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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: Double standards exist in judging traditional and alternative medicine Hilary Bower. 316:doi 10.1136/bmj.316.7146.1694b

Dear Sir
My aim is not to critisizing the double standards which exists between the traditional and alternative medicine.
But I wish my collegues from the traditional medicine to study the main practices of alternative medicine in their own community even they wish to criticize these methods. For example in our part of the world where homeopathy is widely practiced I think every person who is the professor of medicine should study it or other methods of herbal medicine.It is then they can safely comment about it.Similarly in Orthopaedics I think they should study at least something from the osteopathy or chiropractic.
My second point is that here and in most of the other parts of the world simple every day tips are widely practiced in the homes where simple recipes of food items are utilized to treat simple cough, common cold, diarrhoea etc. I have seen these remedies are quite effective in simple ailments.I hope serious research and double blind studies are required to evaluate their effectiveness and also we may get some better new products in the process.

Competing interests: No competing interests

21 July 1998
Tariq Maqsood Khan
Priviate practice in Manipulative Medicine
Lahore
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Re: Confidential inquiry into quality of care before admission to intensive care Alasdair Short, Giles Morgan, Mick Nielsen, David Barrett, et al. 316:doi 10.1136/bmj.316.7148.1853

McQuillan and colleagues1 have demonstrated that patients frequently
receive sub optimal care on wards prior to referral to the Intensive Care
team. We would like to highlight another serious factor which adversely
affects the provision of high quality intensive care to patients in the
North West of England. This is the frequency with which many hospitals are
unable to admit patients to their own Intensive Care Unit (ICU) because of
a shortage of staffed and available beds.

In the North West region, each day an average of 3 patients are transferred
to another Intensive Care Unit. Some of these transfers involve long
distances or protracted transfer times. The number of transfers can rise
to 9 per day during peak periods.

All ICUs in the North West region are contacted four times daily by the
Regional Intensive Care Bed Information Service (ICBIS) to ascertain bed
availability. There are potentially 183 adult general intensive care beds
in the region. When only 10 beds are available an amber alert is declared
by the NHS Executive North West Regional Office and this information is
faxed to all Trusts. When only 5 beds remain a red alert is declared.

This system, however, under-reports the true situation since alerts cannot
be sent out from the Regional Office at night or at weekends. These alerts
also exclude all specialist services and paediatric beds. During June,
traditionally a quiet time of the year, there were 17 occasions when an
amber alert condition was met, and 6 occasions when a red alert could have
been issued.

The inability to satisfy the demands for intensive care in a hospital leads
to a number of consequences. People who, although no longer mechanically
ventilated, could still benefit from intensive care may be discharged
early. Patients who are deteriorating may have to be managed on a general
ward or another area where the facilities are less than ideal, and with
staff who do not work regularly with such critically ill patients. If
these patients are cared for in the operating theatres or recovery area,
then elective surgery may have to be cancelled. We cannot quantify the
resulting morbidity and mortality of these scenarios.

Furthermore, stabilisation and transfer of patients is time consuming (an
average of three and a half hours), and will either put an additional
burden on the already overstretched ICU staff, or place that burden on the
on-call anaesthetic service. There is often a dilemma; whether to use an
experienced hospital doctor for the transfer, which potentially leaves
inexperienced cover for the rest of the hospital.

McQuillan and colleagues rightly pointed out that audit is required to
monitor adherence to standards and guidelines. We have been auditing
intensive care transfers against locally published standards for two and a
half years. While this has demonstrated an increasing number of transfers
which meet the standards, it has also clearly demonstrated an increasing
number of transfers which are the result solely of the lack of staffed ICU
beds in the host hospital. Over this period, transfers for this reason
have increased by 300% in Greater Manchester, and 200% in the rest of the
North West region. Despite sharing this information with local and
regional managers, there appears to be an inability to address the
fundamental issue of insufficient investment in intensive care and high
dependency units in the North West of England. Political direction is
aimed towards reducing waiting times for elective surgery.

Unless McQuillan and colleagues' strategy to improve the care of the
acutely ill patient outside the ICU succeeds then, in the absence of
sufficient high dependency and intensive care beds, it seems inevitable
that patients will continue to require stabilisation and transfer to
distant ICUs.

References

McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, et al.
Confidential inquiry into quality of care before admission to intensive
care. BMJ 1998; 316:1853-8 (20 June)

Intensive Care Society. Guidelines for transport of the critically ill
adult. London: ICS, 1997; page 6, section 9.2

Royal College of Anaesthetists. Basic specialist training guide. London:
RCA, 1991; section 2.1

Dr Peter W Duncan Dr Peter Nightingale
Chairman Secretary
On behalf of the Association of North Western Intensive Care Units

Dr Ian Macartney
On behalf of the Intensive Care Bed Information Service

Dr Johanna Ryan
Regional Intensive Care Audit Co-ordinator

Dr Maire P Shelly
Local Advisor in Intensive Care Medicine

Intensive Care Unit
Withington Hospital
Nell Lane
West Didsbury
Manchester
M20 2LR

Competing interests: No competing interests

21 July 1998
Peter Nightingale
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Re: Population based randomised study of uptake and yield of screening by flexible sigmoidoscopy compared with screening by faecal occult blood testing John M A Northover, et al. 317:doi 10.1136/bmj.317.7152.182

I am interested to know the type of sigmoidoscope used.
I have no data. I use a Kleenspec Wells Allyn rigid
sigmoidoscope for indications like habits change, blood,
pain, tenesmus etc at the time of clinical visit as I
detect these symptoms, without preparations and as it was.
These really cannot be compared with well planned studies
like yours.

Competing interests: No competing interests

21 July 1998
Vincent Ip
General Practitioner
Hong Kong
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Re: Doctors must understand terminology used to describe psychological therapies Judy Young. 317:doi 10.1136/bmj.317.7151.148a

Editor,

Young makes important points 1 when she advocates that psychological interventions
differ in theory and practice. Each must be defined so that the correct terminology
is used by health professionals to facilitate appropriate interventions.
She claims however, that we 2 have erroneously interchanged the terms "psychotherapy",
"counselling" and "adjuvant psychological therapy" (APT) and that we
have "dismissed the benefits of counselling for cancer patients on the
basis of a study that used adjuvant psychological therapy"(APT). She
infers that the low response rate in our study denotes a need to
recognise that APT may not have been appropriate while other
counselling approaches may have been effective.

We believe that since all categories of counselling are part of the therapeutic enterprise3,4, the terminology is interchangeable. Information giving
and reassurance are a form of counselling since they help to "contain" the person to
whom it is given; "containment" being the sine qua non of patient support.
We do not however dispute that differing approaches have their own theoretical
underpinning, nor that they are made explicit . Our report referenced the
theory underlying APT. When we elicited consent from patients to enter the trial,
the method of counselling was described. The low response rate suggests, amongst
other things, coping ability, a wish to be seen to be coping or simply an aversion to
the ethos of counselling in this group. Patients' refusals are as interesting as
their acceptance and it is imperative that we listen to their voices.

We do not dismiss the benefits of cancer counselling. We have evaluated a
specific approach with a specific cancer group and concluded that APT need not
be routinely offered to men with testicular tumours. We make a plea for caution
regarding the"blind faith" that counselling will be gratefully received and
effective despite a dearth of sound evidence.

Clare Moynihan Medical Sociologist
Alan Horwich Professor of Radiotherapy
Academic Department of Radiotherapy
Institute of Cancer Research & the Royal Marsden Hospital,
Downs Road, Sutton, Surrey. SM2 5PT

Judith Bliss Statistician
Department of Epidemiology,
Institute of Cancer Research,
Downs Road, Sutton, Surrey SM2 5PT

1 Young J Doctors must understand terminology used to describe psychological therapies. BMJ 1998; 317:148
2. Moynihan C, Bliss JM, Davidson J, Burchell L, Horwich A. Evaluation of adjuvant psychological therapy in patients with testicular cancer:randomised controlled trial. BMJ 1998;316429-35
3. Rose N. Governing the Soul. The Shaping of the Private Self. USA, Canada:Routledge 1991
4. Burton M, Watson M. Counselling People with Cancer. Wiley & Sons, Chichester. 1998

I can confirm that the authors have no conflicts of interest.

Competing interests: No competing interests

21 July 1998
Clare Moynihan
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Re: Taking precautions with ACE inhibitors A Kumar, M Asim, A M Davison. 316:doi 10.1136/bmj.316.7149.1921

Kumar et al (1) indicate that renovascular disease is more common than was thought in the past. They highlight the increasing use of ACE inhibitors in conditions associated with atherosclerosis, e.g. diabetes mellitus.

However, they present no evidence of an increased prevalence of unilateral renal artery stenosis to justify their suggestions of expensive investigations to rule out a theoretical risk. Even where lesions are detected, it does not necessarily follow that an ACE-I will compromise the perfusion of the kidney.

I agree they have identified a theoretical risk. They must demonstrate this to be a real risk before recommending changes in practice.

Yes, we must exercise caution when prescribing ACE-I. We must not deny the proven benefits from those at greatest risk (e.g. diabetic patients) because of unproven (and probably infrequent) risks.

(1)A Kumar, M Asim, and A M Davison BMJ 1998; 316: 1921-1930

Competing interests: No competing interests

21 July 1998
Peter A Senior
RD Lawrence Fellow
Dept. of Medicine, University of Newcastle upon Tyne
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Re: Chiropractic for low back pain E Ernst, W J J Assendelft. 317:doi 10.1136/bmj.317.7152.160

I find Ernts and Assendelft's article both interesting and incongruent. Failing to referrence Meade's and Koes work comparing chiropractic to physical therapy and traditional medicine for low back pain pubished in BMJ and showing chiropractic's superiority in effectiveness and long term benefit is perplexing. To fail to mention that medically accepted forms of treatment ie. physical therapy modalities and prescriptions like muscle relaxants and injections have shown no valid research basis for therapy is irresponsible literature research review.
If the authors find chiropractic treatment for low back pain lacking validity according to research basis I would like to know what they think is supported as effective for the treatment of low back pain. Lastly let us remember that the choropractic profession did most of their research on validity on a self funded basis where the medical profession and physical therapy profession with federally funded grants available did nothing to investigate the validity of their practices.
In final comment, few medical procedures have a one in one million complication rate. I wonder if physicians warn their patients of the much greater risk of a female smoking patients sustaining a stroke from taking some forms of birth control medications.
Since the US Agency for Health Care Policy and Research came to their conclusions regarding efficacy of treatments for acute low back pain there seems to be a great deal of interest in reexamining spinal manipulation's effectiveness. I think these authors should not throw stones if they live in glass houses.

Competing interests: No competing interests

20 July 1998
Roy M Love
Imed past pres of Pa Chiro Assoc.
Nittany Valley Chiropractic
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Re: Facial structure in the sudden infant death syndrome: case-control study Karen Rees, Anne Wright, Jean W Keeling, Neil J Douglas. 317:doi 10.1136/bmj.317.7152.179

Is this study looking at the chicken or the egg? Facial structure is at least partly inherited, but is also altered by infant feeding method. The bony structure is malleable in infancy and the roof of the mouth can be moulded upward by the pressure of a bottle teat, decreasing the nasal airway.

Feeding from a bottle also uses greater suction than breastfeeding, and can lead to vacuum collase in the throat, further decreasing the airways.

Labbok and Hendershots 1987 study of malocclusion and feeding method suggests that children who were bottledfed are almost twice as likely to develop malocclusion as children who were breastfed.

It is not known whether the malformations caused by bottle-feeding contribute to some cases of sudden infant death syndrome, but there is good evidence they contribute to a number of other oral cavity, airway and middle ear problems. "The Influence of Breastfeeding on the Development of the Oral Cavity: A Commentary" Brian Palmer DDS, JHumLact 14(2), 1998 93-98 should be compulsory reading for anyone assisting mothers making an infant feeding choice.

Competing interests: No competing interests

20 July 1998
Ros Escott
Private practice
Community based lactation consultant
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Re: Clinical governance and the drive for quality improvement in the new NHS in England Gabriel Scally, Liam J Donaldson. 317:doi 10.1136/bmj.317.7150.61

EDITOR-- Scally and Donaldson (BMJ 1998; 317:61-5) use our response rates
inter alia to imply that 'audit' in the NHS has failed. The opposite seems,
to my biassed view, to be the case. These rates have steadily improved since
the Enquiry began and, it should be recalled the responses are voluntary. We
would have been delighted had the profession co-operated more fully with us
because this would have demonstrated convincingly the reality of its concern
over standards and quality. Nevertheless, 80% is not that bad. The
implication of the Government's recent pronouncement does not guarantee
improvement in either the quantity or quality of data submitted to NCEPOD.
Doctors are clever people and, if they do not wish to be involved, the data
they are coerced to submit could prove to be less than valid.

Affiliation: Former Clinical Co-ordinator NCEPOD
Postal address: The old nursery, Tidenham, Nr Chepstow, NP6 7JL

Competing interests: No competing interests

20 July 1998
J N Lunn
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Re: Vitamin B-6: food or medicine? Joe Collier. 317:doi 10.1136/bmj.317.7151.92

Editor,

In the recent editorial on vitamin B-6 Joe Collier discusses the crucial
question of any risk involved in taking it. He concludes that he agrees
with the Committee on Toxicity's decision that there is. Yet in his own
words this is based on a study from over ten years ago, featuring only 172
women. "The results were not consistent with other studies and the trial
design was weak." What is the justification for citing this as conclusive
evidence of risk?

Juliet Cohen General Practitioner

15 Denbigh St, Pimlico, London SW1
Fax 0181 671 7103

Competing interests: No competing interests

20 July 1998
Juliet Cohen
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Re: Deal expected over breast implants Deborah Josefson. 317:doi 10.1136/bmj.317.7152.161a

I know too many women, who were healthy as I, who experienced deteriorating health after implantation whether their implants ruptured or not. The medical system has failed us by sending us to psychiatrists instead of addressing real physical trauma, shock, pain and death in some cases. I almost died twice after having an implant capsulotomy. That same doctor tried to talk me into getting the infamous "safe" foam implants that we now know causes cancer and to this day he maintains breast implants are safe. If a human body rejects a donors organ it will also reject a foreign object. You all know this. Why then were we not given antirejection medication? This is nothing short of medical malpractice. My implanting physican put solu-medrol in a bi-lumen knowing it would leak out eventually or rot in my body. I told him I did not want gel and that is what I got inside the bi-lumen. The physicans think they are safe because time has ran out for them to be sued. But what goes arond in life comes back around.

Competing interests: No competing interests

20 July 1998
S Lane
N/A
N/A
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