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Introducing the postoperative care team
Effective postoperative care remains
surgeons’ role
Editor
—
I am concerned that the sugges-
tions made by David R Goldhill might be
taken too seriously rather than remain a
point for discussion.1Goldhill is right in his
assertion that patients can fare badly in their
postoperative course because of lack of
attention by their attendants and lack of
understanding of common postoperative
complications. I believe, however, that he has
missed the opportunity to lay the blame at
the correct door. Surely it is the surgeons’
role to carry out preoperative assessment,
surgery, and effective postoperative care. If
they choose to emphasise their importance
in the operating theatre, delegating their
other responsibilities to their trainees, the
nurse practitioners, and the anaesthetists,
why should we encourage this path?
Undoubtedly, anaesthetists are fast
becoming the new generalists, with an
increasing role outside the operating thea-
tre. These new skills and responsibilities
include pain control, intensive care, and
transoesophageal echocardiography, to
name but a few. Some of my professional
colleagues may relish even more diversifica-
tion and abhor my comments.
Goldhill implies that anaesthetists and
postoperative care nurses will lead the post-
operative care team; indeed, this is already
happening in North America, where they
have been sent to run preoperative assess-
ment clinics by surgeons based in the oper-
ating room. If the surgical ward round in
your hospital has become a quick look
through the laboratory results and a glance
at the chest radiograph before a rush to the
changing rooms then I suggest that waiting
for the confidential inquiry into peri-
operative deaths to point out the obvious is
not the solution.
Michael J Boscoe Consultant anaesthetist
Harefield Hospital, Harefield, Middlesex UB9 6JH
1 Goldhill DR. Introducing the postoperativecare team. BMJ
1997;314:389. (8 February.)
Such teams deserve a trial of
effectiveness and cost
Editor
—
I share David R Goldhill’s concern
over the management of postoperative care
in many parts of Britain.1Goldhill dismisses
high dependency units as being too
expensive and “unlikely to be available to
most postoperative patients, particularly
beyond the first few hours of surgery.”
Precisely this aspect was addressed in the
joint report of the Royal Colleges of Anaes-
thetists and Surgeons of England on gradu-
ated patient care; the report concluded that
such an organised system, including
adequate high dependency unit facilities,
would make better use of present resources
and was unlikely to be more expensive.2
The use of an itinerant, intermittent
postoperative care team may be an alterna-
tive arrangement at present, necessary
because of architectural constraints making
it difficult to provide sufficient intensive care
and high dependency facilities to deal with
the numbers who require this form of treat-
ment. This idea must first have a trial of
effectiveness and cost.
Michael Rosen Chairman, joint working party,
graduated patient care
45 Hollybush Road, Cardiff CF2 6SZ
1 Goldhill DR. Introducing the postoperativecare team. BMJ
1997;314:389. (8 February.)
2 Royal College of Anaesthetists and the Royal College of
Surgeons of England. Report of joint working party on gradu-
ated patient care. London:RCS, 1996.
Royal College of Surgeons has training
programme for surgical trainees
Editor
—
It is of note to surgeons, and
perhaps a warning, that both main weekly
medical journals in Britain should have taken
it upon themselves to chide their surgical col-
leagues about the standards of care pertain-
ing to operations.1-3 It is to the credit of
surgeons that this topic has been highlighted
by the report of the national confidential
enquiry into perioperative deaths.4The
solution suggested in David R Goldhill’s
editorial smacks of the “modern” answer
—
if
there is a problem then manage it with a
team.1Thus the poor surgical patient will
return from theatre to be seen by the pain
team, the nutrition team, the stoma team, the
lifting and handling expert, and the postop-
erative care team. Alas, with all these teams
the trainee becomes less skilled and less able
to manage ill patients, and the continuing
care of the patients becomes less good.
All the points that Goldhill makes are
those that most surgeons interested in peri-
operative care take for granted and are sur-
prised to see highlighted in an editorial.
Nevertheless, the fact that statements such as
“oxygen therapy is effective at preventing
hypoxaemia” and “it may be necessary to
take on the challenge of postoperative care”
can be made in a serious journal suggests
that in some institutions there is a serious
lack of training in the management of peri-
operative surgical patients. To overcome any
such deficiency the Royal College of
Surgeons has designed a training pro-
gramme for basic surgical trainees to cover
all areas commented on in the editorial. The
critical care course emphasises the
importance of respiratory, cardiac, renal,
and nutritional care in the perioperative
period. There is also emphasis on communi-
cation, which the editorial omits. Without
good communication, management by
multiple teams leads to chaos. If critical care
and good communication skills are taught
to surgical trainees then a comprehensive
system of continuing postoperative care will
decrease morbidity and mortality. Perhaps
the team approach can then wither at
inception.
R C G Russell Consultant surgeon
Middlesex Hospital, London W1N 8AA
1 Goldhill DR. Introducing the postoperativecare team. BMJ
1997;314:389. (8 February.)
2 Cunnion RE, Masur H. Physician staffing in intensive care
units. Lancet 1996;348:1464-5.
3 Russell RCG. What has happened to the surgical
intensivist? Lancet 1997;349:213.
4 National Confidential Enquiry into Perioperative Deaths.
The report of the national confidential enquiry into perioperative
deaths 1993/1994. London: NCEPOD, 1996.
Advice to authors
We receive more letters than we can publish: we
can currently accept only about one third. We
prefer short letters that relate to articles
published within the past four weeks.We also
publish some “out of the blue” letters, which
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(including one to the BMJ article to which they
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Letters should be typed and signed by each
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and address should be stated. We encourage you
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the world wide web before we decide on
publication in the paper version. We will assume
that correspondents consent to this unless they
specifically say no.
Letters will be edited and may be shortened.
Letters
1346 BMJ VOLUME 314 3 MAY 1997
Better to define and enhance role of ward
surgical nurses
Editor
—
Few anaesthetists would disagree
with David R Goldhill’s concerns over
postoperative care.1However, the implica-
tions and the implementation of his propo-
sals send a shudder through the ranks of
anaesthetists.
If we consider establishing peripatetic
postoperative care teams then two problems
must be addressed. Firstly, the ward nursing
and medical staff will be deskilled. Secondly,
the natural providers of the medical skills for
this role are anaesthetists, who may already
be helping to manage postsurgical patients
on the wards. The anaesthetists are also,
however, already running intensive care and
high dependency units, and few need
reminding that currently this is a shortage
specialty.
Acute pain teams have faced similar
problems when they have been set up to
manage all the pain problems on the wards.
Deskilling of staff and overload of the
providers have been the consequence. What
sounded like a good idea at the outset now
needs reconsideration.2
The most important factor in the
improvement of postoperative care is to
define and then enhance the role of ward
surgical nurses. Empowering them to take
therapeutic measures (for example, recog-
nising hypovolaemia and initiating transfu-
sion, seeking appropriate experienced help
early) will avoid so much of the delay and
indecision on the part of inexperienced jun-
ior doctors that contributes to morbidity.
Similarly, they should be routinely manag-
ing 98% of the postoperative analgesia, to
promote early mobilisation. Ever shorter
stays after major surgery require a coordi-
nated approach by the nursing and surgical
team to manage the postoperative period
aggressively.3
Leadership for this surgical system must
come from the senior doctors (that is,
consultant surgeons and anaesthetists), and
they must be full participants in the process.
Junior doctors will participate and learn
from all. Without an integrated approach by
senior doctors and skilled nurses, however,
the system will go on as it is, and wandering
postoperative care teams will not be able to
patch it up.
William Notcutt Consultant anaesthetist
James Paget Hospital, Great Yarmouth NR31 6KA
1 Goldhill DR. Introducing the postoperativecare team. BMJ
1997;314:389. (8 February.)
2 Notcutt WG, Austin J. The acute pain team or the pain
management service? Pain Clinic 1995;8:167-74.
3 Bardram L, Funch-Jensen P, Jensen P, Crawford ME,
Kehlet H. Recovery after laparoscopic colonic surgery
with epidural analgesia and early oral nutrition and mobi-
lisation. Lancet 1995;345:763-4.
Why people stay healthy
Editor
—
George Davey Smith and Martin
Egger explore some theories regarding what
makes people stay healthy.1The concept of
investigating the epidemiology of health as
opposed to disease has not interested main
line epidemiologists. It raises many difficult
questions not always amenable to quantita-
tive analysis and it moves out into the realms
of sociology and psychology, which further
complicate matters.
As indicated by the authors, several
theories are emerging that strongly promote
psychological, economic, and sociological
explanations for why people remain
healthier in different environments. How-
ever, these concepts are far from being new
and I was most disappointed that they did
not mention Antonovsky’s excellent socio-
logically based work on why people remain
healthy despite difficult circumstances.2
Antonovsky asked the question: “Why
do people stay healthy despite being
exposed to seriously adverse circumstances,
eg concentration camps?” and developed
the sense of coherence theory, which
comprises three components: comprehen-
sibility, manageability, and meaningfulness.
The ability to make sense of what is going on
in our lives, the extent to which we feel able
to control this, and a positively dynamic
approach to difficult life challenges are the
three factors which Antonovsky has identi-
fied as maintaining people’s health in the
face of disaster and even the threat of death.
This work was published in the 1980s
and is based on solid research. Surely it is
time to stop reinventing wheels and for well
developed theories such as that propounded
by Antonovsky to be taken on board by epi-
demiologists who want to unravel the
mysteries of disease and ill health.
Frada Eskin Consultant in public health medicine
Sheffield Health,Sheffield S10 3TG
1 Davey Smith G, Egger M. Understanding it all
—
health,
meta-theories, and mortality trends. BMJ 1996;
313:1584-5. (Commentary on Bunker JP, Stansfeld S,
Potter J. Freedom, responsibility, and health. BMJ
1996;313:1582-4.) (21-28 December.)
2 Antonovsky A. Unravelling the mystery of health: how people
manage stress and stay well. San Francisco: Jossey-Bass, 1987.
Exploitative collaborative
research must be discouraged
Editor
—
Jair de Jesus Mari and colleagues
highlight the advantages of high quality col-
laborative research conducted in developing
countries.1They make the case for more col-
laborative research studies, especially when
experience of the disease is likely to be lim-
ited in developed countries. Taken at face
value, this case is difficult to fault, but I ques-
tion who its potential beneficiaries are likely
to be. There is a general distrust of science
from developing countries unless a Western
scientist “policed” the studies. Sometimes
studies that would not be allowed in
developed countries because of ethical
problems are undertaken in developing
countries, where such stringent conditions
may not apply (“The Human Laboratory,”
BBC2 Horizon, 6 Nov 1995). Scientists in
developing countries have occasionally had
cause to be suspicious of some foreign
collaborators because experience has taught
them that financial gain and personal
advancement rather than altruistic reasons
often provide the impetus for collaborative
studies with developing countries. There
have been instances of foreign research col-
laborators obtaining knowledge and skills
from those with whom they were suppos-
edly collaborating and using these for their
own financial gain and to extend their
careers by presenting themselves as advo-
cates for the developing countries. A notable
example of such a case is that of Dr Aklilu
Lemma of Ethiopia, who carried out the
original research on the endod berry for the
treatment of schistosomiasis, only to see his
“collaborators” patent rather than publish.2
Altruistic collaborative research should cer-
tainly be encouraged, but not exploitative
collaborative research.
Babatunde A Gbolade Clinical lecturer in family
planning and reproductive health care
University of Manchester, Palatine Centre,
Manchester M20 3LJ
1 Mari JdeJ, Lozano JM, Duley L.Erasing the global divide in
health research. BMJ 1997;314:390. (8 February.)
2 Mukerjee M. The berry and the parasite. Scientific American
1996;274:18-20.
Persistent fever in pulmonary
tuberculosis
Older doctors had more experience of
tuberculosis
Editor
—
It is understandable that, with the
relatively low level of tuberculosis in Britain,
the present generation of consultants is less
familiar with the vagaries of the disease than
those of us who had experience of it during
the massive postwar problem. In the recent
Grand Round the patient discussed pre-
sented with far advanced disease, clinically
and radiologically, as was not uncommon in
psychotic patients.1His weight is not stated,
but the doses given were well below those
recommended by the World Health
Organisation for a man weighing 33-50 kg.
It is notable that his fever subsided when he
was later given more normal doses, admit-
tedly intravenously. Possibly he had not
swallowed all the doses
—
a real possibility.
Even if psychotic patients are seen to take
each dose into their mouth, they sometimes
keep them and later spit them out. This
could account for the low serum concentra-
tions, though the orange urine suggests
absorption at least some of the time.
Nevertheless, in my experience it was
not uncommon in such severe cases for the
fever to take some weeks to subside. The first
paragraph of the article suggests that the
fever lasted two months, but figure 1
indicates that it had gone by 34 days and
perhaps by 24 days (there is a blank at days
24-34). You should not panic when a
response is delayed. If there is no reason in
the history to suspect primary resistance (a
matter that does not seem to have been
explored) and you are giving established
treatment, keep your nerve and carry on. In
time all will go well. If you start messing
about with treatment you may run into trou-
ble. This could have happened here. Drug
resistance was suspected and streptomycin
Letters
1347BMJ VOLUME 314 3 MAY 1997
added. This is the classic error. If failure to
respond was due to resistance there must
have been resistance to all the drugs being
given. Adding streptomycin would have
amounted to monotherapy. This is how one
drug after another can be lost; it is the
source of much of the present multidrug
resistance in the world.
I am agnostic about the importance of
the low blood concentration of rifampicin. I
have so often seen malabsorption suggested
as an explanation of apparent failure of
treatment when in depth clinical assessment
showed a failure to give effective standard
treatment. Doctors too often think that clini-
cians may make mistakes but that truth
comes out of laboratories. Laboratory work-
ers are also human.
John Crofton Retired professor of respiratory diseases
13 Spylaw Bank Road, Edinburgh EH13 0JW
1 Barakat MT, Scott J, Hughes JMB, Walport M, Calam J,
Friedland JS, et al. Persistent fever in pulmonary tuberculo-
sis. BMJ 1996;313:1543-5. (14 December.)
Several factors were not considered
Editor
—
The Grand Round on persistent
fever in pulmonary tuberculosis deserves
comment for several reasons.1
Firstly, the patient’s weight is not stated.
The dose of rifampicin given (360 mg) was
probably too low and the dose of isoniazid
(150 mg) certainly too low.
Secondly, the possibility of poor bio-
availability from the combination product
does not seem to have been considered.
Thirdly, the white cell count was unchar-
acteristically high for tuberculosis at times of
fever. Both variables were reduced by
intravenous cortisone. This suggests some
form of host/organism/drug hypersensitiv-
ity reaction.
Fourthly, routine liver function testing
was shown to be unnecessary.
Fifthly, the cardinal error of adding a sin-
gle drug to a failing regimen was committed.
Had the patient been resistant to two of the
initial drugs, he would have been resistant to
the third by the time the fourth (streptomy-
cin) was added, so that he was potentially
rendered resistant to the four drugs.
PDODavies Director
Cardiothoracic Centre, Liverpool L14 3PE
1 Barakat MT, Scott J, Hughes JMB, Walport M, Calam J,
Friedland JS, et al. Persistent fever in pulmonary tuberculo-
sis. BMJ 1996;313:1543-5. (14 December.)
Public scare has not deterred
Finnish teenagers from using
oral contraceptives
Editor
—
The increased risk of venous
thromboembolism related to the use of third
generation oral contraceptives has been
widely discussed in the media since October
1995, about two months before the original
research reports were published.12 A few
months after the negative publicity an
increase of 10-11% in the number of
induced abortions was reported from the
United Kingdom.34
In Finland the rate of teenage abortions
has been successfully reduced over the past
10 years, the abortion rate being 9 per 1000
girls aged 15-19 in 1994.5To a great extent
this can be explained by a sharp increase in
the use of oral contraceptives during the
1980s. In 1993,17% of 16 year olds and 38%
of 18 year olds used them.5As the pill scare
was expected to decrease teenagers’ use of
oral contraceptives and increase abortions,
we compared data from school health
surveys carried out six months before and
after the negative publicity. In addition, we
compared the abortion rates in the first four
months of the past three years.
All teenagers aged 15-16 in the ninth
grade of comprehensive schools in the city
of Turku and in the province of central Fin-
land completed a structured questionnaire,
with similar questions on sexual behaviour,
in April-May 1995 and 1996. The number of
respondents was 2995 (1528 girls, 1467
boys; response rate 83%) in 1995 and 3294
(1690 girls, 1604 boys; response rate 89%) in
1996.
The proportion of teenagers who had
had sexual intercourse at least once was the
same in both years: in 1995 it was 32% of
girls (475/1499) and 24% of boys (335/
1408) and in 1996, 30% of girls (502/1671)
and 27% of boys (422/1563). In 1996 only
10% (163/1668) of girls and 7% (109/1478)
of boys were worried about adverse health
effects of oral contraceptives, and there was
no difference according to sexual
experience or earlier or current use of
contraceptives. The distribution of contra-
ceptive methods used at the most recent
intercourse did not change significantly
(table 1). The proportion of teenagers using
oral contraception was 21% in 1995 and
24% in 1996 (table 1). About one fifth of
sexually experienced girls had sometimes
used emergency contraception in both
surveys (19% (92/475) in 1995 and 23%
(116/502) in 1996). The number of induced
abortions did not increase during the first
four months of 1996 (431) compared with
the two earlier years (430 in 1994, 452 in
1995), the abortion rates for the four
months being 2.7, 2.8, and 2.7 per 1000 girls
aged 15-19 years, respectively.
Finnish reactions to the pill scare were
generally moderate. In the main, the mass
media handled the news in a realistic and
responsible way, and health authorities did
not hurry to change official guidelines. This
moderate line may be a reason why Finnish
adolescents seem to have survived the pill
scare without having more abortions.
Elise Kosunen Senior lecturer in general practice
Medical School, University of Tampere, Box 607,
FIN-33101 Tampere, Finland
Heini Huhtala Junior researcher (biometry)
Arja Rimpelä Professor
School of Public Health, University of Tampere,
Box 607, FIN-33101 Tampere
Matti Rimpelä Senior medical officer
National Research and Development Centre for
Welfare and Health, Box 220, FIN-00531 Helsinki,
Finland
Arja Liinamo Research assistant
Department of Health Sciences, University of
Jyväskylä, Box 35, FIN-40351 Jyväskylä, Finland
1 WHO Collaborative Study of Cardiovascular Disease and
Steroid Hormone Contraception. Venous thrombo-
embolic disease and combined oral contraceptives: results
of international multicentre case-control study. Lancet
1995;346:1575-82.
2 WHO Collaborative Study of Cardiovascular Disease and
Steroid Hormone Contraception. Effect of different
progestagens in low oestrogen oral contraceptives on
venous thromboembolic disease. Lancet 1995;346:1582-8.
3 Ramsay S. UK “pill scare” led to abortion increase. Lancet
1996;347:1109.
4 Child TJ, Rees M, MacKenzie IZ. Pregnancy terminations
after oral contraception scare. Lancet 1996;347:1260-1.
5 Kosunen E. Adolescent reproductive health in Finland:
oral contraception, pregnancies and abortions from the
1980s to the 1990s [dissertation]. Tampere: University of
Tampere, 1996:69-78.
Sight tests to detect glaucoma
Reliability of screening procedures and
effectiveness of treatment need to be
assessed
Editor
—
Though Richard Wormald and col-
leagues refrain from advocating a nationwide
screening programme for glaucoma,1any
increase in case finding should be exposed to
the same scrutiny as are screening pro-
grammes and should fulfil most of the
accepted criteria for such programmes.
Firstly, can glaucoma be easily detected
in its early stages? Anyone working in eye
clinics flooded with referrals of patients with
false positive results will have their doubts.
In reality, patients are referred on the basis
of raised pressure or visual field loss or
apparent cupping of the optic disc rather
than a combination of these three variables.
As a result, the specificity of screening for
glaucoma is too low for an increase in case
finding to be advocated.
Table 1 Contraceptive methods used at most recent intercourse by teenagers aged 15-16 in 1995 and
1996
Girls Boys
1995
(n=463)
1996
(n=500)
1995
(n=329)
1996
(n=408)
No method 65 (14) 84 (17) 55 (17) 66 (16)
Condom 273 (59) 280 (56) 220 (67) 276 (68)
Oral contraceptives 97 (21) 119 (24) 37 (11) 41 (10)
Double contraception* 26 (6) 17 (3) 14 (4) 22 (5)
Other 2 (0.4) 0 3 (1) 3 (1)
*Oral contraceptives and condom.
For girls ÷2=5.06, df=3, P=0.167; for boys ÷2=0.77, df=3, P=0.85 for comparison of distributions of contraception in 1995 and
1996. Category other was excluded from analysis.
Letters
1348 BMJ VOLUME 314 3 MAY 1997
Secondly, is blindness due to glaucoma
really preventable? There is room for doubt.
A recent meta-analysis of trials of medical
treatment of glaucoma did not show any
protective effect on visual fields.2Further-
more, medical treatment of glaucoma has
the potential to do harm.3In common with
most ophthalmologists I believe that bigger
and better trials would probably show a pro-
tective effect, but the quality of evidence is
not yet sufficient to justify expansion of the
current screening arrangements.
Before we look again at sight tests we
should look again at the reliability of our
screening procedures and the effectiveness
of our treatment. Only then should we push
for an expansion of screening into high risk
groups.
Philip G Griffiths Consultant ophthalmologist
Royal Victoria Infirmary, Newcastle upon Tyne
NE1 4LP
1 Wormald R, Fraser F,Bunce C.Time to look again at sight
tests. BMJ 1997;314:245. (25 January.)
2 Rosetti L, Marchetti I, Orzalesi N,Scorpiglione N, Torri V,
Liberati A. Randomized clinical trials on medical
treatment of glaucoma: are they an appropriate guide to
clinical practice? Arch Ophthalmol 1993;111:96-103.
3 Diggory P, Franks W. Medical treatment of glaucoma
—
a
reappraisal of the risks. Br J Ophthalmol 1996;80:85-9.
Entitlement to free sight tests should be
reviewed
Editor
—
I share Richard Wormald and col-
leagues’ concern about the failure to detect
early glaucoma in elderly people, and I
agree that one of the measures to be consid-
ered should be a review of the present
exemptions from charges for sight tests.1
These regulations discriminate against cer-
tain groups of patients
—
namely, those with
conditions that require frequent and costly
changes in their prescription and those who
are at increased risk of developing disorders
that could be successfully screened for by an
optician.
In my view, patients with thyroid eye dis-
ease should be entitled to free sight tests. In
this condition the extraocular muscles are
affected by an inflammatory process that
may persist for some years and result in
changes in the shape and size of these mus-
cles, as well as changes in their movements.2
Appreciable swelling of the retro-orbital tis-
sues causes proptosis and influences the
shape of the globe, with subsequent changes
in the refractive error. The muscles are not
always affected simultaneously, hence the
need for frequent prescriptions. Changes in
eye movements may cause diplopia and the
need for prisms, which, if incorporated in
the prescription, increase the cost dramati-
cally. Analysis of one patient’s records from
1988 to 1994, during which time she devel-
oped thyroid eye disease, showed that her
glasses were changed six times at a cost of
£347.90. In that time she developed 1.25
dioptres of astigmatism in the right eye and
1.5 dioptres in the left eye and the axis
varied 40° in the right eye and 30° in the left
eye. Finally, the astigmatism disappeared in
the left eye and halved in the right.
The assessment of corrected acuity in
these patients is of great value. While not all
patients need to be monitored in an eye
department, it is essential that they are
referred urgently if their vision decreases, as
this may be the first indication of sight
threatening compression of the optic nerve.
Finally, there is a recognised association
between hypothyroidism and primary open
angle glaucoma. Smith et al showed that
23.4% of a group of patients with known
primary open angle glaucoma had
hypothyroidism.3Cartwright et al also found
that 30% of patients with normal tension
glaucoma had immune related disease.4
Although we do not know how many
patients with thyroid disease will develop
glaucoma, screening should be considered.
Mick Cole Consultant ophthalmologist
Department of Ophthalmology, Torbay Hospital,
Torquay TQ2 7NP
1 Wormald R, Fraser S, Bunce C. Time to look again at sight
tests. BMJ 1997;314:245. (25 January.)
2 Char DH. Thyroid eye disease. New York: Churchill
Livingstone, 1990.
3 Smith KD, Arthurs BP, Saheb N. An association between
hypothyroidism and primary open angle glaucoma.
Ophthalmology 1993;100:1580-4.
4 Cartwright MJ, Grajewski AL, Friedberg ML, Anderson
DR, Richards DW. Immune-related disease and normal
tension glaucoma. Arch Ophthalmol 1992;110:500-2.
Systemic lupus erythematosus
complicated by
antiphospholipid antibody
syndrome
Young women should be referred to an
obstetrician or gynaecologist
Editor
—
I read the Grand Round about a
patient with systemic lupus erythematosus
and the antiphospholipid antibody syn-
drome with concern.1The absence of an
obstetrician and gynaecologist from the dis-
cussion group led to inaccuracies and omis-
sions in the management advised.
In women
—
with or without systemic
lupus erythematosus
—
the presence of
antiphospholipid antibodies is the most sen-
sitive indicator of late fetal death2and neces-
sitates treatment with low dose aspirin and
either subcutaneous heparin at an anti-
coagulant dose or steroids. Despite the mor-
bidity associated with this regimen, previous
fetal loss should not be a prerequisite for its
prescription. One study reported a success-
ful outcome of pregnancy in six untreated
women with the antiphospholipid antibody
syndrome; it used Doppler studies for fetal
monitoring.3While obstetricians agree that
careful fetal monitoring is the essence of
successful management in most high risk
pregnancies, the relative contributions of
surveillance versus treatment in the
antiphospholipid antibody syndrome have
yet to be studied. No amount of scanning,
however,will prevent fetal or neonatal death
before 24 weeks’ gestation.
The group also failed to mention the
importance of future adequate contracep-
tion and the role of prenatal counselling.
Systemic lupus erythematosus is recognised
to have an adverse effect on the outcome of
pregnancy, and vice versa, not uncommonly
resulting in fetal death and severe maternal
morbidity.Timely referral to a gynaecologist
not only may prevent unwanted conception
but would warn those women who are
anxious to conceive of the potential compli-
cations of pregnancy.Indeed,disease activity
at conception is a major factor in determin-
ing the outcome of the pregnancy. It is
imperative that colleagues involved in the
management of young women with long
term medical or surgical disease consider
this avenue of referral in all cases.
Robert Llewelyn Consultant obstetrician and
gynaecologist
Department of Obstetrics and Gynaecology,
Singleton Hospital, Sketty,Swansea SA2 8QA
1 Cockwell P, Savage COS, Owen JJT, Thompson RA,
Gordon C, Adu D,et al. Systemic lupus erythematosus. BMJ
1997;314:292-5. (25 January.)
2 Lockshin MD, Druzin ML, Goei S, Qamar T, Majid MS,
Jovanovic L, et al. Antibody to cardiolipin as a predictor of
fetal distress or death in pregnant patients with systemic
lupus erythematosus. N Engl J Med 1985;313:152-6.
3 Trudinger BH, Stewart GJ,Cook CM, Connelly A, Exner T.
Monitoring lupus anticoagulant positive pregnancies with
umbilical artery flow velocity waveforms. Obstet Gynaecol
1988;72:215-8.
Pulse treatment with cyclophosphamide
would have been more appropriate
Editor
—
The Grand Round about a woman
with systemic lupus erythematosus merits
further comment.1When the patient pre-
sented at the age of 25 with a malar rash and
polyarthritis, tests confirmed the presence of
systemic lupus erythematosus, with a posi-
tive antinuclear antibody titre and anti-
double stranded DNA titre and hypocom-
plementaemia. Most importantly, she had
haematuria and appreciable proteinuria (3.4
g/24 h) suggesting lupus nephritis, but renal
biopsy was not performed. The normal cre-
atinine clearance and normal ultrasound
scan of the kidneys do not exclude lupus
nephritis, and her subsequent treatment
with only a non-steroidal anti-inflammatory
drug must be questioned. She had to wait a
further seven months before a renal biopsy
confirmed lupus nephritis (World Health
Organisation class III), warranting immuno-
suppressive treatment. A diagnostic delay of
seven months is unacceptable because
prompt and vigorous treatment of classes III
and IV lupus nephritis is crucial to minimise
the risk of permanent renal damage.
Daily cyclophosphamide is not the best
choice in a 25 year old woman. Pulse
treatment with cyclophosphamide and high
dose steroids is the most effective treatment
in lupus nephritis.2Furthermore, pulse
cyclophosphamide rather than continuous
daily treatment probably reduces the risk of
a premature menopause and bladder toxic-
ity, both of which are important considera-
tions in young women.3
Although we accept that this woman
may have had secondary antiphospholipid
antibody syndrome, venous thrombosis is
also a recognised complication of the neph-
rotic syndrome. The degree of proteinuria
andthepresence or absenceofhypoalbumin-
aemia at the time she had a percutaneous
renal biopsy are not stated. An isolated
measurement of the IgM anticardiolipin
antibody also has less diagnostic predictive
Letters
1349BMJ VOLUME 314 3 MAY 1997
value than measurement of the IgG anti-
cardiolipin antibody and lupus anticoagu-
lant status, both of which were negative.4In
this setting we question the decision to
maintain the patient on lifelong warfarin,
especially with the increased haemorrhagic
risk of maintaining the international nor-
malised ratio in the range 3.0-4.5 in this
syndrome.5
Elizabeth M McDermott Clinical research fellow
Michael Duddridge Senior registrar
Richard J Powell Senior lecturer
Clinical Immunology Unit, Queen’s Medical
Centre, University Hospital, Nottingham NG7 2UH
1 Cockwell P, Savage COS, Owen JJT, Thompson RA,
Gordon C, Adu D,et al. Systemic lupus erythematosus. BMJ
1997;314:292-5. (25 January.)
2 Austin HA, Klippel JH, Balow JE, Le Riche NGH,
Steinberg AD, Plotz PH, et al. Therapy of lupus nephritis.
Controlled trial of prednisolone and cytotoxic drugs.
N Engl J Med 1986;314:614-9.
3 Balow JE, Austin HA, Tsokos GC, Antonovych TT,
Steinberg AD, Klippel JH. Lupus nephritis.Ann Intern Med
1987;106:79-94.
4 Cervera R, Font J, Lopez-Soto A, Casals F, Pallares L, Bove
A, et al. Isotype distribution of anticardiolipin antibodies in
systemic lupus erythematosus: prospective analysis of a
series of 100 patients. Ann Rheum Dis 1990;49:109-13.
5 Khamashta MA, Cuadrado MJ, Mujic F, Taub NA, Hunt BJ,
Hughes GRV. The management of thrombosis in the
antiphospholipid-antibody syndrome. NEnglJMed1995;
332:993-7.
Authors’ reply
Editor
—
There is no evidence to support
treatment of patients with antiphospholipid
antibodies who do not have a history of fetal
loss, thrombosis, or other features of the
antiphospholipid syndrome.1Two prospec-
tive studies have addressed the treatment of
antiphospholipid antibodies in pregnancy
for women with two or more fetal losses.
Both indicate that low dose aspirin and
prophylactic heparin is the treatment of
choice.23 There is no good evidence for
using steroids in pregnant patients with the
antiphospholipid syndrome. Indeed, the
inappropriate use of steroids in pregnancy in
this disorder may further worsen outcome.4
We agree with Robert Llewelyn about
the importance of adequate contraception
and prenatal counselling in patients with
systemic lupus erythematosus with or
without an antiphospholipid syndrome. We
provide routine contraceptive advice and,
with our obstetric colleagues, hold a joint
prenatal clinic for all patients with systemic
lupus erythematosus.
This patient underwent an urgent renal
biopsy on referral to this centre, and we
agree with Elizabeth M McDermott and col-
leagues about the usefulness of an early
renal biopsy in the management of sus-
pected lupus nephritis. There is no evidence
that prednisolone plus intravenous pulse
cyclophosphamide is superior to oral cyclo-
phosphamide; the only controlled study
showed no significant difference in renal
survival.5We believe that two to three
months of daily oral cyclophosphamide at a
dose of 1.5-2 mg/kg followed by daily oral
azathioprine causes less gonadal toxicity
and is as efficacious as intermittent pulse
cyclophosphamide for two years. We are
planning a multicentre randomised con-
trolled study to compare the efficacy and
toxicity of these regimens.
Despite having proteinuria the patient
had a normal serum albumin concentration.
We recognise that venous thrombosis is a
complication of the nephrotic syndrome.
The duration of anticoagulation treatment is
determined by the underlying disease and
risk of recurrent thromboembolism. In a
patient with a prothrombotic tendency
(probable antiphospholipid syndrome) with
a potentially fatal ileofemoral thrombosis
(her third), five months after warfarin
treatment was stopped, we believe that most
doctors would accept the risk-benefit ratio of
long term anticoagulation.
P Cockwell Clinical research fellow in medicine
(nephrology)
D Adu Consultant nephrologist
C Gordon Senior lecturer in rheumatology
COSSavage Senior lecturer in medicine (nephrology)
Queen Elizabeth Hospital, Birmingham B15 2TH
1 Lynch A, Silver R, Emlen W. Antiphospholipid antibodies
in healthy pregnant women. Rheum Dis Clin North Am
1997;23:55-70.
2 Kutteh WH. Antiphospholipid antibody-associated recur-
rent pregnancy loss: treatment with heparin and low dose
aspirin is superior to low-dose aspirin alone. Am J Obst
Gynecol 1996;174:1584-9.
3 Rai R, Cohen M,Dave M, Regan L. Randomised controlled
trial of aspirin and aspirin plus heparin in pregnant
women with recurrent miscarriage associated with
phospholipid antibodies (or antiphospholipid antibodies).
BMJ 1997;314:253-7. (25 January.)
4 Silver RK, Macgregor SN, Sholl JS, Hobart JM, Neerhof
MG, Ragin A. Comparative trial of prednisone plus aspirin
versus aspirin alone in the treatment of anticardiolipin
antibody-positive obstetric patients. Am J Obst Gynecol
1993;169:1411-7.
5 Austin HA III, Klippel JH, Balow JE, LeRiche NGH,
Steinberg AD, Plotz PH, et al. Therapy of lupus nephritis:
controlled trial of prednisolone and cytotoxic drugs.
N Engl J Med 1986;314:614-9.
The tobacco industry and
scientific publications
Challenges on grounds of self evident
potential bias are not unfair
Editor
—
Peter N Lee complains about the
concern, expressed by George Davey Smith
and Andrew N Phillips, that Lee’s vested
interest in tobacco industry revenue to P N
Lee Statistics and Computing Ltd might
influence his interpretation of epidemiologi-
cal evidence.12 But what is unfair about
challenges on the grounds of self evident
potential bias? BMJ journals now require a
clear statement from authors on conflict of
interest.
Nevertheless Lee has been given the
privilege of reply, but he asserts only that he
is widely consulted on many issues. Granted,
but may we now see an audited statement on
the proportion ofPNLeeLtd’sgross
income from the tobacco industry during
the past five years?
Lee is the author of Environmental
Tobacco Smoke and Mortality.3In his conclu-
sion to the preface of this book he states that
“There is no convincing evidence that expo-
sure to ETS [environmental tobacco smoke]
results in an increased risk of death from
cancer, heart disease or any other disease in
non-smokers.” Would Lee now clarify in
what way the tobacco industry supported
the publication of his monograph and how
much he received?
The problem for Lee and others who
depend on revenue from the tobacco indus-
try for a large proportion of their consul-
tancy income is that the industry is clearly
determined to corrupt the medical and
scientific literature on tobacco and health
through funding academics, conferences,
publications, and delegates’ attendance at
events supported by the industry in attrac-
tive venues. New initiatives include the
establishment of academic posts in prestig-
ious institutions world wide, and especially
in regions that are now prime targets for
market expansion. The industr y’s apparently
limitless largesse is particularly noticeable in
the Asia Pacific, where it is now trying to
recruit health professionals as its advocates.
P N Lee Ltd and others that take the
industry’s commissions will have to find
more novel reasons why we should not
regard them as its servants and treat their
outputs with circumspection.
A J Hedley Professor
Department of Community Medicine, University of
Hong Kong, Hong Kong
1 Lee PN. Many claims about passive smoking are
inadequately justified. BMJ 1997;314:371. (1 February.)
2 Davey Smith G, Phillips AN. Passive smoking and health:
should we believe Philip Morris’s “experts”? BMJ
1996;313:929-33. (12 October.)
3 Lee PN. Environmental tobacco smoke and mortality. Basle:
Karger, 1992.
Findings of scientists who were and were
not funded by tobacco industry were
strikingly different
Editor
—
It is hard to decide which part of
Peter N Lee’s letter is the most objection-
able, but it is worth commenting on three
points for the sake of truth.1Firstly, Lee
whines that George Davey Smith and
Andrew N Phillips mention that he receives
tobacco industry funding. He implies that
they insinuate that this financial support dis-
torts his scientific veracity. But what is wrong
with noting the truth about the source of his
funding? I suspect that the real problem is
that Lee’s longtime association with the
industry, which for decades has done every-
thing it can to obfuscate the truth, may have
had its effect
—
perhaps subconsciously
—
on
him.
Secondly, to support one of his argu-
ments he cites as prime evidence a report
funded by Philip Morris USA.2He fails to
mention this financial link, incestuous as it is
in the context of his letter, despite his
presumed search for truth. Furthermore, he
does not note how the authors of that
report, LeVois and Layard, obtained the data
they used. For this information we need to
turn to scientists who do not receive tobacco
industry funding.3They say, “Several years
ago the tobacco industry’s lawyers obtained
the American Cancer Society’s CPS [cancer
prevention study] data set, ostensibly to help
in preparation of the defence of a wrongful
death suit against a tobacco company. The
industry’s lawyers subsequently provided
this data set to two consultants, LeVois and
Layard, who conducted an analysis of these
data, which concluded that passive smoking
did not affect the rise of heart disease.”
Letters
1350 BMJ VOLUME 314 3 MAY 1997
Lee also fails to mention that another
group of scientists, not funded by the
tobacco industry, examined the same huge
data set as the one examined by LeVois and
Layard and came up with conclusions strik-
ingly at odds with LeVois and Layard’s.4
These other scientists write that their own
results “are consistent with prior reports that
never-smokers currently exposed to [envi-
ronmental tobacco smoke] have about 20%
higher [coronary heart disease] death rates.”
Thirdly, Lee cites a particular study
about smoking and the sudden infant death
syndrome, hinting that its “adjustment for
numerous risk factors” somehow under-
mines the evidence linking the syndrome
with household smoking habits. The authors
of this study themselves conclude, however,
“Passive tobacco smoking is causally related
to [the sudden infant death syndrome].”5
Phillip Whidden Publications editor
Association for Nonsmokers’ Rights, Edinburgh
EH7 4BU
1 Lee PN. Many claims about passive smoking are
inadequately justified. BMJ 1997;314:371. (1 February.)
2 LeVois ME, Layard MW. Publication bias in the
environmental tobacco smoke/coronary heart disease
epidemiologic literature. Regul Toxicol Pharmacol
1995;21:184-91.
3 Glantz SA, Parmley WW. Passive and active smoking: a
problem for adults. Circulation 1996;94:596-8.
4 Steenland K, Thun M, Lally C,Heath C Jr.Environmental
tobacco smoke and coronary heart disease in the
American Cancer Society CPS-II cohort. Circulation
1996;94:622-8.
5 Mitchell EA, Ford RKP, Stewart AW, Taylor BJ, Becroft
DMO, Thompson JMD, et al. Smoking and sudden infant
death syndrome. Pediatrics 1993;91:893-6.
More intensive care unit beds
are needed
Editor
—
PeterGMWallace and Paul G
Lawler highlight the need for regional
intensive care unit transfer teams.1As mem-
bers of a regional transfer team based at the
Western Infirmary in Glasgow we write to
confirm the value of such teams and the
need for more beds in intensive care units.
The Western Infirmary’s transfer team,
which was established in 1975, has trans-
ferred 3595 critically ill patients, with only
one death in transit. We provide a transfer
service to over 32 hospitals in west Scotland,
serving a population of about 2.5 million.
The service is funded by the purchasing
boards in the west of Scotland on a pro rata
basis. Reviews of our team in the past have
shown the importance of skilled staff,
suitable monitoring and equipment, and
stabilising patients before transfer.23
It has become increasingly common for
us to have to transfer patients because an
intensive care unit bed is not available at the
referring centre. Such transfers due to lack
of beds are termed bedspace transfers,
whereas transfers for specialist intervention
or an upgrade in care are termed upgrades.
We have examined our workload over
1993-6; data on the total number of
transfers, number of bedspace transfers, and
time for each were collected from the
database.
The total number of transfers increased
from 343 in 1993 to 459 in 1996. The
percentage of bedspace transfers increased
from 12.8% (95% confidence interval 9.27%
to 16.33%) in 1993 to 32.7% (28.41% to
36.99%) in 1996. There was no significant
difference between the time taken for a bed-
space transfer or an upgrade (2.30 h v2.46
h, P > 0.2). This reflects the time needed for
resuscitation and stabilisation regardless of
the indication for moving the patient.
The increased workload experienced by
our team is likely to be reflected nationally
due to the lack of locally available intensive
care unit beds. The national bed bureau will
speed up the process of allocating beds.
Nevertheless, a considerable number of
intensive care unit patients who are trans-
ferred will continue to be accompanied by
inexperienced, ill equipped staff.4The
setting up of regional dedicated transfer
teams is urgently required to reduce the
inherent risks associated with the transport
of critically ill patients.5This should not,
however, deflect attention from the need, as
our figures show, for more intensive care
unit beds. Until this happens, the number of
transfers of critically ill patients due to the
shortage of locally available beds will
continue to rise.
Pamela A Cupples Research fellow
Andrew P Makin Research fellow
Susan S McKinnon Research fellow
Neil D Storey Research fellow
Clinical Shock Study Group, Western Infirmary,
Glasgow G11 6NT
1 Wallace PGM, Lawler PG. Regional intensive care transfer
teams are needed. BMJ 1997;314:369. (1 February.)
2 Runcie CJ, Reeve W, Reidy J, Wallace PGM. Secondary
transport of the critically ill adult. Clin Intensive Care
1991;2:217-25.
3 Reeve WG, Runcie CW, Reidy J, Wallace PG.Current prac-
tice in transferring critically ill patients in the west of Scot-
land. BMJ 1990;300:85-7.
4 Hicks IR, Hedley RM, Razis P. Audit of transfer of head
injured patients to a stand-alone neurosurgical unit. Injury
1994;25:545-9.
5 Bion JF, Wilson IH, Taylor PA. Transporting critically ill
patients by ambulance: audit by sickness scoring. BMJ
1988;296:170.
Submucosal haemorrhage—or
ruptured nodule in a
multinodular goitre?
Ultrasound scan suggested recent
haemorrhage in a left upper pole thyroid
nodule
Editor
—
A woman known to have a multi-
nodular goitre and primary hyperpara-
thyroidism presented with a two day history
of sudden onset of pain and swelling in the
left side of the neck, sore throat, and
dysphagia. Two days later she developed
bruising over the front of the neck and
upper chest (fig 1). Ultrasound examination
confirmed the presence of a multinodular
goitre and strongly suggested recent haem-
orrhage in a left upper pole thyroid nodule
that had presumably ruptured. Her symp-
toms and signs gradually subsided over the
next few days. She presented shortly after a
photograph of a patient with similar
symptoms had been reported on by R M
Walsh andJTLittle in the Minerva section
of the BMJ; the presumed diagnosis was
spontaneous submucosal haemorrhage in
the pharynx.1
B G Issa Senior registrar
M F Scanlon Professor
Department of Endocrinology, University Hospital
of Wales,Cardiff CF4 4XN
1 Walsh RM, Little JT. Minerva. BMJ 1996;312:1682.
**
*This letter was sent to the authors of the
original report in Minerva for reply.
Author’s reply
Editor
—
The subcutaneous bruising with
which my patient presented is unlikely to
have been due to a ruptured nodule in a
multinodular goitre as he did not have a pal-
pable goitre and the subcutaneous bruising
extended deeply into the walls of the larynx,
hypopharynx, oral pharynx, and indeed into
the posterior wall of the nasal pharynx.
Blood is unlikely to track this high from the
region of the thyroid gland.
However, the aetiology of this patient’s
pharyngeal and subsequent subcutaneous
bruising is still not known, despite thorough
ear, nose, and throat investigations and
medical tests. The patient remains com-
pletely well. I would be grateful for any
further suggestions on diagnosis.
R Walsh Senior ear, nose,and throat registrar
North Staffordshire Hospital, Royal Infirmary,
Stoke on Trent ST4 7LN
Journals and the internet
Medical journals will continue to be
important in prioritising important data
Editor
—
Over the past three years I have
tried to keep track of the developments on
the internet that relate to medicine.
Although a computer enthusiast, I still find
Fig 1 Patient in case (published with patient’s
permission)
Letters
1351BMJ VOLUME 314 3 MAY 1997
that few examples of organiser software can
match the convenience of a well structured
Filofax. The perceived divide between the
information superhighway and paper bio-
medical journals seems to be an artificial
one
—
just as few couples decide on “televi-
sion or radio” or “television or film” or “film
or book.”The media, which are seemingly in
great competition when a new medium is
launched, usually settle with time into a
redesigned corner of the market and there-
after develop alongside each other.
The internet is a marvellous phenom-
enon. There is no other way of conducting a
discussion forum among tens or hundreds or
thousands across the globe. There is no other
means of having such a vast amount of infor-
mation at one’s fingertips for retrieval. At the
same time, data gluttony is not the answer.
The information overload (and data in
printed form are much more responsible for
this than the internet is) can be handled only
if the important few data are prioritised,
sorted, and concentrated on. Medical journals
do a great job with this, as Richard Smith
says.1There is little doubt that they will
continue to do so
—
far beyond the time when
obituaries have been published about all of
that pre-computer generation, for whom a
chip was something you ate with fish.
M Palat Physician
Fachkrankenhaus Bernried, Clinic for Internal and
Psychosomatic Medicine, 82347 Bernried/
Starnberger See, Germany
1 LaPorte RE, Hibbitts B, Smith R,Hor ton R,Lundberg GD,
Davidoff F. Rights, wrongs, and journals in the age of
cyberspace. BMJ 1996;313:1609-12. (21-28 December.)
Use of the internet for on line peer
review must be explored further
Editor
—
Debate about the role of the inter-
net in medical publishing continues,1and
some form of democratisation of the peer
review process may soon arrive. The impact
of an internet based open review of articles
accepted for publication is already being
explored (http://www.library.usyd.edu.au/
MJA/mja), but on line peer review could go
further, abandoning both directed submis-
sion and selective review.
(1) Articles would not be submitted to
any particular journal but placed on the
internet in a review forum web site.
(2) Rather than there being reviewers
selected by editorial staff, any interested party
could comment and suggest modifications.
Relevant email comments would be posted
alongside any response from the authors.
(3) Authors could modify their work in
response to comment at any stage.
(4) Journal editors would be able to
offer publication at any stage.
(5) Authors could either accept the first
offer of publication or wait for subsequent
offers from their preferred journals.
(6) A time limit would be set (for
example, six weeks), at the end of which the
authors would have to accept an offer to
publish or withdraw the paper. Papers not
attracting any offers of publication would
sink at this stage
—
although useful data could
be archived for future systematic reviews.
Anyone could have early access to new
data in their field and the chance to offer
constructive criticism. Comments could be
either open or anonymous.2Papers might
attract a mixture of both, the onus being on
authors to confront or ignore criticism
regardless of its provenance. The maximum
duration of review would be six weeks, but
well developed papers might be published
much sooner, with journal editors essen-
tially competing to publish high impact
papers quickly.
For an open on line review forum to
work, one or more of the leading hard copy
journals would have to break ranks over the
notion that placing a paper on the internet
in this way constitutes prior publication,3
rendering the paper ineligible for further
consideration. Anxiety about this among
journal editors may revolve around the
possibility of a shift in the focus of their
readership towards the review forum and
away from the journal itself. In reality, a
healthy symbiosis should develop, with
readers using the review forum to sustain an
up to the minute, interactive view of their
narrow fields of interest but relying on
definitive publication in hard copy or
electronic journals for the broader context.
Bruce Allan Senior registrar
Nigel Morlet Research fellow
Richard Wormald Consultant ophthalmologist
Moorfields Eye Hospital, London EC1V 2PD
1 LaPorte RE, Hibbitts B, Smith R,Hor ton R,Lundberg GD,
Davidoff F. Rights, wrongs, and journals in the age of
cyberspace. BMJ 1996;313:1609-12. (21-28 December.)
2 Fabiato A. Anonymity of reviewers. Cardiovasc Res
1994;28:1134-9.
3 Kassirer JP, Angell M. The internet and the journal. N Engl
JMed1995;332:1709-10.
Copyright must be reconsidered
Editor
—
The points raised by Ronald R
LaPorte and Bernard Hibbitts about the
relation between the scientific community
and journal publishers are particularly valu-
able as the present, paper based copyright
laws are adapted to electronic documents.1
Technology has the potential to ensure a
better spread of medical information to
developing countries, but it could make dis-
tribution worse if copyright practices
become more restrictive.
Many important medical libraries in
sub-Saharan Africa have been unable to
subscribe to any journals for over 10 years.2
For these and many others in the developing
world, licensing or subscription arrange-
ments for electronic versions of journals
offer no improvement on the present
situation. For them the most cost effective
way of obtaining their information require-
ments is on an article by article basis; this is
improved by the speed with which electronic
documents can be delivered.
Current trends in the handling of
electronic copyright (especially in Britain)
are not reassuring in this respect. In Belgium
and Germany, documents requested by indi-
vidual people for their personal study and
research may be scanned by the holding
library and sent over the network or internet
to the requester. This is also possible in the
United States, with some limitations.In Brit-
ain most electronic copying is prohibited;
photocopied articles for developing coun-
tries have, therefore, to be sent by mail,
which is often very slow
—
two to three weeks
is not uncommon.
The increasing number of suppliers of
electronic documents now entering the
market automatically charge the copyright
fee demanded by the publisher unless
subscription or licensing arrangements are
in place. Such practices bypass the “fair
dealing” exemption to copyright, which
allows an individual person one copy of one
article from any one issue of a journal for his
or her personal study or research. Ignoring
this exemption makes research and study
more expensive
—
a very great disadvantage,
if not an absolute deterrent, to those in
developing countries.
It is difficult to escape the conclusion that
some publishers charge a copyright fee on
the basis of what the market in the developed
world will stand rather than added value.
Transfer of copyright to a publisher needs to
be matched contractually by the publisher’s
responsibilities and obligation to the scien-
tific community. Allowing large areas of the
world’s population to be unduly disadvan-
taged through the powers of copyright is one
of the issues that need to be addressed.
Jean G Shaw Research officer, SatelLife UK
The Old Rectory, Bath BA2 8NB
1 LaPorte RE, Hibbitts B, Smith R,Hor ton R,Lundberg GD,
Davidoff F. Rights, wrongs, and journals in the age of
cyberspace. BMJ 1996;313:1609-12. (21-28 December.)
2 Levey LA. Wired for information: using technology to meet the
needs of Rockefeller Foundation grantees. Washington, DC:
American Association for the Advancement of Science,
Sub-Saharan Africa Program, 1996.
Regulations on registration of
a fetus papyraceus need to be
revised
Editor
—
I read with interest the disparate
views about the registration of a fetus papy-
raceus expressed byPODPharoahandR
W I Cooke1and Malcolm Griffiths2in reply
to my previous letter.3I was unaware of the
association of fetus papyraceus with cerebral
palsy in surviving twins cited by Pharoah
and Cooke and am converted to their view
that cases of fetus papyraceus should be
notified and recorded centrally.
Such notification need not, however,
entail the registration of these fetuses as still-
births, with all that this entails, as the law cur-
rently insists. The requirement that Pharoah
and Cooke identify could be addressed by
retaining the present ruling that all births
after 24 weeks be notified to the Office for
National Statistics with relevant circumstan-
tial details but agreeing that, in accordance
with the World Health Organisation’s advice,
only fetuses weighing >500 g that are born
dead be classified as stillbirths for statistical
purposes. Such a measure would also
overcome the reluctance of clinicians such as
myself to notify a fetus papyraceus: in
Pharoah and Cooke’s study, clinicians failed
to do this in six of 18 cases.
Letters
1352 BMJ VOLUME 314 3 MAY 1997
Griffiths’s experience was similar to mine
and confirms the inconsistency with which
the present laws in this regard are upheld. I
too had given instructions that the birth be
regarded as a singleton, but in my case the
parents mentioned the second fetus to the
local registrar, who insisted on the death
being registered as a stillbirth. It surely
cannot be acceptable that the registration of
such cases be subject to the whim of such
officials or that obstetricians be placed
—
as
Griffiths advocates
—
in the invidious position
of countermanding legal requirements, how-
ever “technical” these may be considered.
What is clearly apparent from this corre-
spondence is that current regulations are
seriously flawed and in urgent need of
revision.
Robert F Heys Retired obstetrician and gynaecologist
River Lodge, 53 Bar Lane, Ripponden, Sowerby
Bridge, West Yorkshire
1 Pharoah POD,Cooke RWI. Registering a fetus papyraceus.
BMJ 1997;314:441-2. (8 February.)
2 Griffiths M. Registering a fetus papyraceus. BMJ
1997;314:442. (8 February.)
3 Heys RF. Selective abortion. BMJ 1996;313:1004. (19
October.)
Risk of lung cancer needs to
be studied in younger patients
who keep pet birds
Editor
—
The prevalence of pet birds and of
lung cancer differs between the Netherlands
and Sweden. Mortality from lung cancer is
much higher in the Netherlands than in
Sweden
—
even higher than that in the
United States. Compared with Sweden, the
Netherlands has a higher percentage of
people who breed birds and a higher
concentration of the international bird
trade. Breeding birds and keeping birds in
family homes result in higher amounts of
dust in the indoor air, poorer hygiene, and a
greater risk of having infected birds. More
young families than old families keep and
breed household birds, and breeding is
primarily a sport of adult men, not of elderly
people. Cecilia Modigh and colleagues
suggested12 that the positive results of the
earlier European studies3-5 could be due to
the confounding influence of the higher
prevalence of ownership of pet birds among
the lower socioeconomic classes, who have
higher rates of lung cancer. This does not
apply to our study in the Netherlands, which
adjusted for social class.4
There was an important difference in the
patients selected for analysis between our
study in the Netherlands and the studies in
Sweden and the United States. Modigh and
colleagues analysed patients of all ages and
have not published an analysis of patients
aged 65 and under. Our patients were aged
65 and under. During the 10 years of the
general practice survey3I observed that the
percentage of people who kept birds seemed
not to be increased among patients with lung
cancer aged over 65 in my own and in neigh-
bouring general practices. Elderly people
often have a medical contraindication to
keeping pets, having previously had lung dis-
ease. Moreover, we thought that the influ-
ence of variables other than smoking would
be easier to see in younger patients, who
have not had so much time to accumulate
the effects of smoking over large numbers of
pack years. Our study among new patients
with lung cancer in The Hague4was
therefore designed to analyse only patients
aged 65 and under. Among newly diagnosed
patients half are older than 65. To make our
results comparable I would therefore ask
Modigh and colleagues to analyse the
patients in their study aged 65 and under.
Because of the size of the Swedish and
Missouri studies it should also be possible to
analyse the patients aged 60 and under.
Peter Holst Doctor
Graaf Florisweg 48, 2805 AM Gouda,
The Netherlands
1 Modigh C, Axelsson G, Alavanja M, Andersson L,
Rylander R. Pet birds and risk of lung cancer in Sweden: a
case-control study. BMJ 1996;313:1236-8. (16 November.)
2 Alavanja M, Brownson R, Berger E, Lubin J, Modigh C.
Avian exposure and risk of lung cancer in women in Mis-
souri: population based case control study. BMJ
1996;313:1233-5. (16 November.)
3 Holst P. Bronchial carcinoma in bird keepers: an investiga-
tion in a general medical practice on a possible common
relation. Ned Tijdschr Geneeskd 1984;128:899-902.
4 Holst P, Kromhout D, Brand R. Pet birds as an
independent risk factor for lung cancer. BMJ
1988;297:1319-21.
5 Kohlmeier L, Arminger A, Bartolomeycik S, Bellach B,
Rehm J, Thamm M. Petbirds as an independent r isk factor
for lung cancer: case-control study.BMJ 1992;305:986-9.
CS gas is not a chemical means
of restraining a person
Editor
—
Peter Trigwell’s report about police
officers’ use of CS gas in an attempt to
restrain a mentally ill person concerns me.1
This action was obviously premeditated
because Trigwell was instructed to be
prepared to move out of the way “so that we
can spray him with the CS gas.” CS gas is not
a restraining agent but a harassing one, pro-
ducing a severe irritation on exposed body
surfaces
—
in particular, the external eye, skin,
and the mucous membranes of the respira-
tory tract. People so exposed become highly
motivated to escape from the environment
contaminated with the agent. CS gas
produces disabling symptoms at atmos-
pheric concentrations as low as 0.73 ìmol/l,2
yeta5%solutionofCSgaswassprayed
directly into the patient’s face. It is my
understanding that the action described is
contrary to the Association of Chief Police
Officers’ guidelines on the use of CS sprays
and that the safety of these sprays was
inferred from the reports of the Himsworth
committee after the use of CS gas to control
rioting in Ulster in 1969.34This obviously is
a different scenario from that reported by
Trigwell,with a population being exposed to
low doses of CS gas in open spaces rather
than high concentrations of a chemical war-
fare agent being sprayed directly into a per-
son’s face. The patient reported on by
Trigwell had probably already received
some pharmacological sedatives, which
would impair his natural defence mecha-
nisms, such as blinking and coughing; thus
he would have been more likely to sustain
sequelae of the lacrimatory agent, which
may be as severe as a fatal respiratory arrest.5
The use of CS gas in the circumstances
described should be deplored. The gas is not
a chemical means of restraining or subduing
a person but an effective and safe agent for
controlling riots.
Peter J Gray Ophthalmologist
8 Broomfield Road, Surbiton KT5 9AZ
1 Trigwell P. CS gas has been used as chemical restraint in
mentally ill person. BMJ 1997;314:444. (8 February.)
2 Ballantyne B, Swanston DW. The irritant potential of dilute
solutions of ortho-chlorobenzylidene malononitrile (CS)
on the eye and tongue. Acta Pharmacol Toxicol
1973;32:266-77.
3 Himsworth H. Report of the enquiry into the medical and toxi-
cological aspects of CS (orthochlorobenzylidene malononitrile).
Par t 1. London: HMSO, 1969. (Cmnd 4173.)
4 Himsworth H. Report of the enquiry into the medical and toxi-
cological aspects of CS (orthochlorobenzylidene malononitrile).
Part 2. Enquiry into toxicological aspects of CS and its use for
civil purposes. London: HMSO, 1971. (Cmnd 4775.)
5 Chapman AJ, White C. Death resulting from lacrimatory
agents. J Forensic Sci 1978;23:527-30.
Talk works—if the patient is
willing
Editor
—
That cognitive behaviour therapy
works well in certain psychiatric disorders
and that there is evidence from good quality
research to support this is an important fact
forcibly made in Gavin Andrews’s editorial.1
However, to state that “the effective [cogni-
tive behavioural techniques] are as good as
drugs” is oversimplistic. Cognitive behaviour
therapy (as all psychotherapies) cannot be
“prescribed” but depends on the patient
being both willing and able to engage
actively in the therapeutic process, usually
over a period of several weeks.For a number
of reasons this is often simply not practica-
ble. In a recent study investigating the use of
cognitive therapy in acute psychosis, for
example, only 40 of 69 patients satisfying the
inclusion criteria out of a sample of 117
inpatients with acute non-affective psychosis
could be randomised to the treatment
groups.2It should also be noted that
cognitive therapy in this study was used as
an adjunct to pharmacotherapy in acute
psychosis, not as an alternative. Similar limi-
tations affect the use of cognitive behav-
ioural approaches in other psychiatric
illnesses,34 and this needs to be explicitly
stated in any discussion of the use and
efficacy of this therapy. Failure to do so gives
a distorted impression of an easy and
universal applicability of these techniques
that is at odds with the clinical realities
which not infrequently limit their use.
Andrew F Blakey Consultant psychiatrist
Macclesfield District General Hospital, Macclesfield
SK10 3BL
1 Andrews G. Talk that works: the rise of cognitive behaviour
therapy. BMJ 1996;313:1501-2. (14 December.)
2 Drury V, Birchwood M, Cochrane R, MacMillan F.
Cognitive therapy and recovery from acute psychosis: a
controlled trial. I. Impact on psychotic symptoms.BrJPsy-
chiatry 1996;169:593-601.
3 Salkovskis PM, Westbrook D. Behaviour therapy and
obsessional ruminations: can failure be turned into
success? Behav Res Ther 1989;27:149-60.
4 Rush AJ, Shaw BF. Failures in treating depression by
cognitive behavioural therapy. In: Foa EB, Emmelkamp
PMG, eds. Failures in behaviour therapy. New York: Wiley,
1983:217-28.
Letters
1353BMJ VOLUME 314 3 MAY 1997
