Feb 26, 1983 - MALCOLM A LEWIS. Northern ... Letters to a young doctor. SIR,-As a doctor ... influence on young doctors to encourage them to practise high ...
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looked at over three months there is no significant difference between regional and general anaesthesia. Let us be strong advocates of regional anaesthesia if we so wish, if only for the immediate benefits; but let us not promote benefits which may not last, for that will not promote our cause. D P CARTWRIGHT Derbyshire Royal Infirmary, Derby DE1 2QY
Can infection be abolished?
BRITISH MEDICAL JOURNAL
Haemophilus influenzae type b resistant to chloramphenicol and ampicillin SIR,-In 1982 we reported that a patient in Liverpool had become infected with a strain of Haemophilus influenzae type b which was resistant to both ampicillin and chloramphenicol.' Turk subsequently pointed out that the slide agglutination of growth from a chocolate agar plate was not a reliable means of serotyping this organism.2 We therefore had our results reviewed by another laboratory. The organism was confirmed as H influenzae by its Gram stain appearance and nutritional requirements (X and V factors). Resistance to both ampicillin and chloramphenicol was confirmed. The organism was a l lactamase producer and it also inactivated chloramphenicol. No capsule was seen on Levinthal's -agar, however, and no capsule was seen on phase contrast microscopy. No precipitant bands were obtained on counter immunoelectrophoresis against H influenzae capsular (A-F) antisera. This highly resistant organism was therefore a non-capsulated strain of H influenzae. We have in addition sent a specimen of this organism to Dr Turk in Sheffield and he too has confirmed that the organism is a noncapsulated strain. The significance of our original report must therefore be re-evaluated as life threatening H influenzae infection in childhood is nearly always due to a type b capsulated strain. Chloramphenicol therefore still remains a drug of choice for treatment of severe haemophilus infections in this country.
SIR,-Dr J A N Emslie and others (29 January, p 394) in their comments on the leading article by Sir James Howie emphasised the importance of an integrated approach to the problems of infection and noted that collaboration may be impeded by man made administrative barriers. There are clearly many advantages in having a national organisation for the investigation of infection and this exists in England and Wales as the Public Health Laboratory Service. It came into being as a wartime measure in 1939 as the Emergency Public Health Laboratory Service, but it proved to be of such value to medical officers of health, general practitioners, and others concerned with control of infection in the community that it was retained after the war. Thus at the inception of the National Health Service in 1948 there was already in existence, as the Public Health Laboratory Service (no longer "emergency"), a national network of laboratories for the investigation of J A SILLS infectious diseases. P MACMAHON Many of the original laboratories of the E HALL Emergency Public Health Laboratory Service T FITZGERALD were established in hospitals, and today 50 of the 52 first line laboratories of the service are Alder Hey Children's Hospital, responsible for microbiological investigations Liverpool L12 2AP not only for the local community but also for 'MacMahon P, Sills J, Hall E, Fitzgerald T. Haemothe hospital in which they are located. Direcphilus influenza type b resistant to both chloramphenicol and ampicillin in Britain. Br Med J tors of laboratories of the Public Health 1982 ;284 :1229. Laboratory Service are consultant medical 2 Turk DC. Haemophilus influenza type b resistant to both chloramphenicol and ampicillin in Britain. microbiologists in day to day contact with Br MedJ 1982;284:1634. clinical consultants, particularly those in infectious diseases, general practitioners, community physicians, environmental health Missed jaundice in black infants officers, and when appropriate the veterinary investigation service. SIR,-Dr W 0 Tarnow-Mordi and Dr D The Public Health Laboratory Service Pickering (5 February, p 463) asked whether includes the Central Public Health Laboratory missed jaundice in coloured infants was a and the Communicable Disease Surveillance common hazard. I think that it is not rare and Centre at Colindale and the Centre for would like to quote two recent cases in support Applied Microbiology and Research at of this statement. Porton Down, which provide ready access to Case 1-An Asian girl was born by vaginal reference services for the investigation of at 36 weeks' gestation weighing 2200 g. special problems, to sources of information delivery Initial examination was normal. At 26 hours of age (to which both service and hospital laboratories the baby was noted to have a purulent discharge contribute) about infection, including both from the left eye; eye swabs were sent for analysis epidemic outbreaks and long term trends, and and treatment begun. On review at 36 hours of age to workers engaged in research on problems the baby was noted to be slightly jaundiced. Serum and new methods in the diagnosis and control bilirubin concentration measured the next morning of infection. To provide facilities of this kind was 532 t4mol/l (31-1 mg/100 ml), all unconjugated. this hyperbilirubinaemia was not a national organisation is clearly appropriate The cause of The mother was blood group A rhesus established. for compelling financial and administrative positive and the baby was group AB rhesus reasons. positive. ABO incompatibility was suggested but Dr Emslie and others are right to emphasise never proved. Three exchange transfusions were the need to pool the skills of those engaged in required. At follow up at the age of 18 months the investigation, management, and control of development was within normal limits except for infection. The Public Health Laboratory speech delay secondary to profound deafness. Full Service exists to further the attainment of this audiological assessment is in progress. Case 2-A boy weighing 2970 g was born to commendable objective. Ugandan Asian parents at 36 weeks' gestation. The G C TURNER baby caused no concern until day four, when he was Public Health Laboratory Service Regional Laboratory, Fazakerley Hospital, Liverpool L9 7AL
thought to be jaundiced. His serum bilirubin concentration was 500 4mol/l (29-2 mg/100 ml), all unconjugated. Exchange transfusion was
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carried out. Subsequently the baby was shown to have glucose-6-phosphate dehydrogenase deficiency. This baby is now four weeks of age and appears normal so far.
Dr Tarnow-Mordi and Dr Pickering mentioned several available screening tests for jaundice; all have their drawbacks. In view of the severity of the handicap caused by hyperbilirubinaemia and the cost to the community of providing for these children, would it not be worthwhile performing a laboratory serum bilirubin estimation on a capillary blood sample from all coloured infants between 36 and 60 hours of age ? MALCOLM A LEWIS Northern General Hospital, Sheffield S5 7AU
Sabbaticals in general practice SIR,-As someone currently on prolonged study leave from general practice I read Dr Simon Jenkins's article on his experiences in Israel (11 December, p 1707) with interest. I thought, however, that to any general practitioner contemplating a sabbatical his comments on receiving a locum allowance if in group practice were unduly pessimistic. Provided the locum is from outside the practice, and subject to a few other conditions comprehensively covered in the statement of fees and allowances, the locum allowance should be forthcoming. (The condition applying to engaging a locum when a partner is sick-that the remaining partners would have to have more than 3000 patients each-does not apply to prolonged study leave.) I am one of two general practitioners from the UK, both from group practices, studying in Canada for 12 months, and both of us are receiving full locum allowances in addition to the educational allowance. For those general practitioners contemplating a sabbatical and worrying about financial suicide I hope this letter will be a source of some optimism. GORDON McNEISH Department of Family Medicine, University of Western Ontario, London, Canada
Letters to a young doctor
SIR,-As a doctor working abroad who plans to return to hospital medicine in England I was interested in Professor Philip Rhodes's article on becoming a consultant (11 December, p 1723). Having declared my interest I want to comment on his advice to those who wish to become consultants that they should obtain a higher diploma first and not go abroad for more than two years. I appreciate that this may be good advice for those wishing to regain their place on the career ladder when they return, but I think it is not the most useful type of service for a developing country. A doctor who has already gone some way along his career path usually wants to work in a university hospital, to pursue his research, and to produce publications. Such doctors, unless they have a research interest of special importance to developing countries, are not in short supply. University hospitals in developing countries are littered with broken
equipment-for example, radioimmunoassay kits and endoscopes-brought out by enthusiastic research registrars who used them for a
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year or two and then went home. They make little or no contribution to the health of the country and in fact do harm by suggesting to the indigenous junior doctors that such gadgets are important for the practice of good medicine. They are part of the hidden curriculum described by Dr David Morley, which exerts such a powerful and harmful influence on young doctors to encourage them to practise high technology medicine inappropriate to their nation's needs. The true beneficiary of such service abroad is the doctor himself, who usually manages to publish a paper or two about his African patients. Developing countries need doctors prepared to go to areas where there is a shortage of doctors to practise relatively simple medicine. Two years is probably the minimum period that is really useful. It takes at least that long to shake off the high technology attitudes ingrained by a traditional medical
training. Perhaps appointment committees should give some consideration to the usefulness of a candidate's work abroad. After all a doctor who provided care appropriate to the real needs of people in developing countries might also be the one who will provide the most appropriate health care in Britain. J G THORNTON
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screening for autonomic dysfunction in a busy Ensure, Ensure Powder, Ensure Plus, Flexical, diabetic clinic. Forceval Protein, Isocal, Triosorbon, and SHIRLEY A SMITH Vikonex should be available on prescription STEPHEN E SMITH for treating patients with anorexia nervosa. Department of Pharmacology, Caloreen and Hycal are not included. St Thomas' Hospital Medical School, I hope that this will serve as a stimulus to London SE1 7EH the pharmaceutical industry to produce cheap, ' Smith SE, Smith SA. Heart rate variability in healthy subjects measured with a bedside computer based palatable, high calorie, low volume foodstuffs, technique. Clin Sci 1981 ;61:379-83. available on prescription for treating patients with anorexia nervosa as outpatients. Further work on this neglected area is underway in Ventilation in operating rooms our department. MICHAEL A LAUNER SIR,-The letter from Dr J K Wardle and of Psychological Medicine, others (12 February, p 557) detailing their Department Burnley General Hospital, use of prophylactic antibodies in neurosurgery Burnley, cannot be allowed to pass without comment. Lancs BB10 2PQ Surely it is now accepted that prophylactic Launer MA. Anorexic therapy is hit and miss. antibodies must be in the tissues before Doctor 1982, 23 Sept. Marshall M. Anorexia nervosa: dietary treatment and organisms are innoculated into the wound.' re-establishment of body weight in 20 cases studied It is at best inefficient and may well be useless on a metabolic unit. J Hum Nutr 1978;32:349-57. Kean FDV, Fennel JS, Tompkin GH. Acute pancreato start prophylactic treatment, as they have titis, acute gastric dilation, duodenal ileus following done, when the patient returns to the ward receeding in anorexia nervosa. Ir 7 Med Sc 1978; 147:191-2. after surgery. Similarly, there is no good 4 Pertschuck MJ, Forster J, Busby G, Muller JL. evidence to show that continuing the antiThe treatment of anorexia nervosa with total nutrition. Biol Psychiat 1981;16:539-50. parenteral biotics after surgery is of any benefit.2 3 ' Browning CH. Anorexia nervosa. Complications of Prophylactic antibiotics clearly have a place in somatic therapy. Compr Psychiatry 1977 ;18 :399all branches of surgery, but it is important ' 403. MA. Problem Launer awaiting solution. Br Med 7 that they are used correctly. 1982 ;285 :367. R S CROTON Royal Livcrpool Hospital, Liverpool L7 8XP
Chogoria Hospital, C hogoria, Keivya
Burke J F. rhe effective period of preventive antibiotic action in experimental incision and dermal lesions. 2
'
Reduced sinus arrhythmia in diabetic autonomic neuropathy SIR,-Dr W Wieling and Dr C Borst (5 February, p 476) have drawn attention to an interesting aspect of testing for autonomic neuropathy in diabetes using measurement of heart rate variations on deep breathing. We described a single breath test in which the shortest R-R interval during inspiration (I) and the longest during expiration (E) are measured to obtain the EB: ratio (4 December, p 1599). This ratio declines with age and is independent of resting heart rates below 100 beats/minute. Dr Wieling and Dr Borst recommend taking the E-I difference averaged from six consecutive respiratory cycles. We have shown, however, that this measure depends on both age and baseline heart rate and so must be used with a normal range that accounts for both of these variables.' We have compared the repeatability of both the EJ: and the E-I from single and repeated breath tests in 20 healthy subjects (mean age 40 years, range 20-87 years) measured at two separate visits, 3-8 months apart (see table). Repeatability of different methods of analysing sinus arrhythmia Single breath (first of five cycles) Average of five consecutive cycles
E-I
E:I
28-6",, 21 9",
89",,
6-3",,
Values are the coefficients of variation of the within
subject variance.
There is a clear advantage in taking the ratio since it is independent of differences in resting heart rate occurring between tests. The repeatability of the averaged values was slightly better than the single breath. We do not consider, however, that this small improvement is great enough to justify the more cumbersome repeated breath test when
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Swurgery 1961 ;50:161-8. Strachan CJL, Black J, Powis SJA, et al. Prophylactic use of cephazolin against wound sepsis after cholecvstectomv. Br Medy 1977 ;i :1254-6. Stone HH, Hanev BB, Kolb LD, Geheber CE, Hooper CA. Prophylactic and preventive antibiotic therapy. Ann Stirg 1979;189:691-9.
High calorie supplements for patients with anorexia nervosa SIR,-Until recently there has been a rather prominent loophole in the options available for the treatment of anorexia nervosa. To admit a patient with anorexia nervosa to hospital is a major step, and the resultant difficulties between doctor, patient, nurses, and relatives can be extremely disruptive. Despite repeated family tuition about high calorie foodstuffs the end result of outpatient treatment is often just as disastrous.' Refeeding often requires admission to hospital with feeding regimens supervised by a dietitian,2 and vigorous refeeding has resulted in acute pancreatitis, acute gastric dilatation and duodenal ileus,3 hypophosphataemia,4 gastric rupture, and gangrene of the stomach.5 I have found that high calorie supplements are a painless and easily monitored way of dealing with the outpatient care of this illness. If, in addition to being readily available, the supplement were palatable and acceptable to a patient with anorexia nervosa it would provide a handy form of management at surprisingly low cost. Unfortunately, these supplements are borderline substances and they have not been available on prescription except for certain defined conditions. The non-availability may be used by patients to reinforce their resistance to taking any food which may put weight on at a more rapid rate than they would like.6 As a result of a letter published in theBM_Ji I was approached by the Department of Health and Social Security, and, after submitting evidence, I received a letter informing me that the DHSS had agreed that Clinifeed,
Responsible use of resources: day surgery SIR,-I warmly welcome the proposals and views expressed by Dr J M B Burn (5 February, p 492) concerning the value of day surgery and would like to add my own experience of treating patients referred to a plastic and reconstructive surgical department in a district hospital. Three years ago a 14 bedded ward vacated by enforced bed closures in this hospital was converted into a day surgery unit. In 1981 I treated 571 patients in the main theatre and 566 in the new day surgery unit. For 1982 numbers were 541 and 541 respectively. In other words Dr Burn's suggestion that half of most surgery could be managed on a day basis applies to the specialty of plastic surgery. The range of procedures include: excision of benign and certain malignant skin tumours with direct closure, local flaps, or skin grafts; scar revisions and dermabrasions; excision of tattoos; surgery of axillary hyperhidrosis; limited palmar-digital fasciectomy; synovectomy of hand joints; peripheral nerve decompressions; nail bed resection and digital amputations; tenolysis and release of trigger finger; correction of prominent ears; penile meatoplasty; minor rhinoplasty; capsulotomy after breast reconstruction; and nipple and areolar reconstruction after mastectomy. Apart from the obvious advantages to the patient, the surgical waiting lists, and the district economy, day surgery provides good training ground for student nurses or maturer nurses returning to hospital work. In one department they have an opportunity to follow the patient from admission, into the theatre, the recovery area, discharge, and to subsequent change of dressings or suture removal. Furthermore, the team spirit generated in a small autonomous unit leads to a happy unit-working in day surgery can be fun. The practice of day surgery, however, implies a change of surgical tradition and habit. Although this system has been widely
