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All rapid responses

Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on thebmj.com. Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

Re: Netlines . 316:doi 10.1136/bmj.316.7140.1294

The Washington Post reported on 23 April 1998 that a recent US court case has distinguished internet services from other types of publishers: they cannot be sued in civil courts for content provided to them by others.

"In recognition of the speed with which information may be disseminated and the near impossibility of regulating information content, Congress decided not to treat providers of interactive computer services like other information providers such as newspapers, magazines or television and radio stations, all of which may be held liable for publishing or distributing obscene or defamatory material written or prepared by others," the ruling says.

This ruling would, at least for the US, seem to place internet content providers in the class of "common carrier" (like the telephone system as I understand it) rather than editorial voice. In the specific case, a libel suit was brought by a Clinton advisor against a journalist and AOL (which carried the journalist's online column).

Competing interests: No competing interests

20 May 1998
John Sack
Director, HighWire Press
Stanford University
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Re: Too drunk to care?Ethanol, emergencies, and ethical dilemmasCommentary: Guidelines could never be developedCommentary: Balance the risk as best you canCommentary: Doctors can never have a moral holiday Inez de Beaufort, et al. 316:doi 10.1136/bmj.316.7143.1515
Dr. Cressey was faced with the decision whether to act as a good Samaritan to give medical treatment to a fellow spectator whilst under the influence of a recent alcoholic drink. (1) Legal considerations may further compound the dilemma if he were not a member of a medical defence organisation.

The Crown Indemnity scheme was introduced in 1990 under which Trusts take direct responsibility for costs and damages arising from medical negligence actions in the course of the doctors’ NHS employment (2). Although it is strongly advisable to join a medical defence organisation, doctors are not obliged to do so under their contracts of employment. However, “good Samaritan” acts are not part of the doctors’ work for the employing authority, and are explicitly excluded from the Crown Indemnity scheme. (2)

If Dr. Cressey were not a member of a medical defence organisation, he might be made bankrupt in the unlikely event of being sued for negligence. It has been held that inexperience (3) or personal idiosyncrasies (such as being unwell or having consumed alcohol) (4) are irrelevant to the issue of the required standard of care. Whether the emergency or the good Samaritan nature affect the required standard of care is not clear. (3) Hence, whilst he should treat the patient under ethical considerations, he might be inhibited from doing so from legal considerations.

The present system where doctors obtain insurance against negligence claims for good Samaritan acts are illogical for several reasons. Firstly, as the doctors do not benefit financially from such acts, they should not be required to bear the financial cost of the risk of litigation. Secondly, doctors should be encouraged to fulfil their moral duties without the unlikely possibility of bankruptcy hanging over their heads. Thirdly, patients may not obtain proper compensation for negligent emergency treatment by doctors, as the doctors’ personal wealth may not meet the damages awarded by the Courts.

The medical profession should advocate for a centrally-funded system of compensation for victims of medical negligence incurred in a good Samaritan act. The cost of funding such a scheme should be minimal.

(348words)

References

1) Cressey DM. Ethanol, emergencies, and ethical dilemmas BMJ 1998; 316: 1515-7

2) Health Circular HC(89)34

3) Wilsher v Essex Area Health Authority [1988] 1 All ER 871

4) Nickolls v Ministry of Health. The Times, February 4, 1955, C.A.

Competing interests: No competing interests

20 May 1998
Wai-Ching Leung
Senior Registrar in Public Health Medicine
Sunderland Health Authority, Durham Road, Sunderland SR3 4AF
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Re: Rapid resolution of symptoms and signs of intracerebral haemorrhage: case reports Saman B Gunatilake. 316:doi 10.1136/bmj.316.7143.1495

Gunatilake [1] illustrates the importance of obtaining imaging studies in cases of transient neurological events prior to starting anti-platelet agents, by reporting 2 cases of putaminal haemorrhage, which were associated with rapidly resolving neurological deficits. Presentation of intracerebral haemorrhage with transient neurological deficits is uncommon in younger age groups [2,3], but can occur in the setting of cerebral amyloid angiopathy (CAA) in the elderly [4,5]. CAA is a major cause of spontaneous lobar haemorrhages in the elderly. Greenberg and colleagues [4] reported 7 cases of CAA, which were not associated with hypertension, trauma or other antecedent causes. 5 of these cases were associated with transient neurological events. The transient neurological events in such cases may be due to either focal seizures relating to petechial haemorrhages or true short-lived neurological deficits.

References

1. Gunatilake SB. Rapid resolution of symptoms and signs of intracerebral haemorrhage: case reports. BMJ 1998; 316: 1495-1496.

2. Sohn YH, Kim SM, Kim JS, Kim DI. Benign brainstem hemorrhage simulating transient ischemic attack. Yonsei Med J 1991 Mar;32(1):91-93

3. Chen WH, Liu JS, Wu SC, Chang YY. Transient global amnesia and thalamic hemorrhage. Clin Neurol Neurosurg 1996 Nov;98(4):309-311

4. Greenberg SM, Vonsattel JPG, Stakes JW et al. The clinical spectrum of cerebral amyloid angiopathy: Presentations without lobar hemorrhage. Neurology 43: 2073 -

5. Smith DB, Hitchcock M, Philpott PJ. Cerebral amyloid angiopathy presenting as transient ischemic attacks. J Neurosurg 1985; 63: 963-964

Competing interests: No competing interests

20 May 1998
Joe Verghese
(1) Chief resident , (2) Reseach Assistant
Anne Felicia Ambrose
Department of Neurology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, New Yo
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Re: Calcium channel blockers Alice V Stanton. 316:doi 10.1136/bmj.316.7143.1471

To the Editor: The editorial on calcium channel blockers (CCBs) by Dr. Stanton is a carefully considered opinion, but it is unfortunately based on an incomplete review of the available evidence. In my search of the literature I have found 6 published randomized controlled trials (RCTs), in which CCBs are compared to other drugs in the treatment of hypertension, and outcome data are collected and reported. The 3 RCTs Dr. Stanton has not considered are the GLANT(1), CASTEL(2), and VHAS(3) trials. The GLANT trial compared an ACE inhibitor, delapril, with dihydropyridine CCBs; the CASTEL trial compared the combination of chlorthalidone and atenolol with nifedipine in an elderly hypertensive population (I have been kindly provided with 12 year outcome data for the individual drugs by Dr. Casiglia); and the VHAS trial compared chlorthalidone with verapamil. If one combines the total cardiovascular events (stroke, coronary heart disease, and congestive heart failure) for the non-CCB drug as compared to the CCB, all 6 trials show a trend towards a benefit for the non-CCB drug; overall odds ratios is 0.50 (99% CI, 0.35 to 0.72). Can all of these trials be discounted as due to random error?

It is of course important to be certain that data from all RCTs is included; I would be most interested in hearing about any RCTs I may have overlooked. Relevant data has been collected in the TOMHS trial(4) and should be included, but when I asked for the information, the authors refused to provide it.

At the present time many doctors are prescribing CCBs as first-line drugs for hypertension, presumably with the assumption that the overall benefits for the patient will be better than with a thiazide, beta-blocker or ACE inhibitor. In my opinion, the chances that CCBs, particularly dihydropyridines, will cause modest benefit as compared to other anti-hypertensive classes is vanishingly small; on the other hand the chances that they will cause modest harm is substantial. Physicians should therefore act based on this growing evidence, and begin to change their prescribing habits accordingly.

James M. Wright, MD, PhD, FRCP(C)
Associate Professor (presently on sabbatical in New Zealand)
Departments of Pharmacology & Therapeutics and Medicine
2176 Health Sciences Mall
University of British Columbia
Vancouver, B.C. V6T 1Z3

1. The GLANT Study Group. A 12-month comparison of ACE inhibitor and Ca antagonist therapy in mild to moderate essential hypertension - The GLANT Study. Hypertens Res 1995;18:235-44.

2. Casiglia E, Spolaore P, Mazza A, et al. Effect of two different therapeutic approaches on total and cardiovascular mortality in a Cardiovascular Study in the Elderly (CASTEL). Jpn Heart J 1994;35(5):589-600.

3.Agabiti Rosei E, Dal Palu C, Leonetti G, et al. Clinical results of the verapamil in hypertension and atherosclerosis study. J Hypertens 1997;15:1337-1344.

4. Neaton JD, Grimm,Jr RH, Prineas RJ, et al. Treatment of mild hypertension study: Final results. J Amer Med Assoc. 1993;270:713-724.

Competing interests: No competing interests

20 May 1998
James M Wright
Associate Professor
University of BC, Vancouver, BC, Canada
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Re: Netlines . 316:doi 10.1136/bmj.316.7140.1294

About a decade ago, if my memory serves correctly, Stanford's information technology management team (of which I was a member) made a decision to ban from the campus servers the group supported a public newsgroup (USENet bulletin board) that redistributed jokes that were sometimes racist or ethnically-derogatory.

The campus librarians -- who were later to become a part of that same information technology management team -- counseled that this ban was a bad thing. After study, a panel of faculty agreed that the ban was a mistake and the newsgroup was reinstated.

The debate -- unlike one over child pornography -- was not whether the material was legal or not. As I recall, it had to do with whether university resources should be involved in seeming support of content that the university itself would distance itself from, or whether the university should be selecting out material without a clear and consistent principle for doing so. That is to say, in the end it seemed that the librarians -- who make content-selection decisions all the time, and have clearly-formulated principles and traditions for doing so -- were well-trained to take on such a decision and the information technology staff could learn from them.

Competing interests: No competing interests

20 May 1998
John Sack
Director, HighWire Press
Stanford University
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Re: Africa needs leadership by Africans of high calibre John Lwanda. 316:doi 10.1136/bmj.316.7142.1457a

There have been several articles in the past and recently in the BMJ discussing the desperate poverty in Sub-Saharan Africa. They have all failed to come up with credible suggestions for a permanent solution. John Lwanda's answer was so far the best. I would like to take his argument one step further.

The only person who can permanently bring to an end the plight of the African is the educated African man or woman. This includes myself, and all the educated Africans and their descendants world over. It is the educated African too who makes the African government(s). Until the educated African owns up to his responsibilities over the welfare and future of his children, his people and the future African generations, then the African people will forever suffer. The Europeans and their charities, IMF, World bank etc may help (thankfully) but ultimately and rightly they are there to look after the welfare of their own people. We expect far too much from them. No one else but you the educated African holds the answer. Without you striving and fighting in every way for the development of Africa, Africa and its children (your children) will have no future and you too will have no future.

It is disgraceful and shameful that the educated African has so far either directly brought on more misery to his own people or has become a dim second class
European and consequently absolved himself of all responsibilities over his people. I hope when you the educated African reads this letter you go and look at yourself in the mirror and answer these questions, "What will you do to stop the African children from dying and what can you do to make this world a happy one for the African child?."

Competing interests: No competing interests

20 May 1998
G Nyamugunduru
Specialist Registrar Paediatrics
City Hospital Stoke -on-Trent
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Re: Women lose legal battle over radiotherapy Clare Dyer. 316:doi 10.1136/bmj.316.7143.1477f

The doctors who treated these two unfortunate patients did so within the "standard" therapy of the time and cannot be held culpable for negligence. An burning issue that faces state sector radiation oncologists in South Africa at present is that due to huge cuts in funding, radiation services are crumbling and yet the patient load is rising. The politicians responsible tell the public that "standards will be maintained". This is a patent absurdity. What I can tell you is that there is de facto pressure on us to cut corners and use either ineffective or dangerous methods.
I wonder what the legal position would be if I was sued for excessive radiotherapy induced toxicity from being forced to used hypofractionated radiation schemes in order to get around the pt backlog?

Competing interests: No competing interests

20 May 1998
Neil Wilson
Radiation Oncologist
Tygerberg Hospital Cape Town South Africa
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Re: Food allergy Carsten Bindslev-Jensen. 316:doi 10.1136/bmj.316.7140.1299

Professor Bindslev-Jensen dismisses the potential use of oral sodium cromoglycate in the management of food allergy as being " generally unhelpful" and that clinical trials have given " conflicting results". These comments may result form early trials that either did not select patients with food allergy or an inadequate dose was used.

Oral sodium cromoglycate can often be a useful support to diet in the management in two ways, by giving improved symptomatic control when diet alone is inadequate and by allowing small amounts of the foods to which the patient is sensitive to be consumed. Thes uses do the correct diagnosis to have been made and the main causative foods to have been identified. Adequate doses must be used. In his original case study report Kingsley (1) showed that single doses of up to 400 mg may be required to give adequate protection against reasonable amounts of food.This was confirmed in a double-blind trial by Basomba et al. who showed that to be sure of providing good protection against food challenge doses of between 400 - 800 mg are needed. In the one case of anaphylaxis reported in this latter trial a dose of 800mg did not provide complete protection which indicates that this use of the drug should not be contemplated if anaphylactic reactions are involved. Doses of 400-500 mg were used in trials reported by Dahl (3), Papageorgiou et al. (4) and by Carini et al (5). All of these trials reported positive results but trials in which lower dose were used were more likely to give negative results.

Recent positive trials of the beneficial uses of continuous treatment in irritable bowel syndrome due to food allergy have used daily doses of 1600-2000mg/day (6,7). Positive results have been in patients who have a psoitive history of foods exacerbating symptoms and who demonstrate positive skin tests or RAST to foods.

Whilst an elimination diet remains the primary management of food allergy, this has become increasingly difficult at a time when many foods hae multi-ingredients. In these circumstances the selected use of oral sodium cromoglycate can be very beneficial.

Alan M Edwards
19 May 1998.

References

1.Kingsley PJ. Oral sodium cromoglyate in gastrointestinal allergy. Lancet 1974; 2: 1011.

2. Basomba A, Campos A, Villalmanzo IG, Pelaez A. The effect of sodium cromoglycate (SCG) in patients with food allergy. Acta Allergol; 1977; 32(Suppl13): 96-101.

3.Dahl R. Disodium cromoglycate and food allergy. Allergy 1978; 33:120-124.

4.Papageorgiou N, Lee Th, Nagakura T, Cromwell O, Wraith DG, Kay AB. neutrophil chemotactic activity in milk-induced asthma. J Allergy Clin Immunol 1983;72: 75-82.

5. Carini C, Brostoff J. Evidence for circulating IgE complexes in food allergy. Ric Clin Lab 1987; 17(4):309-322.

6. Lunardi C, Bambara LM, Biasi D, Cortina P, Peroli P, Nicolis F, Favari F, Pacor M. Double-blind cross-over trial of oral sodium cromoglycate in patients with irritable bowel syndrome due to food intolerance. Clin Exp Allergy 1991;21: 569-572.

7. Stefanini GF, Saggioro A, Alvisi V, et al. Oral cromolyn sodium in comparison with elimination diet in the irritable Bowel Syndrome, diarrhoeic type. Scand J Gastroenterol 1995; 30: 535-541.

Competing interests: No competing interests

20 May 1998
Alan M Edwards
Honorary Clinical Assistant
Southampton General Hospital
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Re: Sex and death: are they related? Findings from the Caerphilly cohort study George Davey Smith, Stephen Frankel, John Yarnell. 315:doi 10.1136/bmj.315.7123.1641

Dear Sirs:

Over the years I have found an effective method of educating my patients is to make a copy of the first page of selected journal articles regarding topics which I feel are important to their health.

This has proven to be a useful way to motivate patients to make changes in their lifestyle, or to accept new therapies. There is something about seeing a recommendation in writing with the title of the journal at the top of the page that seems to motivate patients better than just the doctor's word.

I recently made a copy of Dr. George Smith's article on "sex and death", and presented a copy to several of my married female patients for their opinion as to it's usefulness.

I was caught completely off guard by their response. I was informed in no uncertain terms that if their husbands were ever made aware of this article or given a copy, I would have a very unhappy patient on my hands.

I have since taken a random survey of several more married female patients and hospital employees, and have found almost unanimous agreement with the sentiments of my initial group of patients. Several individuals felt this information might even lead to a deterioration in their marital relationship.

Hence, although this article presents some very interesting statistical data, it may not have a lot of practical significance in the real world, at least in one area of rural USA.

Sincerely,

Gary W. Berger, M.D.

Competing interests: No competing interests

20 May 1998
Gary W Berger
Family Practice Physician
Office
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Re: Resolution of peanut allergy: case-control studyScience commentary: Why do some children grow out of peanut allergy? Jonathan O'B Hourihane, Abi Berger, Stephen A Roberts, John O Warner. 316:doi 10.1136/bmj.316.7140.1271

The letters posted so far typify the problem parents of allergic children face in trying to protect and care for them.

One father reports the results of a blood test and seeks more info about the significance of the reported levels of IgE. I do not think tests of antigen mixtures are useful. One needs to know about individual nuts to base advice on the relative risk. Having said that, nut and peanut allergic people need to avoid all nuts, unless they have eaten them safely before and they are CERTAIN that there is no possibility of confusion or mix up of one nut (a risk) for another(previously safe).

The 2nd letter is about testing before school entry. This is the time of greatest parental fear, as the child will be away from them for long periods. One cannot predict resolution of peanut allergy in any individual without a consultation,tests (skin prick and blood) and a challenge if necessary. My practice is to challenge children before school entry, if they have not had a reaction for about 2-3 years and if the reaction described was not life-threatening (see article). If the challenge is negative, dietary and lifestyle restrictions can be relaxed. If the challenge is positive, nothing has been lost. Anecdotally, families are usually reassured by the mild reaction elicited in positive challenges and with reinforcement of response strategies, feel more confident sending the child to school.

I am aware of only very few severe reponses among 1000s of formal food challenges. Nevertheless they must be done in hospital. Our paper reflects the experience of 2 of the very rare centres that frequently do such challenges. More allergists and allergy clinics need to be provided by the NHS to meet the already huge and increasing demand for advice and expertise. The BMJ's current series/book "ABC of allergy" should make a huge contribution to the advice available to the public via GPs and clinics not dealing with severe allergies every day

Competing interests: No competing interests

20 May 1998
Jonathan Hourihane
Lecturer, Immunobiology
Institute of Child health, London
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