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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
the guideline didn't fail
- Bob Bury (7 December 2001)
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The guidelines are correct.
- Ian Runcie (9 December 2001)
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Re: The guidelines are correct.
- David Syme (10 December 2001)
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When clinical diagnosis fails
- Robert Kerslake (11 December 2001)
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A satirical allegory on ' When Guidlines Fail'
- Tom Vandor (17 December 2001)
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Bob Bury, Consultant radiologist Leeds General Infirmary LS1 3EX
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The guideline in question was correct - radiography to detect calcaneal spurs is a waste of everyone's time. If the putative diagnosis is plantar fasciitis, then soft tissue ultrasound is more useful, assuming imaging is required at all. Of course, if things had happened differently, and the unfortunate patient had been known to have metastatic disease and had then presented with disabling pain in the calcaneus, no radiologist would have refused an x-ray to determine whether there was a bone lesion to account for it. No matter how useful and evidence-based a guideline is, there will always be the occasional case where it appears to fall down. However, it is clearly excessively unusual for a patient to present with metastatic disease in the calcaneus, and for this to be the only symptomatic lesion must be vanishingly rare. So to discard the guideline on the basis of one such case would be to fly in the face of reason. As has been said in a different context 'hard cases make bad law'. |
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Ian Runcie, consultant radiologist RH16 2JS
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The guidelines were produced utilising firm clinical evidence and did not fail with this patient. Dr Godfrey states in his article that plantar fasciitis is self limiting. This was not the case with his patient and it would have been reasonable to review the diagnosis when she requested a home visit some two weeks later with the same symptoms. X Rays in 78 year olds with unexplained bone pain are allowed under the guidelines. |
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David Syme, GP Killin
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I think we will now be able to X-ray all our plantar fasciitis patients. Two weeks seems tad short for "self-limiting" in the context of plantar fasciitis. I'm sure the guidelines could be bettrer defended than by this sophistry! |
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Robert Kerslake, Consultant Radiologist QMC Nottingham NG7 2UH
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Dr Godfrey’s problem lies not with the guidelines but with the fact that he had not considered and, by his own admission, was not aware of the possibility of calcaneal metastases. To quote from another filler in this issue of BMJ (2001;323:1339) ‘although common things are common, rarities do occur’. The RCR guidelines recommend radiographs in patients with bone pain, which is presumably what his patient was suffering from. Unjustified radiological examinations should not be performed. |
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Tom Vandor, McGill Family Medicine Ormstown Quebec, Canada J0S-1K0
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Your story about 'When Guidlines Fail' prompted me to retrieve something I wrote, exposing in an allegorical way, how ridiculous these things can become. We are bombarded by articles about evidence based medicine, guidlines, and studies with interesting acronyms . If the rest of the world conducted their lives as we do in medicine, we would find ourselves in some very ridiculous situations. The following ' news release' illustrates my point. Recent incidents of injuries on stairs prompted the Task force on Life Challenges, affectionately known as the TLC Gang, to commission a study on the safety of stairs versus elevator lifts. The study group, named SILI ( Stair Injury vs Lift Injury) examined 12,345 individuals, ranging in age from 5 to 95, matched for age and sex, in a double blind crossover study over a period of 5 years. Their findings were consistent with others done in Asia, Africa, and Europe, confirming it¹s cross cultural, ethnic, and geographic relevance. The Task force¹s recommendation is thus, based on a broad consensus of evidence. Altogether there were 4.8 injuries per 1000 person/years in the Stairs group versus 2.8 injuries per 1000 person/years in the Lift group. Fig 1 illustrates their findings in terms of relative risk. As is evident, there appears to be a J curve distribution of injuries, depending on the age of the subjects. The steep rise in risk, as aging takes place, is of concern. Fig 1
The SILI study also discovered that most injuries occurred on descent rather than ascent (RR 1.5) and that falls occurred more often when two or more flights of stairs were attempted. (RR1.9 ). Of interest, educational level was inversely correlated with the risk of falling. After due study of these findings, the TLC Gang, a group of 13 highly recognized members in their respective specialties, released their recommendations. Despite their best efforts to find a compromise, two members of the committee refused to sign the final draft. They were members of the group SOIL, (Society Of Inflamed Lodgers) who represent tenants concerned about fire safety in apartment dwellings. They are known to be a powerful lobby group that is able to make quite a stink about these matters. The following are the guidelines set out by the TLC. Their recommedations are based on this and other evidence based studies. 1) All buildings more than one story must have a lift(s) by the year 2005 2) All buildings less than three floors should ban stairs. The temptation to use stairs as a means of reaching the exit is too high a risk . 3) All doors to stairwells must have clear warnings about the danger of descending stairs. The description must include a pictorial illustration to ensure those who are literary challenged are able to comprehend. 4) Governments should be encouraged to invest into research to develop both a fireproof elevator and one which is not dependent on power. The public health of our nation demands that this challenge be met. The committee is confident that with proper investment by the authorities success will be achieved. Tom Vandor md
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