care Evaluation Team. Integrated care for
diabetics:
clinical, psychological, and economic evaluation. BMJ 1994;308:1208-12.

(5)Khunti K, Baker R, Lakhani M, Rumsey M. Quality of care of
patients with
diabetes: Collation of data from multi-practice audits of diabetes in
primary
care. Family Practice (in press).

Competing interests: No competing interests

11 September 1998
Kamlesh Khunti
Click to like:
13
Re: Chiropractic for low back pain E Ernst, W J J Assendelft. 317:doi 10.1136/bmj.317.7152.160

Many of the gross misinterpretations in the article in question have already been addressed, such as efficacy and safety. These topics have so exhaustively been researched that it's time to move on to other uses for the limited funds available
in research. The one area which has not been addressed is the comparison of manipulation with mobilisation. In William Kirkaldy-Willis's current edition of the reference work Managing Low Back Pain, not only is there a comparison made between the two, manipulation is shown to be significantly more effective. Perhaps the most important point in this, though, is that the authors do not themselves know the difference. Neurologically mobilisation and manipulation are vastly different. Lower back conditions, such as we are discusing here, are primarily reflexogenic activities. Mobilisation fires muscle spindle fibers which increase the frequency of firing of the target muscle while manipulation fires Golgi tendon organs causing a resetting of the gain and resting length of the target muscle. This is not only different; this is critical. It also explains why manipulation is so much more effective than anything utilised to date. To not understand this difference and claim to treat spinal conditions is an inexcusable ignorance of the basic neurophysiology of the very thing you are claiming to be an expert in. It is disappointing that such a well respected journal would publish such an
article.

Competing interests: No competing interests

11 September 1998
Garland D Glenn
private practice
Fordingbridge, UK
Click to like:
8
Re: Call to needle times after acute myocardial infarction in urban and rural areas in northeast Scotland: prospective observational study Norman Waugh, et al. 317:doi 10.1136/bmj.317.7158.576

Sir the article by Rawles et al highlights the difficulties
experienced by many rural GPs who aim to provide optimal care for patients
with suspected acute myocardial infarction (1). The advantages of
immediate thrombolysis must always be balanced with the risks encountered
in a location remote to resuscitation facilities. The risk to benefit
ratio can only be optimised if acute myocardial ischaemia is accurately
diagnosed, early treatment instituted and the complications of such
treatments minimised. Whilst early thrombolysis is clearly important,
patients remote from inpatient hospital facilities may be disadvantaged by
deficiencies in any three of these criteria.

In Southampton, we are aware that cruise-ship passengers are
frequently remote from shore-based hospital facilities. As the popularity
of cruising increases and with the predominance of an older passenger
population, the incidence of acute-onset chest pain at sea is increasing.
A large cruise-ship with a passenger population of 2000 may expect to see
15 patients with suspected acute myocardial infarction per year. The
management of these passengers provides a further challenge to the ship's
medical team.

The proximity of on-board medical services may afford early
thrombolysis, (passengers with chest-pain are typically seen within 10
minutes by a medical officer) yet the remoteness of the ship to full shore
-based hospital facilities may add to the morbidity associated with the
complications of thrombolysis. Some of the larger cruise ship companies
have already addressed this problem. By developing a strategy based on
rapid confirmation of diagnosis and a strict protocol recognising
indications and contraindications to thrombolysis, the risk to benefit
ratio of treatment in this remote location can be optimised.

Technology such as satellite-fax enables ECG analysis by a consultant
cardiologist within 30 minutes. Routine on-board testing for troponin-I,
CK-MB and transaminases is performed on some ships, with results again
available in 30 minutes. This rapidly acquired knowledge enables prompt
diagnosis and commencement of thrombolysis in less than 60 minutes.

The opportunity to thrombolyse patients in these circumstances can
now occur within the guidelines recommended by the British Heart
Foundation (2). The advantages of a diagnosis supported by rapidly
obtained investigations, and with good resuscitation facilities means that
thrombolysis aboard ship minimises any dangers implicit to its remote
location. This management may exceed the standards of many less remote
locations.

Dr Matthew Hough MRCP FRCA Specialist Registrar in Anaesthesia
Southampton University Hospital Trust, Tremona Rd., Southampton SO16 6YD

Dr John Knighton MRCP FRCA Specialist Registrar in Anaesthesia
Salisbury District Hospital, Salisbury, Wiltshire. SP2 8BJ.

References
1. Rawles J, Sinclair C, Jennings K, Ritchie L,Waugh N. Call to needle
times after acute myocardial infarction in urban and rural areas in
northeast Scotland: prospective observational study. BMJ 1998;317:576-578

2. Weston CFM, Penny WJ, Julian DG on behalf of the British Heart
Foundation Working Group. Guidelines to the early management of patients
with myocardial infarction. BMJ 1994;308:767-71

Conflict of interest

None

Competing interests: No competing interests

11 September 1998
Matthew Hough
SpRs in Anaesthesia
John Knighton
Southampton Hospital NHS Trust, Salisbury District Hospital.
Click to like:
0

Pages