Aug 16, 1986 - BRITISH MEDICAL JOURNAL VOLUME 293 ... Royal Postgraduate Medical School, .... subscription to the Medical Defence Union of £168 a.
454
BRITISH MEDICAL JOURNAL
VOLUME 293
16 AUGUST 1986
bibliography that may become a white elephant logical factors involved has to be "confrontational" or and are to be preferred to an indwelling catheter, that the idea is incongruent with the treatment which is fraught with problems, particularly in through the vagaries of the computer industry. described. Inclusion of this possibility in the relation- women. ship with the patient has the merit of honesty and may DAVID L MAXWELL open way to discussion of emotional or practical FRANCIS M CUSS issues the with some benefit to the patient and family, Department of Medicine, Royal Postgraduate Medical School, Hammersmith Hospital, London W12 OHS I Alagesan K, McLeod GF. A system for storage of references. A method of storage and retrieval of references on a personal microcomputer. Anaesthesia 1985;40:1123-6.
Points Effect of fish oil on systolic blood pressure Drs S ROGERS and K S JAMES (MRC Epidemiology Unit, Cardiff CF2 3AS) write: Dr P G Norris and colleagues (12 July, p 104) reported a beneficial effect of fish oils on the systolic blood pressure of patients with mild hypertension. We have also found a blood pressure lowering effect in a group of normal volunteers taking 10 g of Maxepa per day compared with controls taking olive oil. However, we do not believe that 16 g or even 10 g of Maxepa per day is a practical maintenance dose for long term treatment of mild hypertension. Some of us tried 16 capsules of Maxepa a day for two weeks before embarking on our study and found this a most inconvenient obsession. Ultimately we took the decision to ask our volunteers to take a "loading dose" of 16 capsules a day for one week followed by nine capsules a day for the remainder of the trial. But still, like the Chelmsford trial, this was an experiment in biology not in pragmatism. Maxepa is an unlikely answer to the problems of treating mild hypertension if it has to be given in such large quantities.
The practice nurse: is history repeating itself? Dr GRAHAM CALVERT and Ms JEAN CALVERT (Maidstone ME16 8SR) write: We fully support the contention of the Boldens (5 July, p 19) that general practitioners have an important part to play in supporting their treatment room nurses as they attempt to define a role and establish a proper professional structure. A course for practice nurses structured on the lines described for the 1984 course in Exeter was recently completed in mid-Kent. We are pleased to report that the Kent Family Practitioner Committee has agreed to reimburse 70% of the course fees for our own practice nurse. This should be an encouragement to the Boldens and others and makes the long term outlook appear less bleak.
Successful rehabilitation in conversion paralysis Dr D M BOWKER (Rochdale Health Authority, Birch Hill Hospital, Rochdale OL12 9QB) writes: Dr M A Delargy and others (28 June, p 1730) suggest that rehabilitation in conversion paralysis can be achieved "without psychiatric intervention" and describe a rigorous and optimistic programme of physiotherapy with a number of other psychological ploys which enable the patient to regain function with minimum loss of dignity. Limitations of space perhaps excluded more detail in the case histories and there is no mention of whether referral to psychiatrists had been made on behalf of these unfortunate patients, who had lingered, apparently unnecessarily, for a mean of 3 3 years in a disabled condition in other (?) medical hands. Many psychiatrists (and neurologists) would suggest such a programme of rehabilitation in the first instance without favouring admission to a psychiatric unit. The problem then would be the ability and willingness of the other medical team concerned to arrange and support a potentially long inpatient programme-perhaps when there are pressures from inadequacies in staffing or bed numbers. I do not believe that the implication that there may be psycho-
whether or not these may be theoretically important in Efficacy of a new nystatin formulation in oral candidiasis the aetiology of the loss of function.
Professor CRISPIAN SCULLY and Mr C M WOODHEAD (Bristol Dental Hospital and School, Bristol BS I 2LY) write: Dr P J Thompson and others (28 June, p 1699) refer to the established association between dentures and infection. However, we are not aware of any Professor J A DAVIS (Department of Paediatrics, evidence for the authors' suggestion that "Dentures ... Addenbrooke's Hospital, Cambridge CB2 2QQ) diminish salivary flow" and do not agree that the writes: Those concerned with the medical assessment reference quoted provides any evidence for that of suspected cases of inflicted injury in children will be statement. Indeed, clinical experience suggests that grateful for the information marshalled by Mr Peter dentures might, if anything, increase salivary flow. Worlock and others (12 July, p 100), albeit that they do not make clear whether the attribution of cause was made or confirmed independently of the pattern of fracture. It would now be helpful if someone with Informed consent considerable experience in the management of osteogenesis imperfecta of the Lobstein type would make it Dr R McGLONE (Accident and Emergency Departgenerally known what types and distribution of ment, Hull Royal Infirmary, Hull HU3 2JZ) writes: fracture occur in this disease in infants, toddlers, and Despite all the guidance about informed consent, children over 5, since it is becoming almost a rule for patients do not always receive this courtesy. During the possibility of brittle bone disease to be raised by a my wife's last pregnancy my wife and I decided not to defence counsel with the support of so called expert have an a-fetoprotein estimation because of our objecwitnesses when cases of suspected child abuse come to tions to abortion. This decision was recorded by our court; and in the present state of knowledge this general practitioner on the antenatal card, but my wife suggested explanation of unexplained injury cannot be was subsequently asked about the test by the comdefinitely excluded, leading to the danger that an munity midwife twice, the registrar, and a staff nurse. abused child may be returned to the care of dangerous Finally, a nursing sister told my wife to have a blood parents. test at the 16 week check up, and only when my wife guessed what it was for did the sister admit that it was an a-fetoprotein estimation. When she refused she was taken aside for a "chat." Doctors and nurses should Events surrounding organ transplantation remember that venepuncture done without consent is an assault. Dr ROGER GABRIEL (Renal Unit, St Mary's Hospital, London, W2 lNY) writes: Dr J D Hill is to be congratulated on his detailed chronology of events resulting in four organs for transplantation from a Prevention of cardiovascular disease in young woman who died of a subarachnoid haemor- general practice rhage (26 July, p 264). The necessity for donor organs is considerable. Nevertheless, it is an unhappy reflec- Drs J J K ROBERTS and J H SMITH (West Granton tion on British medicine that what should be a routine, Group, Edinburgh EH4 4PL) write: As one albeit infrequent, event is subject matter for a Medical the participating centres in the lifestyle managePersonal View. Perhaps Dr Hill's piece will help to of programme (19 July, p 177) and having been rectify the persistent and increasing deficiency of ment concerned in several large screening exercises, we donor organs. think that the success of any screening programme depends on the personality and competence of the screening sister or nurse employed. It seems inAiring operating theatres appropriate to attribute the success of this programme solely to microtechnology in the forms of Dr ROBERT CUTLER (Surbiton, Surrey KT6 6PR) computers and dry biochemical techniques. It is writes: The difficulty experienced by Dr Charles surprising that not even an acknowledgment was Wakeley (19 July, p 209) is understandable and well given to the nurses, who in our experience in this recognised by dentists since air turbine drilling motors project have worked incredibly hard and are directly were introduced many years ago; dentists usually wear responsible for any success and subsequent future the protective goggles or wide cover spectacles and a lifestyle management programme may have. mouth mask. The trouble is that unless the exhaust air is given unrestricted passage back pressure builds up and the motor torque seriously diminishes, so that any exhaust conduit to some convenient location has to be A local difficulty with pregnancy tests of large bore and inconvenient to accommodate. It is assumed that microbically clean air and water filters Dr S J P ADCOCK (Southampton S02 3AY) writes: Is it are fitted to the compressor, as the effluent from an not ironic that Dr D R Boswell, senior lecturer in industrial compressor, although filtered for, say, chemical pathology at Southampton, should say (26 July, p 262) that the most reliable results in urine cellulose spraying, is otherwise far from perfect. pregnancy tests will be obtained when urine specimens are sent to a chemical pathology laboratory for analysis, when this service has recently been withBladder dysfunction in progressive drawn from general practitioners in this area owing to autonomic failure financial cutbacks?
Patterns of fractures in accidental and non-accidental injury in children
Mr C A C CHARLTON (Department of Urology, Royal United Hospital, Bath BAI 3NG) writes: Mr R S Kirby and Sir Roger Bannister omitted to mention that there exist additional measures by which these bladders may be helped to empty, other than with cholinergic drugs, bladder neck surgery, or urinary incontinence devices. I have managed a 56 year old woman with the Shy-Drager syndrome (as we labelled it here) who had chronic retention with overflow incontinence by teaching her suprapubic manual expression and intermittent self catheterisation (before retiring to bed). These measures proved adequate
High costs of medical insurance Dr ANN BOLITHO-JONES (Watford WDI 4PS) writes: Since my original letter was published (5 July, p 52) I have learnt that I qualify (just) for the reduced rate subscription to the Medical Defence Union of £168 a year. I was also pleased to discover that doctors on maternity leave are also entitled to three months' free membership. It would be helpful if these reductions were more widely publicised.
