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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: Rapid resolution of symptoms and signs of intracerebral haemorrhage: case reports Saman B Gunatilake. 316:doi 10.1136/bmj.316.7143.1495

Gunatilake reported two patients with intracerebral haemorrhage and resolution of symtoms and signs within 24 hours (1). Previously, Aparicio et al and Alvarez reported other two patients with similar clinical course( 2,3), one due to anticoagulant therapy (3),
On the other hand, Rey et al (4) reviewed all the clinical trials in which aspirin was used in the secondary and primary prevention of ischemic stroke and there was an increased risk associated with the use of aspirin as a compared to a placebo with respect to a intracerebral haemorrhage (Odd ratio= 2,08; IC 95%=1,32-3,29; p=0,0009).
In conclusion, it is felt that a cranial CT should be also mandatory before starting antiplatelet therapy and should be performed within 6 hours after the symptoms onset. Bogousslavsky et al (5) reported 15 patients with cerebral intra-infarct haematoma (type 2 of cerebral haemorragic infarct) in whom cranial CT showed no bleeding within 6 hours of stroke onset but showed intracerebral haemorrhage less than 18 hours later. The findings in the second cranial CT sugessted intracerebral haemorrhage in a review by two radiologist and two neurolgist whom were blinded to the first cranial CT. In these patients a primary infarct was suspected only because they had a cranial CT within 6 hours after the infarct onset.

REFERENCES:

1. Gunatilake SB. Rapid resolution of symtoms and signs of intracerebral haemorrhage: case reports.

2. Aparicio A, Sobrino J, Arboix A, Torres M. Hematoma intraparenquimatoso que simula un accidente isquémico transitorio. Med Clin ( Barc) 1995; 104: 478-479.

3. Alvarez J. Hematoma intraparenquimatoso que simula un accidente isquémico transitorio. Med Clin ( Barc) 1995; 105: 598.

4. Rey A, Martí-Vilalta. Enfermedad cerebrovascular yatrogénica. Rev Neurol 1995; 23(Supl 1): 131-146.

5. Bogousslavsky J, Regli F, Uské A, Maeder P. Early spontaneous hematoma in cerebral infarct: is primary cerebral hemorrhage overdiagnosed?. Neurology 1991; 41: 837-840

Competing interests: No competing interests

22 May 1998
Antonio Arjona
neurologist
Neurology Center La Bodega Nº 5 , E-14008 Cordoba, Spain
Re: Investigating and managing infertility in general practice T B Hargreave, J A Mills. 316:doi 10.1136/bmj.316.7142.1438

The laboratory and biochemical aspects of the investigation of infertility suggested by Hargreave and Mills (9 May, p1438) cannot be allowed to go unchallenged.

Firstly, they appear to suggest that serum oestradiol and testosterone should be routinely estimated in all anovulatory patients. These two tests are only necessary in a select few patients. Serum oestradiol is very variable in patients with polycystic ovary disease (PCO), and is therefore of limited value both in the diagnosis and management of such patients. The only indication for oestradiol is suspected secondary amenorrhoea due to hypopituitarism.

Serum testosterone is also not indicated routinely in all non-hirsute anovulatory patients; the only indication for this test is in the investigation of hirsutism to identify some of the distinct endocrine disorders associated with hyperandrogenism.

Secondly, it is important to clarify the role of serum androstenedione in the investigation of patients with suspected PCO. While serum androstenedione may be slightly elevated in PCO, this is a non-specific finding and this test is of little use in the diagnosis or management of such cases. Androstenedione is not readily available in most district general hospital laboratories, and has to be sent to specialist centres for estimation. Clinicians may be led to believe that they should be requesting this test more frequently in patients with suspected PCO, when they should probably be doing the reverse. The only indications for androstenedione are:

a) diagnosis of congenital adrenal hyperplasia due to 17b-hydroxy steroid dehydrogenase deficiency
b) management of congenital adrenal hyperplasia due to 11b- or 21 hydroxylase deficiency.

Thirdly, it is time to dispel the myth that gonadotrophins are low in pituitary failure. Gonadotrophins are almost always normal in patients with hypopituitarism, and the clue to this condition is a low serum oestradiol in the presence of normal FSH and LH. The most important use of the estimation of gonadotrophins in amenorrhoeic patients is to exclude primary ovarian failure.

PCO is perhaps the commonest cause of infertility, and is a heterogeneous disorder that commonly presents as amenorrhoea, infertility or hirsutism occurring separately or in combination. The biochemical investigation of such patients depends largely on the clinical presentation, and there is no such thing as a "routine PCO screen".

1. Hargreave TB, Mills JA. Investigation and managing infertility in general practice. BMJ 1998;316:1438-41.

Competing interests: No competing interests

22 May 1998
Sudha Bulusu
Consultant Chemical Pathologist
Newham General Hospital, Glen Road, London E13 8RU
Re: Non-steroidal anti- inflammatories should not be used after orthopaedic surgery D Varghese, S Kodakat, H Patel. 316:doi 10.1136/bmj.316.7141.1390

NSAIDs should be used after orthopaedic surgery whenever possible

EDITOR-We would like to comment on the letter by Varghese et al. in which they state that "non-steroidal anti-inflammatories should not be used after orthopaedic surgery". 1 They highlight the interesting point that spinal fusion and fracture healing of the femur in rats was poorer when the rats were administered a high dose (equivalent to maximum dose in humans) of NSAIDs for a ten to twelve week period.
Whilst this is an interesting phenomenon, they make the contentious statement above without any further evidence. NSAIDs do inhibit prostaglandin synthesis but the factors involved in bone osteogenesis and reabsorption are complicated and multifactorial. Prostaglandins "can stimulate and inhibit bone resorption and formation". 2 We could not find any published studies in Medline which demonstrated a link between NSAIDs and reduced bone healing. In fact NSAIDs have been shown to be of benefit in the longterm by reducing heterotopic ossification 3 and reversing osteolytic changes around the femoral prosthesis. 4 They are undoubtedly very effective analgesics for musculoskeletal and incident pain and reduce opioid consumption, pain scores and myocardial ischaemia in the immediate post-operative period after orthopaedic surgery. 5 By improving patient mobilisation (ask any physiotherapist) they will reduce other morbidity issues such as disuse atrophy and deep venous thromboembolism. As long as the NSAID is not contra-indicated by the usual reasons, it seems that to deny this drug for reasons based on extraneous evidence would be a crime.

Conflicts of interest. None

Marjorie Muir, Senior House Officer in Anaesthesia

Jean McCallum, Pain Sister

Mick Serpell, Consultant in Anaesthesia, Western Infirmary, Glasgow, G11 6NT

Fax. 0141 211 1806, E-mail. mgserpell@altavista.net

1.Varghese D, Kodakat S, Patel H. Non-steroidal anti-inflammatories should not be used after orthopaedic surgery. BMJ 1998; 316: 1390.

2.Kawaguchi H, Pilbeam CC, Harrison JR, Raisz LG. The role of prostaglandins in the regulation of bone metabolism. Clinical Orthopaedics & Related Research 1995; 313: 36-46.

3.Gebuhr P, Sletgard J, Dalsgard J, Soelberg M, Keisu K, Hanninen A, Crawford M. Heterotopic ossification after hip arthroplasty: a randomized double-blind muticenter study of tenoxicam in 147 hips. Acta Orthopaedica Scandinavica 1996; 67: 29-32.

4.Steinberg GG. Reversible osteolysis. Journal of Arthroplasty 1995; 10: 556-9.

5.Beattie WS, Warriner CB, Etches R, Badner NH, Parsons D, Buckley N, Chan V, Girard M. The addition of continuous intravenous infusion of ketorolac to a patient-controlled analgetic morphine regime reduced postoperative myocardial ischemia in patients undergoing elective total hip or knee arthroplasty. Anesthesia and Analgesia 1997; 84: 715-22.

Competing interests: No competing interests

22 May 1998
M G Serpell
Consultant Anaesthetist
Western Infirmary, Glasgow
Re: EU approves rights to genetic material Rory Watson. 315:doi 10.1136/bmj.315.7121.1485e

Sirs:

I feel sure that the European Union would not have agreed to grant companies exclusive rights to research use of genetic materials, had the public been adequately consulted.

Individuals are wholly unaware that, when they undergo surgery, their removed tissue can become patentable and profitable property for researchers and biotechnology companies.

Cancer cell lines have long been developed without their "contributors" being consulted or having the chance to benefit.

With the intense new scientific interest in genetic material, no one can predict just how outrageous the unauthorized uses of patients' body substances might become.

Although I have not seen the text of the decision on which the BMJ article was based, it would seem that the EU has stooped to endorsing the greed of corporations who would prey on an unsuspecting public. There has to be a better way, and the better way is based on honesty and disclosure.

Competing interests: No competing interests

22 May 1998
Ceil Sinnex
Editor & Publisher
Ovarian Plus International: Gynecologic Cancer Prevention Quarterly
Re: Screening for Chlamydia trachomatis Fiona Boag, Frank Kelly. 316:doi 10.1136/bmj.316.7143.1474

The plan by the Chief Medical Officer of the UK for an immediate action on chlamydia trachomatis is a step in the right direction. However it does not go far enough. Nearly all of the main recommendations are already going on in several parts of the country. Several studies have identified age as an independent predictor of sexually transmitted infections after controlling for behavioural characteristics (1). There is evidence that screening women under 30 years of age missed only 7% (2). Likewise in the report from Coventry (3) the recommendation was to screen women under 30 years of age. As such it may be prudent to use 30 years rather than 25 years.

Following a diagnosis in a female patient, every effort should be made to contact and treat the male partner/partners otherwise these men will serve as untreated reservoirs of sexually transmitted infections (4) since many of these men will be asymptomatic.

On the issue of difficulties with contact tracing, the use of modern techniques for detecting chlamydia trachomatis eg from urine (5) and various self sampling methods should increase the population being screened. Further application of these methods in the community should increase yield. Patients (males and females) can then take samples themselves and submit these to their GP's, school nurses or family planning clinics.

Finally, there is the issue of commitment by several groups. These include doctors - G U Physicians, Gynaecologists (hospital and community), GP's; the politicians and the press for community education on this subject. The contribution of the pathogen to the nation's morbidity is substantial and can no longer be ignored. Where there is a will, there is a way.

1 ARNO J.N.; KATZ B.P.; McBride R et al: Age and clinical immunity to infections with chlamydia trachomatis. Sex Trans Dis. 1994; 21:47-52.

2 HOWEL M.R.; QUINN T.C.; GAYDOS C.A.; Screening for Chlamydia trachomatis in asymptomatic women attending family planning clinics. Ann Intern Med 1998; 128:277-284 (Medline).

3 OPANEYE A. A.; Sexually transmitted diseases among women in Coventry, England. J Roy. Soc. Hlth 1997;117(1):37-40.

4 HARRY T.C.; Reproductive tract infections and abortions among adolescent girls in rural Nigeria. Lancet 1995; 345:869.

5 HIGGINS S.P.; KLAPPER P.E.; STRUTHERS J.K.; BAILEY A.S.; GOUGH A.P.; MOORE R.; CORBITT G.; BHATTACHARYYA M.N. Detection of male genital infection with Chlamydia trachomatis and neisseria gonorrhoea using an automated multiplex PCR system (Cobas Amplicor). Int JSTD AIDS 1998 Jan;9(1):21-24.

Competing interests: No competing interests

21 May 1998
A A Opaneye
Consultant G U Medicine
Middlesbrough General Hospital
Re: Plunged in at the deep end Kevin Molloy. 316:doi 10.1136/bmj.316.7142.1466a

May I comment on the perception of intubation and IPPV in Mission Hospitals being dependent on hi-tech monitoring. Nothing could be further from the truth: most episodes of intubation and IPPV this century will have taken place without capnography/digital pulse oximetry etc. The educated finger, the Mk1 eyeball and a manually operated BP cuff is more than sufficient: training, understanding the physiology and experience will suffice.

May I also comment on the editorial advocating caution when on an elective period: as one who has spent many years in the Third World including three years in Nepal where I was the sole UK trained anesthetist and gave the anaesthesia for the first ever cardiac operation in that country--without capnography or pulse oximetry--and where medical students were always welcomed, I felt that the editors where only half way down the steps of their ivory tower. Talking about "patient's rights" is all fine and dandy when that patient as a citizen possess basic human rights. These, like medical care--and UK medical students--are rare commodities throughout most of the Thirld World.

Competing interests: No competing interests

21 May 1998
Richard Knight
Cons Anaesthetist
King Faisal Specialist Hospital Riyadh KSA
Re: How should different life expectancies be valued? Norman Waugh, David Scott. 316:doi 10.1136/bmj.316.7140.1316

Waugh and Scott suggested that the benefits of a life year gained may be more if the duration of life left is shorter, and invited BMJ readers to comment on how weightings should be used to guide commissioners of health care.(1) How this problem should be approached must depend on the reasons the authors have in mind for their suggestions, and these reasons should be made explicit.

It may be argued that patients, their dependants or the society may potentially derive higher benefits for the time closer to death. For the patients, they can make preparations for the arrangements of their estates and the care of their dependants; to complete their work for which they have unique abilities; to say goodbye to their relatives, friends and acquaintances; and to come to terms with their deaths. Their dependants and family members may benefit from the financial and practical arrangements made and possibly reduce the risks of complicated grief.(2) The society may benefit from any work which the patient may be in a unique position to complete.

However, there are several difficult issues. Firstly, these factors apply more to some groups of patients than others. For example, older people may be more likely to have already made suitable arrangements for their estates, less likely to have dependants, and more likely to be psychologically prepared for death. It is difficult to have a policy which takes these factors into consideration without appearing inequitable. Secondly, the suggested higher benefits are entirely attributable to knowing the timing of one’s death earlier. If we endorse this approach, one may argue that it is cost-effective under some circumstances to screen for diseases for which no treatments are available. Thirdly, whilst only the average increase in life expectancy of a treatment and its costs are required for the traditional cost-utility analysis, we must also gather data on the variations for the increase in life expectancy if we wish to take into account the “duration of life left” effect in commissioning. Fourthly, some patients may prefer not to live with a death sentence over their heads for any period of time.

Most importantly, health professionals and BMJ readers are not in a better position than anyone else in judging the benefits associated with the “duration of life left” effect, and questionnaires to the general public using time trade-off methods would be more appropriate.

(394 words)

References

1 Waugh N, Scott D. How should different life expectancies be valued? BMJ 1998; 316: 1316. (25 April)

2 Parkes CM Bereavement in adult life. BMJ 1998; 316: 856-859

Competing interests: No competing interests

21 May 1998
Wai-Ching Leung
Senior Registrar in Public Health Medicine
Sunderland Health Authority, Durham Road, Sunderland SR3 4AF
Re: Rethinking NHS networking Justin Keen. 316:doi 10.1136/bmj.316.7140.1291

Editor,

Justin Keen raises a number of issues in his recent article(1) about the cost effectiveness of NHSnet for General Practices.

Firstly, he appears to present Internet as an alternative to NHSnet. Possibly implying there is a choice for practices between one or the other. In fact the Internet can be accessed from NHSnet though a secure gateway (though visa versa is not true - Internet users cannot browse NHSnet.) Thus practices connected to NHSnet can access useful Internet sites like Medline, Bandolier and the Cochrane Data base; as well as a range of on-line journals including the BMJ. These can be accessed directly using their Internet addresses or via sites designed to bring together useful sites of electronic information .

Secondly we believe that he has not taken into account the rate of development of General Practice computing. Increasing numbers, around 10%(2) , of GPs are now "paperless" - consulting just electronically. Many of these receive their pathology reports electronically but have to rely on scanning or manual summarising of paper hospital letters to ensure there is an electronic record of these hospital consultations. These documents could be passed from consultant's secretaries word processor to practice by electronic mail cutting out the expense of printing/postage/handling and manually entering/scanning the data into the GP system. There are large cost savings to be had if this information can be sent within a secure network. An ISDN (high-speed digital phone line) connection to the NHSnet can be acquired for less than the cost of setting up a scanning system.

Thirdly, creating links to source of good evidence is not given significant emphasis. The importance of "Clinical Governance" has been stressed in the recent White Paper(3) . Primary Care Groups of around 100,000 population will have to communicate and share policy -the NHSnet provides a secure medium within which this should take place. Information systems giving timely access to sources of Evidence Based Medicine (EBM) such as those listed above are a part of this. We have found in our project- the Doctors Desk(4) where pilot GP practices have been given access to these EBM sources via NHSnet that this information on the consulting room PC can be useful in decision making. Given the tools in an appropriately presented way NHSnet can be an information source to foster good practice.

(1) Keen J. Rethinking NHS networking BMJ 1998;316:1291-1293, 25 April

(2) Personal communication NHSE IMG Leeds, May 98.

(3) Department of Health. The new NHS: modern, dependable. London: Stationery Office, 1997(Cm 3807.)

(4) URL: Doctors Desk http://drsdesk.sghms.ac.uk

Competing interests: No competing interests

21 May 1998
Simon de Lusignan
Hon Senior Lecturer and GP & Research Fellow
Adrian Brown
St George's Hospital Medical School
Re: Rethinking NHS networking Justin Keen. 316:doi 10.1136/bmj.316.7140.1291

Keen constructed a positive case for a large scale NHS computer network using classical marginal economic analysis, pointed out the slow progress to date, and highlighted the need for long term changes in attitude and values.(1)

In fact, the Prisoner’s Dilemma completely explains the slow progress of networking. The complexity of the Prisoner’s Dilemma and the obstacles to success it presents have been extensively studied in economics (2) (3), business (4), and a wide range of other situations5. The dilemma is based on a relatively simple story told by Albert Tucker, a mathematician. Two men charged with conspiracy to murder were arrested and put in separate cells. The police had no good evidence for conspiracy against them, but presented the following 3 options. If both confessed, each could expect a 8-year prison sentence. If one confessed, he would go free but the other could expect a 12-year sentence. If neither confessed, each could expect a 1-year sentence for affray.

Now, each prisoner was uncertain what his collaborator would do, but noted that he would have a lighter sentence if he confessed whatever his collaborator did. Hence, both confessed and each received a 8 year sentence. However, it is clear that the best outcome for them jointly would have been if neither confessed and each received a 1-year sentence.

Similarly, in deciding whether to get linked up with the NHSnet, each general practice will incur a higher net benefit if this is postponed until the majority of NHS bodies are connected. This decision is entirely rational even if they are fully convinced of the arguments of the marginal economic analysis on the NHS as a whole as advocated by Keen.(1)

This dilemma is even more difficult to resolve than the simple prisoners’ story, as there are many general practices and NHS bodies each with numerous decision-makers unknown to them. Kay (4) argued convincingly that consummate co-operation (where parties work together to a mutual end, responding flexibly, sharing skills and information) will not solve the Prisoner’s Dilemma. He argued that the two possible solutions are changing the structure of the pay-offs (e.g. subsidising the cost of joining the NHSnet and penalising those who refuse to join) and “perfunctory” co-operation (e.g. legal regulations coupled with threat of sanctions).

(373 words)

References

1) Keen J. Rethinking NHS networking BMJ 1998: 316: 1291-3. (25 April.)

2) Samuelson PA, Nordhaus WD. Economics. New York: McGraw-Hill Inc, 1992

3) Fudenberg D, Tirole J. Game Theory. Massachusetts: MIT Press, 1992.

4) Kay J. Foundations of Corporate Success. Oxford: Oxford University Press, 1993.

5) Poundstone W. Prisoner’s Dilemma. Oxford: Oxford University Press, 1993.

Competing interests: No competing interests

21 May 1998
Wai-Ching Leung
Senior Registrar in Public Health Medicine
Sunderland Health Authority, Durham Road, Sunderland SR3 4AF
Re: Protecting the public from risk of harm Lorraine E Ferris. 316:doi 10.1136/bmj.316.7137.1033

Ferris reported Ontario’s forthcoming regulatory law requiring doctors to inform the authorities when a patient threatens serious harm to others and violence is considered likely.(1) She argued that this international precedent would protect doctors, patient and the public. However, I believe that she did not fully consider the advantages of permissive over mandatory reporting.

Permissive reporting in England and Wales has not left doctors open to litigation. It is clear from a Court of Appeal decision (2) that a doctor will not be held liable for a breach of duty of confidence if he reports a patient’s risk of violence to the authority in the interests of public safety. The GMC is also unlikely to find a doctor guilty of serious professional conduct(3) acting in good faith under these circumstances, especially as the standard of proof required for this charge is “beyond reasonable doubt”. On the other hand, if a doctor makes an informed judgement not to report, she is also unlikely to be held liable to an injured third party, as English law does not generally impose a liability for the acts of a third party.

With a mandatory reporting system, however, patients with a violent tendency due to their psychiatric disorders may be deterred from seeking treatment by fear of being reported. This may exacerbate the difficulty of establishing rapport with and securing compliance from this group of patients. Not only will this be detrimental to the patients, the public will be exposed to a higher risk of violence.

In fact, similar dilemma applies to reporting patients harbouring potentially serious contagious diseases who refuse to take precautions to avoid infecting others. The need to encourage potential infected patients to seek advice was considered at length in a High Court case(4), and also accounted for the decision not to make AIDS a notifiable disease in England and Wales.

Even psychiatrists are not accurate in predicting violent behaviour in their patients.(5) Considering doctors are much better in predicting the risks of transmission of serious infectious disease than predicting the risk of violence, it is perhaps surprising that reporting violence is given a higher priority than reporting infectious disease with potential consequences to others which are equally serious.

(366 words)

References

1) Ferris LE. Protecting the public from risk of harm BMJ 1998; 316:1033-4 (4 April)

2) W v Egdell [1990] 1 All ER 835

3) General Medical Council. Duties of a doctor - confidentiality, London: GMC, 1995.

4) X v Y and others [1988] 2 All ER 648

5) Janofsky JS, Spears S, Neubauer DN. Psychiatrists’ accuracy in predicting violent behaviour on an inpatient unit. Hospital and Community Psychiatry 1988; 39(10): 1090-4

Competing interests: No competing interests

21 May 1998
Wai-Ching Leung
Senior Registrar in Public Health Medicine
Sunderland Health Authority, Durham Road, Sunderland SR3 4AF

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