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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: Initiating angiotensin converting enzyme inhibitors in mild to moderate heart failure in general practice: randomised, placebo controlled trial Alan Wade, et al. 317:doi 10.1136/bmj.317.7169.1352

It is unfortunate that the trial was stopped early, and that a
surrogate endpoint was used, as it has potentially great implications for
physicians such as myself in isolated practices with limited access to
specialists. I am only mildly reassured that in this small study no
adverse events occurred, although I start almost all my patients with CHF
on ACEI's immediately, as per the current evidence. It would be
interesting to see the same study done with diuretics--I bet the outcomes
and side effects would be worse...

YS

Competing interests: No competing interests

19 November 1998
Y Sehgal
family medicine
terrace bay, on, Canada
Re: Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful stiff shoulder in primary care: randomised trial B A de Jong, L M Bouter, et al. 317:doi 10.1136/bmj.317.7168.1292

Editor,

The recent paper by van der Windt et al1 helps to highlight some of
the challenges which exist in clinical studies of shoulder disorders.
These include the use of appropriate terminology and diagnostic criteria,
the need to establish a well designed study with comparable study groups
and adequate duration of follow-up and drawing appropriate conclusions
from the results obtained.

The study involved cases with ‘painful stiff shoulder', a term rarely
used now, as it represents a set of symptoms rather than a diagnostic
entity (somewhat paradoxically, ‘frozen shoulder' remains widely
accepted). It appears that the authors aimed to study individuals with
adhesive capsulitis. If this were the case then the diagnostic criteria
used should have included the global limitation of passive and active
movement in the absence of degeneration of the glenohumeral joint2.
Indeed, some workers have suggested that, particularly in clinical
studies, the diagnosis should be confirmed by arthrography 3 . Some cases
of adhesive capsulitis, particularly those in the later stages, exhibit
restriction in the absence of pain; such cases were excluded in this
study. Hence only a subset of the possible wide spectrum of cases - those
who are more likely to respond to anti-inflammatory approaches such as
corticosteroids - were included. Failure to exclude subjects with
glenohumeral arthritis, in addition to subjects who are known to have more
severe forms of adhesive capsulitis (in particular, those with diabetes
mellitus) may also have significantly affected the outcome. Administration
of the injections by such a large number of practitioners is another
avoidable source of error.

The important differences between the study groups which were noted
by the authors make interpretation of the results difficult. The
conclusions, that the benefits of corticosteroids ‘are superior to
physiotherapy', should be qualified. The results implied a short term
benefit with corticosteroids, but little benefit over physiotherapy in the
long term, as has been shown by other workers 4. Perhaps a control (no
treatment) group would have helped to indicate whether either treatment
makes any difference in the long term; other studies have implied that
they do not 4. Finally, the relatively high incidence of side-effects
noted with corticosteroid injections may have been related to the high
doses administered over a short period of time, doses which many would not
use in clinical practice.

Cathy Speed Clinical Fellow
Rheumatology Department,
Addenbrooke's Hospital,
Cambridge. CB2 2QQ.

1. van der Windt DAWM, Koes BW, Deville W, Boeke AJP, de Jong BA,
Bouter LM. Effectiveness of corticosteroid injections versus physiotherapy
for treatment of painful stiff shoulder in primary care: randomised trial.
Br Med J 1998; 317: 1292-6.

Competing interests: No competing interests

Re: Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38 . 317:doi 10.1136/bmj.317.7160.703

I read with interest the results the reports from UKPDS.My person
interest is in Epidemiology and its relevance to coal face General
Practitioners, whose task is to decide what is relevant for the patient in
front of them.

There is one glaring omission from the reports. I have not seen any
reference to the side effects of medication, no mention of metformin
diarrhoea, no mention of ACEI cough, no mention of atenolol tiredness.
Similarly there is no mention of patient satisfaction with insulin
injection nor the guilt syndrome imposed on patients whose "diabetic
numbers" do not meet the Guidelines set by specific disease issue
crusaders.

The primary care clinician must decide whether the morbidity induced
( fear of the label, cost/pain of tests, multiple visits to the doctor,
side effects of medication) is worth the morbidity that only MIGHT be
prevented.

In the BP arm of this trial with tight control there were 42
cardiovascular events per 1000 patient years and 59 per 1000 in the less
tight group. This is a difference of only 17 per 1000 treatment years. How
many per 1000 had side effects? and how many patients would object if they
knew that the effort of optimising the BP only benefited 1.7% per annum?.

It is no wonder many GP's do not seem to reach the Guidelines set by
"Experts" as many of us intuitively sense that the effort is not worth the
benefit for the individual.

Lastly it is a great same that such a large GP based trial has lost
total objectivity by not looking at the other side of the equation.

Competing interests: No competing interests

18 November 1998
Paul Neeskens
General Practitioner
Hervey Bay QLD AUSTRALIA
Re: Tea for two and two for tea Lee-Suan Teh. 317:doi 10.1136/bmj.317.7162.874

I can empatise your frustration. Perhaps it helps to know that seeing
'teh' being changed in 'the' by my
word processer, always makes me think of you. As I'm a bad typer this is
very often.

Good luck,
Martine van Eijk; Van Eyk; v. Eijck etc....

Competing interests: No competing interests

18 November 1998
M van Eijk
researcher
breda, the Netherlands
Re: Thalassaemia in Britain: a tale of two communities Paramjit S Gill, Bernadette Modell. 317:doi 10.1136/bmj.317.7161.761

Editor,

Further to your editorial (19th September), I wish to raise some
points and comment on the paper by Modell et al. Regarding incidence of
carriers the figure by Weatherall (1) indicates that up to 1 in 7 Asians
in this country may be carriers. There have been no large epidemiological
studies undertaken to provide a true picture (prone to variability due to
religion, marriage practices and culture). It is true that awareness
levels are unacceptably low and our survey carried out in November 1996 of
Asians in England showed that only 5% were aware of thalassaemia(2).

We have calculated the cost of supporting a patient from birth to 30
years and note that figures vary depending on the calculation method and
whether the cost of borrowing to the State is considered. Accordingly, we
feel quoting a range of between £250,000 and £1,000,000 is safer.

It is true that the Cypriot community in particular has benefited
from having Health Education available both at home and here. The
message has been further re-inforced by the Church in Cyprus and this
community's frequent travel to Cyprus. Whereas in India, thalassaemia
education as at the Wadia Hospital in Bombay, (WHO Project) may not have
any impact on those living here who may not originate from the catchment
area.

Whilst Modell has looked at the use of nurse facilitators to
enhance screening it would be interesting to know the background of the
Practitioner. The Thalassaemia Society has a project over three years to
increase awareness of thalassaemia in Asians as well as increase pre-
conception testing in Primary Care. We have found that in those areas
where there is need to increase public awareness there appear to be a
higher number of ethnic minority practitioners.

Our Society also acts as an information and resource centre for
primary care workers. Our health education material has the advantage of
having community involvement and sensitivity. Information is also
available on our Website. (3)

With increased emphasis on Health Improvement Programmes, we feel
the time is now correct for Primary Care Groups to respond positively to
screening.

Yours sincerely,

Dr. N. Lakhani
President of U. K. Thalassaemia Society
Chairman of the National Advisory Committee of the Asian Awareness
Project.

1. British Journal of Haematology; 1991 Vol. 78, Page 242/247, Prof.
Weatherall et al.
2. U. K. Thalassaemia Society Sample Survey 1996.
3. Website:- www.ukts.org

Competing interests: No competing interests

Re: Effect of sex of fetus on asthma during pregnancy: blind prospective stud N Beecroft, G M Cochrane, Heather J Milburn. 317:doi 10.1136/bmj.317.7162.856

Editor- Beecroft et al reported an intriguing association between
the gender of the fetus and symptoms of asthma during pregnancy1. They
speculate that women with male fetuses have improved asthma symptoms
during pregnancy, possibly due to androgen production by the male fetus.
We recently reported a population based study from Nova Scotia, Canada of
perinatal outcomes in women with asthma during pregnancy, but did not
consider fetal sex2.

Although we do not have specific data on asthma severity or symptoms,
pregnant asthmatics were classified into three treatment groups; no
medication use during pregnancy, beta agonists only, and steroids with our
without other asthma medications. As seen in the table, 14% of women with
a male fetus required steroids during pregnancy as compared to 20% of
women with a female fetus. Conversely, more women with a female fetus
used beta agonists only than women with a male fetus.

If we assume that asthmatics requiring steroids have more severe
symptoms than asthmatics not taking steroids or asthmatics using beta
agonists only, it would appear that our data support the association noted
by Beecroft et al. Unfortunately, we are not able to confirm this
assumption and conclude that this interesting association is worthy of
further study.

Table: Sex of fetus and medication usage among pregnant asthmatics

Sex No medication Beta agonist only Steroids of fetus n=375 n=303 n=139 ______________________________________________

# (%) # (%) # (%)

Male 192 (46.3%) 164 (39.5%) 59 (14.2%)

Female 183 (45.5%) 139 (34.6%) 80 (19.9%)

1. Beecroft N, Cochrane GM, Milburn HJ. Effect of sex of fetus on asthma during pregnancy: blind prospective study. BMJ 1998;317:856-7. 2. Alexander S, Dodds L, Armson BA. Perinatal outcomes in women with asthma during pregnancy. Obstet Gynecol 1998;92:435-40.

L Dodds, Epidemiologist Reproductive Care Program 5980 University Ave. Halifax, Nova Scotia, Canada B3H 4N1

BA Armson, Obstetrician Department of Obstetrics and Gynecology Dalhousie University Halifax, Nova Scotia, Canada B3H 4N1

S Alexander, Epidemiologist Newfoundland and Labrador Provincial Perinatal Program St. John's , Newfoundland, Canada A1A 1R8

Competing interests: No competing interests

18 November 1998
Linda Dodds
Epidemiologist
Reproductive Care Program of Nova Scotia
Re: Obstetric care and proneness of offspring to suicide as adults: case-control study Bertil Jacobson, Marc Bygdeman. 317:doi 10.1136/bmj.317.7169.1346

EDITOR- The suggestion that some violent suicides are scripted by a
traumatic birth relates to theories that the near-death experience (NDE)
is a re-activation of birth memories in symbolic form.1 Like birth, NDE's
involve travel through a tunnel into light. Some are blissful but others
involve panic and paranoia. 2,3 New data show foetal memory at 20 weeks
4, and adults have appeared to re-experience birth in LSD and ketamine
research. 2,3 The birth trauma frequently appeared as a core imprint,
described by Grof in 4 parts: (1) The amniotic universe: no boundaries.
The re-experiencing adult describes ocean, galaxy, heaven, cosmic unity
beyond time and space. Arriving toxins or lack
of nourishment link with images of poison, danger, and evil forces.(2)
Engulfment and no exit: stage 1 of delivery. There are contractions but
the cervix is closed so there is no way out. Symbolism includes engulfment
and imminent disaster, expulsion from Eden, the sense of original sin (to
have deserved this fate) and hell: entrapment in a claustrophobic, endless
nightmare of pain from which escape is impossible. (3) The death-rebirth
struggle: contractions continue but the cervix is dilated. The baby moves
through the birth canal, struggling against suffocation and compression.
Symbolism includes a titanic struggle with energy building up towards
explosive release, cataclysm, with sadomasochistic, aggressive elements.
The person may identify with both killer and victim, relevant to violent
suicide. (4) The death-rebirth experience: Tension is released, the child
is born into light. In adults, annihilation of all previous reference
points, ego death, is followed by rebirth: visions of white light,
arriving in paradise, and positive feelings about self, others and life.
The stages may not be worked through sequentially, and may be repeated
many times.3

A 're-doing' of birth within a therapeutic alliance allows some
resolution of the trauma. Ego death can resolve a deep sense of
inadequacy, an unrealistic need to be prepared for hidden dangers, and a
compulsion to be
in control linked to negative aspects of birth. NDE's can be followed by
more joy in living, less anxiety and neurosis, and a sharp fall in
suicide attempts.2 In over 1,000 patients, death-rebirth psychotherapy
using
ketamine has had good results at longterm follow-up.5 The safe induction
of NDE's for psychotherapeutic purposes, as may be achieved with
anesthetics and guided imagery, may offer a powerful treatment for those
at risk: a brief ego death that may be life-saving.

*Dr. Karl L.R. Jansen, MB.ChB., M.Med.Sci., D.Phil. (Oxon),
MRCPsych.
Current appointment: Director, The Chaucer Centre, 13 Ann Moss Way, off Lower Rd, Rotherhithe, London SE16 2TH

Professor Bruce Greyson, M.D.
Current Appointment: Bonner-Lowry Professor of Personality Studies
Current Address:
Division of Personality Studies
Box 152, Health Sciences Center
University of Virginia
Charlottesville, VA 22908
U.S.A.

Dr. Evgeny Kupritsky, M.D., Ph.D., DSci.
Current Appointment: Chief of the Research Laboratory
Current address: St.Petersburg Regional Center of Alcoholism and
Addictions,
Novo-Deviatkino 19/1, St.Petersburg Region 188661, Russia.

No authors have a competing interest.

1. Jacobsen B, Bygdeman, M. Obstetric care and proneness of offspring
to
suicide as adults: case control study. BMJ 1998 ; 317: 1346-9 (14
November).

2. Jansen K L R. The ketamine model of the near -death experience: a
central role for the NMDA receptor. Journal of Near-Death Studies 1997;
16: 5-27.(http://www.iands.org/jndsind.html)

3. Grof S. Realms of the Human Unconscious: Observations from LSD
Research. New York, Viking Press, 1975.

4. Evans W S. Ontogenesis of auditory perception and memory at 20
weeks'
gestation. Abstracts of the 1998 Annual Conference of the British
Psychological Society, Brighton, 1998, p8.

5. Kupritsky EM, Grinenko AY. Ketamine psychedelic therapy (KPT): a
review
of the results of ten years of research.J Psychoactive Drugs 1997;
29:165-183.

Competing interests: No competing interests

Re: Theories of race, ethnicity and culture Naomi Pfeffer. 317:doi 10.1136/bmj.317.7169.1381

Editor- A meaningful and sensitive descriptive vocabulary of
peoples'identity is an important social tool. It will aid increased
understanding and promote effective research in areas such as socialpolicy
and healthcare.

Pfeffer's use of the "Black is beautiful" slogan as an illustration
of the essentialism of new social movements is superficial.(1) Rather than
falling "into the trap of essentialism" this slogan has been used as a
political device. It facilitated empowerment and helped focus on the
legacy of centuries of oppression by overcoming internalised racism and
being an affirmation of humanity.

It does not in itself deny the diversity of individuals who consider
themselves Black nor does it oppress those who do not.

The multiple factors involved in determining the fluid identity of
individuals are not under estimated by Pfeffer. The identity of those
defining and the nature of their interaction with those defined remains
highly problematic even in the postmodern era.

Stephen Walker,Senior house officer in dermatology.
St.Thomas' Hospital,Lambeth Palace Rd.,London.SE1 7EH
Telephone 0410 431184

(1) Pfeffer N, Theories of race,ethnicity and culture.

BMJ 1998;317:1381-4 (14 Nov.)

Competing interests: No competing interests

Re: Minerva . 317:doi 10.1136/bmj.317.7169.1398

Dear Editor,

I read with interest in Minerva (1) last
week about the potential effects of surveillance equipment
on pacemakers. Were I to find a 72 year old man collasped
in a bookshop, I doubt that electromagnetic interference
with his defibrillating pacemaker would have entered my
head as a possible cause. All credit is due to the "canny
bystander" who made the connection and dragged the
unfortunate individual away from the offending equipment.
Perhaps it is time to introduce this into the list of
possible causes of collaspe which is so frequently taught
in the Undergraduate Curriculum. It would be interesting
to know the occupation of the aforementioned bystander - a
consultant cardiologist perhaps.

Yours faithfully,

Lindsay I. Grant

Final Year Medical Student

University of Aberdeen

Foresterhill

Aberdeen AB25 2ZD

1. Minerva BMJ1998;317:1398

Competing interests: No competing interests

Re: Assessing and interpreting arterial blood gases and acid-base balance Adrian J Williams. 317:doi 10.1136/bmj.317.7167.1213

Dear Sir,

In his recent article on arterial blood gas analysis, Dr Williams repeats
the commonly read advice to perform a modified Allen's test prior to
attempting radial artery puncture [1].
It is my impression that this advice is never carried out in practice and
a brief survey of my anaesthetist colleagues confirmed that none of six
specialist registrars and eight consultants (with a combined experience of
several thousand radial artery punctures) used the test routinely.
In fact Allen's test has a poor sensitivity and specificity for
complications following radial artery cannulation. In a series of 1699
patients undergoing arterial cannulation for coronary artery surgery, of
411 patients who had an Allen's test, 16 were abnormal. None of these 16
had complications from radial arterial cannulation [2]. There is a further
report of serious complications in 2 of 982 patients who had a normal
Allen's test prior to radial arterial cannulation [3].
The available evidence does not support the routine use of Allen's test
prior to radial artery puncture. Nevertheless, because of the rare
incidence of serious complications common sense suggests that all patients
should have regular clinical observation of their hand and finger blood
supply following arterial puncture or cannulation.

Yours sincerely,

Adrian Steele BA MRCP FRCA
Specialist registrar in Anaesthesia, St Helier Hospital, Wrythe Lane
Carshalton, Surrey

1.Williams AJ. Assessing and interpreting arterial blood gases and
acid-base balance. BMJ 1998;317:1213-16 (31 Oct)

2. Slogoff S, Keats AS, Arlund C. On the safety of radial artery
cannulation. Anaesthesiology 1983;59:42-47

3. Mandel MA, Dauchot PJ. Radial artery cannulation in 1000 patients:
precautions and complications. Journal of Hand Surgery 1977;2:482-85

Competing interests: No competing interests

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