1337

(England and Wales) or a procurator fiscal in emergency departments in England worked (Scotland). Having and in Scotland we have noted striking differences in the application of the two reporting systems. A coroner will usually ask for a post-mortem examination in cases of uncertainty; a procurator fiscal, after discussion with the doctors concerned, may encourage certification of death without a necropsy. Therefore, in Scotland, more often than in England, part I of the death certificate will sometimes be based on the clinician’s "best guess" as to the cause of death, and in the absence of evidence to the contrary this is inevitably myocardial infarcdon/ischaemic heart disease. Although Scotland does have many reasons for a high prevalence of heart disease this apparent difference in legal practice may falsely increase published CHD mortality rates in some areas. be notified to

a coroner

Accident and

Emergency Department, Glasgow Royal Infirmary, Glasgow G4 OSF, UK

CHRISTOPHER MOULTON ALAN PENNYCOOK

1. Marmot MG.

Lifestyle and national and international trends in coronary heart disease mortality. Postgrad MedJ 1985; 60: 3-8. 2. Tunstall-Pedoe H, Smith WCS, Crombie IK. Levels and trends of coronary heart disease mortality in Scotland compared with some other countries. Health Bull (Scot) 1986; 44: 153-61. 3. Arrundale J, Cole SK. Death certification and mortality statistics. Health Bull (Edinb) 1991; 49: 82-90. 4. Tunstall-Pedoe H, Smith WCS, Crombie IK, Tavendale R. Coronary risk factor and lifestyle variation across Scotland: results from the Scottish Heart Health Study. Scot Med J 1989; 34: 556-60.

The Italian system for academic promotion is haphazard because people with no strong scientific background may be promoted to full professor while well-qualified scientists are rejected. We are not saying that other criteria are irrelevant to the appointment of professors of paediatrics. We simply wish to stress that publications in international journals, citations, and impact factors should be primary threshold criteria in validating the scientific maturity of candidates, which is required by the Italian law on academic promotion. The selection criteria must be modified, if only to reduce outflow of research workers from Italy. 3,4 Department of Allergy and Clinical Immunology, University "La Sapienza", 00185 Rome, Italy

F. AIUTI

Department of Pathology, University "La Sapienza"

C. BARONI

Department of Paediatrics, University of Cagliari

A. CAO

Department of Molecular Genetics, University "La Sapienza", Rome

A. FANTONI

1. Gaetani GF, Ferraris AM. Academic promotion in Italy. Nature 1991; 353: 10. 2. Fabbri LM. Rank injustices and academic promotion. Lancet 1987; ii: 860. 3. Amati P. Cammarano B, Fantoni A, Macino G. Troubles at Rome University. Nature 1990; 345: 658. 4. Cantani A. Problems of Rome University. Nature 1990; 346: 788.

Social Academic

promotion in Italy

SiR,—The unusual system of academic promotion to professor in Italian medical schools has received attention in scientific joumals.1,2 It has been reported that the winners of national competitions for both associate professor and full professor have significantly lower "scientific maturity" than the losers, as judged by the number of papers in international scientific journals, the number of citations, and impact factors. 1,2We report here the results of a national competition for full professors of paediatrics. Some of the winners had produced publications of low scientific value as judged on the above indices and did not have a single full paper in any language other than Italian. After almost 3 years of discussions a committee of five Italian full professors of paediatrics, appointed to promote 25 new full professors out of 74 candidates, released its verdict in September, 1991. After the first year, two members of the committee resigned and were replaced. We have evaluated, using the MEDLINE database, the scientific impact factor (SIF) of publications from 1960 to 1988 (1988 was the deadline for applications), the citation half-lives (HL), and the number of citations (provided in the Science Citation Index) of 5 winners and 5 losers. The 5 failures were selected in that they were given by a National University Council of Italian professors from different faculties and by the Minister of University and Scientific Research as examples of misjudgment. The 5 successes comprise 2 candidates also named by the minister and the council and 3 more selected at random. These scores for quantity and quality of scientific output were higher in the losers than in the winners, and 2 very well-known scientists were rejected:

inequalities in health

SiR.—Ms Whitehead and Mr Dahlgren’s report (Oct 26, p 1059) is encouraging and contains many good ideas. The main trouble in the UK is the lack of any national lead and commitment. Eleven years on1,2 the Department of Health plainly does not know what to do about a situation that shows little or no sign of resolving.3,4 There are several aspects of the issue of inequalities. The most sensitivethe worst and possibly deteriorating health of the poorest sections of the population-could also be the most critical to the Department’s strategic hopes for improving the health of the nation. Traditionally, the approach to such an impasse is the setting up of an independent committee of inquiry to assess and recommend. In the present instance a Royal Commission on social inequalities in health alone could have the necessary authority across government. Perhaps we should now be advocating this? Department of

Public Health and London School of Hygiene and Tropical Medicine, University of London, London WC1E 7HT, UK

Policy,

J. N. MORRIS

Department of Health. The health of the nation: a consultative document for health in England. London: HM Stationery Office, 1991. 2. Waldegrave W. The Independent, June 5, 1991. 3. Davey Smith G, Bartley M, Blane D. The Black report on socioeconomic inequalities in health 10 years on. Br Med J 1990; 301: 373-77. 4. Morris JN. Inequalities in health: ten years and little further on. Lancet 1990; 336: 1.

491-93.

Access to

patient records

SIR,—The Access to Health Record Act 1990 came into effect on Nov 1, 1991. There is much concern about the extra workload for doctors and record departments.! We have questioned the first 100 consecutive patients attending a busy oncology clinic in this centre. All patients had cancer (excluding squamous and basal cell carcinomas of skin). 17 were new referrals and 83 were attending for

follow-up (table). 91 % of patients

declined the offer records. The reasons stated were:

to

inspect

their medical

3 winners of the 5 evaluated by us are co-workers of members of the

committee. The Minister for University and Scientific Research has

postponed validation of these appointments and the committee has been asked

candidates.

to

look

again

at

the

same

same

list of

The oldest of the 9 patients who wished to inspect their records 83 and the youngest 35. Average inspection time was 5 min, apart from 1 patient who spent 55 min looking through his records. was

1338

intensity of the aiming beam, and 38% did not know whether their biomicroscopes had been fitted with filters. Only 27% had had their

PATIENT DETAILS

When asked, 7 of these 9 patients did not gain any new information. 1 patient corrected the details of the next of kin, and another patient with breast carcinoma, although she knew the diagnosis, was surprised by the size of the tumour. Our practice is to inform patients of their diagnosis when appropriate and to alert them to any development during followUp.2 This may be why only 9% requested inspection. We do not think that this Act will add much extra work for medical records staff or doctors. We propose that patients should be offered inspection of their records during their clinic visit when the notes would be readily available and any questions could be answered by the clinic nurse or the doctor. Regional Centre for Clinical Oncology, St Luke’s Hospital, Guildford GU1 3NT, UK

A. Y. ROSTOM A. R. GERSHUNY

K. Patient access to notes puts extra burden on doctor. Oct 17: 34. 2. Rostom AY. Talking about cancer Lancet 1980; ii: 481. 1.

Hay

Laser safety and

Hospital Doctor 1991;

ophthalmologists

SIR,-In 1989, Arden! reported that colour-contrast sensitivity, especially at short wavelengths, was impaired in doctors using medical lasers. These colour discrimination losses were the result of "flashbacks" from the aiming beam hitting the surface of the contact lens used during laser therapy. Independently, Arden and the College of Ophthalmologists3 wrote to all UK ophthalmologists recommending argon-green in preference to argon-blue lasers, short-wavelength filters for biomicroscopes, and a reduced intensity of the aiming beam used in photocoagulation treatment. What has been the impact of these guidelines and on ophthalmological practice in the UK? We sent a questionnaire to the consultant-in-charge of all NHS ophthalmology units using a directory of training posts,4 and sought information on ophthalmologists’ knowledge of laser-induced colour-vision damage and their compliance with safety recommendations. Using the 100-Hue test,s we measured colour discrimination before and immediately after a laser session in 10 ophthalmologists of average age (36) whose laser experience was between 1 and 10 years. All 10 had normal Snellen acuity and all had been following, for at least 12 months, the above safety guidelines. (Previously they had all used an argon-blue laser with a highintensity aiming beam and a biomicroscope without shortwavelength filters.) Colour discrimination was compared with that in 10 healthy, age-matched controls. The response rate was 53% (85/160). The respondents, of average age 48 years, were in charge of ophthalmology units and had on average 12 years of personal laser experience and were responsible for 5 other laser users. Almost all the units used argon lasers. 70% of respondents were aware that laser therapy could adversely affect their colour vision and most knew that flashbacks were a potential cause of colour discrimination loss in ophthalmologists. 35% had experienced between 1 and 20 flashbacks during their careers. However, one-third of consultantsin-charge denied having been warned of the hazard or being told about precautions. A similar proportion had not reduced the

colour vision assessed between 1985 and 1990. Colour discrimination in the 10 ophthalmologists was significantly worse than that in the controls: 100-Hue error scores averaged 512 (SE 16-3) for the ophthalmologists and 14-8 (48) for the controls (p < 001). 4 of them showed selective impairment of short-wavelength discrimination. Despite publications in UK and US ophthalmology joumals1,2,6 and guidelines from the College of Ophthahnologistsone-third of senior UK ophthalmologists denied having received any communication about the potential hazard to their colour vision of laser therapy and were not taking precautions. We found, much as Arden did,1,2,6 that colour discrimination was significantly worse in ophthalmologists. Professor Arden is now evaluating the natural history of laser-induced visual impairment by testing all UK ophthalmologists annually. Until the results of that work are known, every effort must be made to protect laser operators. Recommended safe practices seem to be effective, and should be instituted as soon as is practicable. We thank the ophthahnologists who took part in this Arden for helpful advice. K. J. H. is supported by Pharmaceutical Ltd.

study and Prof G. B. a

grant from Scotia

Department of Endocrinology and Diabetes, North Staffordshire Royal Infirmary, Stoke-on-Trent ST4 7LN, UK

KEVIN J. HARDY

Department of Ophthalmology, Wolverhampton Eye Infirmary

JONATHAN R. LIPTON

Department of Communication and Neuroscience, Keele University, Staffordshire DAVID H. FOSTER North Staffordshire

Royal Informary

JOHN H. B. SCARPELLO

1. Gunduz K, Arden GB. Changes m colour contrast sensitivity associated with operating argon lasers. Br J Ophthalmol 1989, 73: 241-46. 2. Beminger TA, Canning CR, Gunduz K, Strong N, Arden GB. Using argon laser blue light reduces ophthalmologists’ color contrast sensitivity. Arch Ophthalmol 1989; 107: 1453-58. 3. Anon. Lasers. Quart Bull Coil Ophthalmol 1990 (Spring) 4. Hawkins R, ed. The directory of training posts in ophthalmology. London. Hawker Publications, 1990. 5. Farnsworth D. The Farnsworth-Munsell 100-Hue test manual. Baltimore: Munsell

Color, 1957. GB, Berninger T, Hogg CR, Perry S A survey of color discrimination in German ophthalmologists: changes associated with the use of lasers and operating microscopes. Ophthalmology 1991, 98: 567-71.

6. Arden

Failure of chloroquine and proguanil prophylaxis in travellers to Kenya SIR,-Against a background of the rising frequency of imported Plasmodiumfalciparum malaria in Britain,! we are concerned about the still widely used prophylaxis of chloroquine and proguanil for travel to East Africa.2,3 12 patients with falciparum malaria have been admitted to our unit since mid-July, 1991,7 of whom acquired malaria in Kenya. 3 individuals were fully compliant with the standard prophylactic regimen for sub-saharan Africa-namely, chloroquine 300 mg base weekly and proguanil 200 mg daily. Of these 3 patients, 2 had mild infection with parasitaemias of less than 1 %. The remaining patient was a 21-year-old British woman who returned from a 2-week package holiday in coastal Kenya. 8 days later symptoms of frontal headache, nocturnal fever, and vertigo developed, while she was still taking chloroquine and proguanil. The diagnosis of malaria was not initially taken into account, and she received two courses of antibiotics from her general practitioner. On admission, she was anaemic, toxic, and hypotensive, with splenomegaly and a right retinal haemorrhage. Her haemoglobin was 6.9 g/dl, with a platelet count of 13 x 109/1, and there was evidence of disseminated intravascular coagulation. The blood film showed 18% parasitaemia with Pfalciparum. She made a full recovery with parenteral quinine therapy and intensive management. All 3 patients were advised to take chloroquine and proguanil by their

general practitioners. We would draw attention to such a potentially fatal failure of chloroquine and proguanil prophylaxis. Kenya is being intensively

Access to patient records.

1337 (England and Wales) or a procurator fiscal in emergency departments in England worked (Scotland). Having and in Scotland we have noted striking...
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