Journal of the Royal Society of Medicine Volume 84 August 1991
in pain, and would mostly endorse their recommendations. However, certain issues merit further consideration. The marked sex difference in benzodiazepine use (user group 92% female) is surprising, as is its interpretation as due to a difference in pain threshold. This is at variance with our sample of 286 patients with chronic pain of various aetiologies referred for behavioural/cognitive management. While a third of both women and men took night sedation, a higher proportion of women took benzodiazepines by day, but not significantly so (25% women, 15% men). It would be most interesting to discover how frequently a strong gender difference emerges: simple audit of drug-taking in rheumatology outpatient clinic patients could answer this question. There are a great many variables which should be-considered before assuming medication consumptidn to be determined by a biological variable as equivocal as pain threshold. We were disappointed that patients' reports of quality and duration of sleep were not analysed: itmight have identified surprisingly little difference between groups. We- wotuld suggest that the sleep difficulties common in pain patients should be more systematically assessed', and targeted directly with non-pharmacological advice and treatment before the patient is given benzodiazepines. A range of behavioural and cognitive strategies for facilitating sleep can be very effective2. There is poor evidence on restoration of sleep or function by benzodiazepines, and we would strongly endorse Hardo and Kennedy's suggestion that counselling should be tried before benzodiazepine prescription. St Thomas' Pain Management Centre CHARLES PITHER St Thomas' Hospital AMANDA C DE C WILLIAMS Lambeth Palace Road, London SE1 7EH
References 1 Jenkins CD, Stanton B-A, Niemcryk SH, Rose RM. A scale for the estimation of sleep problems in clinical research. J Clin Epidemiol 1988;41:313-21 2 Lacks P. Behavioural treatment for persistent insomnia. New York: Pergamon, 1987 The author replies below:
I believe the marked sex difference in the use of
benzodiazepine in our study is multifactorial including: (1) The majority of arthritic patients attending the clinic were female and, this has also been noticed in a recent (unpublished) similar work done in Leeds. (2) Patients' attitude towards chronic arthritis/disability. (3) Social impact. In the recent similar work in Leeds we found that the majority of benzodiazepine-users were living alone. (4) Duration of illness. I agree that the quality and duration of sleep in the benzodiazepine group which is important was not properly investigated in our study. However, a second study results with detailed questionnaire about sleep is being analysed. We would be interested to learn from other rheumatology departments about their exrperience. P G HARDO
30 Clarendon Road Leed.s L82 9NZ
Adenocarcinoma of the gallbladder With reference to correspondence (June 1991 JRSM, p382) regarding our reot on adenocarcinoma of the gallbladder (February 1991 JRSM, p 84), we are
511
EXEMPT FUNDJERSEY INVESTMENT PLAN £12 BIL;LION FUND * Backed by a major financial institution it can provide you with tax-free benefits payable in sterling from Jersey to any part of the world. * A secure sterling investment and Norwich Union guarantees your Capital can never fall in value. * An.offshore tax-haven with guaranteed profit, with no risk and the investor retains control. * The fund has achieved an average growth of' between 16-20% since 1975. A Plan for the longer term investor (31-0 years) not looking for immediate income. This investment opportunity is available to all non-residents of the United. Kingdom, Isle of Man and Channel Islands. For further details please, contact Home & Overseas Ltd or return the coupon below to: Home & Overseas Ltd 10/12 Swan Place, Dublin 4, Ireland Tel:' 353-1-607355 Fax: 353-1-607348 Dl Please send full. details: Name Address
Date of Birth Amnount to invest single yearly
-(min. £5000) (min. £600)
512
Journal of the Royal Society of Medicine Volume 84 August 1991
grateful to Dr Bolger and Ramakrishnan for pointing out the reference omission and for the opportunity to reply. The value of radiotherapy for the treatment of adenocarcinoma of the gallbladder is still controversial and any detected improvement in survival reported is measured only in terms of months. Houry et al.1 report the largest series of patients followed after radiotherapy treatment. Their study suggests that there was some improvement in those patients treated after palliative surgery, or with unresectable lesions. There is no evidence available to support the use of routine adjuvant radiotherapy for in situ or intramucosal lesions. With regard to the comments by Dr Penman, the question arises as to what subsequent treatment should be offered after resection of an occult carcinoma of the gallbladder. For in situ tumours, cholecystectomy may suffice. However, invasive carcinoma, despite its poor prognosis, probably demands further local wedge resection of the gallbladder bed, with clearance of nodes at the porta to confirm staging of the disease. If gallbladder carcinoma is suspected at elective cholecystectomy, frozen section examination is recommended, to allow decision on further treatment to be made at the initial operation. Mr Carty and Johnston reiterate that patients with intramucosal disease alone still have a relatively poor 5-year survival rate. The controversies concerning treatment of early adenocarcinoma of the gallbladder may justify creation of a national register of cases, to determine the true incidence and prevalence of the disease and to establish the current consensus on treatment. P BURGESS Department of Surgery, Newcastle General Hospital, P D MURPHY Newcastle upon Tyne NE4 6BE M B CLAGUE Reference 1 Houry S, Schlienger M, Huguier M, Lacaine F, Penne F, Laugier A. Gallbladder carcinoma: role of radiation therapy. Br J Surg 1989;76:448-50
Wire-guided balloon coloplasty - a new treatment Balloon dilatation of colonic strictures, of various aetiologies, is becoming an increasingly used procedure. I would disagree with several points raised in the discussion ofthe paper by Baneijee et aL (March 1991 JRSM, p 136) 1 feel that colonoscopy with biopsy is an essential first step to elucidate the aetiology of the colonic stricture and therefore colonoscopy, with an accepted low complication rate, is not avoided. There are two methods of colonoscopic balloon dilatation. The first is passing a guide wire alongside the colonoscope, under direct vision. The balloon catheter, with a maximum diameter up to 40 mm, is then passed over the guide wire. For accurate placement, fluoroscopic screening can be used or the colonoscope can be re-inserted and the position of the balloon viewed directly. The second method is to pass the complete balloon dilatation system (Radiologic Limited, Letchworth) which is 2.8 mm in diameter, down the biopsy channel. The catheter can be positioned accurately, without removing the colonoscope. Strictures, even less than 1 cm, can be dilated up to 28 mm. Following this direct visualization ofthe proximal bowel is possible through the colonoscope.
I would feel that passing a guide wire or dilatation system under direct vision would be superior in terms of a lower complication rate than passing a dilator or guide wire system under fluoroscopic control, especially for more proximal colonic strictures. I M BAIN
Sandwell District General Hospital, Lyndon, West Bromwich, West Midlands B71 4HJ
Cardiac resuscitation: a panacea or an ethical decision? I was most interested in the article by Westwood et al. (November 1990 JRSM, p 713). Perhaps a better subtitle would have been 'a panacea or a curse'. One of my duties being to respond to 'Codes' in a hospital, I can hardly believe the ancient, suffering wrecks I am occasionally expected to resuscitate. There are those of us in the second half of life who, in spite of present good health, wish to miss an uncertain and inhibited future so are happy to call it quits when circumstances have so dictated. Following is the addendum to my own 'Do Not Resuscitate' order, which better expresses the attitude I wish was more common. When this fine heart of mine has ceased to beat, it is the time and accepted. Physicians' hands should stay their care; leave me in peace for I'm aware. Death, not unexpected at the end of this, a life so blessed with adventure, love and nothing missed.
Enough's enough; I've had my share no one should weep or even care; I died content, enjoyed my bones, may memories sing, I'm n'er alone. I need no choir or sad lament; so light the fire, drink well fo' me, I'm nae Hell bent but off wi' the birds to fly ag'in around the sun.
On Winters' nights you may hear my song or see me in the smoke; be not a'feared, I mean well to all, nae need fo' thee ta choke. The greatest thing about snuffing out like a light, is the favoured ability to avoid senility.
There's nothing morbid in this cry: Death has no fear for me, would others felt as I. EDWARD L MCNEIL
Tishlub House, Bedford, NY 10506-0507, USA
in pain, and would mostly endorse their recommendations. However, certain issues merit further consideration. The marked sex difference in benzodiazepine use (user group 92% female) is surprising, as is its interpretation as due to a difference in pain threshold. This is at variance with our sample of 286 patients with chronic pain of various aetiologies referred for behavioural/cognitive management. While a third of both women and men took night sedation, a higher proportion of women took benzodiazepines by day, but not significantly so (25% women, 15% men). It would be most interesting to discover how frequently a strong gender difference emerges: simple audit of drug-taking in rheumatology outpatient clinic patients could answer this question. There are a great many variables which should be-considered before assuming medication consumptidn to be determined by a biological variable as equivocal as pain threshold. We were disappointed that patients' reports of quality and duration of sleep were not analysed: itmight have identified surprisingly little difference between groups. We- wotuld suggest that the sleep difficulties common in pain patients should be more systematically assessed', and targeted directly with non-pharmacological advice and treatment before the patient is given benzodiazepines. A range of behavioural and cognitive strategies for facilitating sleep can be very effective2. There is poor evidence on restoration of sleep or function by benzodiazepines, and we would strongly endorse Hardo and Kennedy's suggestion that counselling should be tried before benzodiazepine prescription. St Thomas' Pain Management Centre CHARLES PITHER St Thomas' Hospital AMANDA C DE C WILLIAMS Lambeth Palace Road, London SE1 7EH
References 1 Jenkins CD, Stanton B-A, Niemcryk SH, Rose RM. A scale for the estimation of sleep problems in clinical research. J Clin Epidemiol 1988;41:313-21 2 Lacks P. Behavioural treatment for persistent insomnia. New York: Pergamon, 1987 The author replies below:
I believe the marked sex difference in the use of
benzodiazepine in our study is multifactorial including: (1) The majority of arthritic patients attending the clinic were female and, this has also been noticed in a recent (unpublished) similar work done in Leeds. (2) Patients' attitude towards chronic arthritis/disability. (3) Social impact. In the recent similar work in Leeds we found that the majority of benzodiazepine-users were living alone. (4) Duration of illness. I agree that the quality and duration of sleep in the benzodiazepine group which is important was not properly investigated in our study. However, a second study results with detailed questionnaire about sleep is being analysed. We would be interested to learn from other rheumatology departments about their exrperience. P G HARDO
30 Clarendon Road Leed.s L82 9NZ
Adenocarcinoma of the gallbladder With reference to correspondence (June 1991 JRSM, p382) regarding our reot on adenocarcinoma of the gallbladder (February 1991 JRSM, p 84), we are
511
EXEMPT FUNDJERSEY INVESTMENT PLAN £12 BIL;LION FUND * Backed by a major financial institution it can provide you with tax-free benefits payable in sterling from Jersey to any part of the world. * A secure sterling investment and Norwich Union guarantees your Capital can never fall in value. * An.offshore tax-haven with guaranteed profit, with no risk and the investor retains control. * The fund has achieved an average growth of' between 16-20% since 1975. A Plan for the longer term investor (31-0 years) not looking for immediate income. This investment opportunity is available to all non-residents of the United. Kingdom, Isle of Man and Channel Islands. For further details please, contact Home & Overseas Ltd or return the coupon below to: Home & Overseas Ltd 10/12 Swan Place, Dublin 4, Ireland Tel:' 353-1-607355 Fax: 353-1-607348 Dl Please send full. details: Name Address
Date of Birth Amnount to invest single yearly
-(min. £5000) (min. £600)
512
Journal of the Royal Society of Medicine Volume 84 August 1991
grateful to Dr Bolger and Ramakrishnan for pointing out the reference omission and for the opportunity to reply. The value of radiotherapy for the treatment of adenocarcinoma of the gallbladder is still controversial and any detected improvement in survival reported is measured only in terms of months. Houry et al.1 report the largest series of patients followed after radiotherapy treatment. Their study suggests that there was some improvement in those patients treated after palliative surgery, or with unresectable lesions. There is no evidence available to support the use of routine adjuvant radiotherapy for in situ or intramucosal lesions. With regard to the comments by Dr Penman, the question arises as to what subsequent treatment should be offered after resection of an occult carcinoma of the gallbladder. For in situ tumours, cholecystectomy may suffice. However, invasive carcinoma, despite its poor prognosis, probably demands further local wedge resection of the gallbladder bed, with clearance of nodes at the porta to confirm staging of the disease. If gallbladder carcinoma is suspected at elective cholecystectomy, frozen section examination is recommended, to allow decision on further treatment to be made at the initial operation. Mr Carty and Johnston reiterate that patients with intramucosal disease alone still have a relatively poor 5-year survival rate. The controversies concerning treatment of early adenocarcinoma of the gallbladder may justify creation of a national register of cases, to determine the true incidence and prevalence of the disease and to establish the current consensus on treatment. P BURGESS Department of Surgery, Newcastle General Hospital, P D MURPHY Newcastle upon Tyne NE4 6BE M B CLAGUE Reference 1 Houry S, Schlienger M, Huguier M, Lacaine F, Penne F, Laugier A. Gallbladder carcinoma: role of radiation therapy. Br J Surg 1989;76:448-50
Wire-guided balloon coloplasty - a new treatment Balloon dilatation of colonic strictures, of various aetiologies, is becoming an increasingly used procedure. I would disagree with several points raised in the discussion ofthe paper by Baneijee et aL (March 1991 JRSM, p 136) 1 feel that colonoscopy with biopsy is an essential first step to elucidate the aetiology of the colonic stricture and therefore colonoscopy, with an accepted low complication rate, is not avoided. There are two methods of colonoscopic balloon dilatation. The first is passing a guide wire alongside the colonoscope, under direct vision. The balloon catheter, with a maximum diameter up to 40 mm, is then passed over the guide wire. For accurate placement, fluoroscopic screening can be used or the colonoscope can be re-inserted and the position of the balloon viewed directly. The second method is to pass the complete balloon dilatation system (Radiologic Limited, Letchworth) which is 2.8 mm in diameter, down the biopsy channel. The catheter can be positioned accurately, without removing the colonoscope. Strictures, even less than 1 cm, can be dilated up to 28 mm. Following this direct visualization ofthe proximal bowel is possible through the colonoscope.
I would feel that passing a guide wire or dilatation system under direct vision would be superior in terms of a lower complication rate than passing a dilator or guide wire system under fluoroscopic control, especially for more proximal colonic strictures. I M BAIN
Sandwell District General Hospital, Lyndon, West Bromwich, West Midlands B71 4HJ
Cardiac resuscitation: a panacea or an ethical decision? I was most interested in the article by Westwood et al. (November 1990 JRSM, p 713). Perhaps a better subtitle would have been 'a panacea or a curse'. One of my duties being to respond to 'Codes' in a hospital, I can hardly believe the ancient, suffering wrecks I am occasionally expected to resuscitate. There are those of us in the second half of life who, in spite of present good health, wish to miss an uncertain and inhibited future so are happy to call it quits when circumstances have so dictated. Following is the addendum to my own 'Do Not Resuscitate' order, which better expresses the attitude I wish was more common. When this fine heart of mine has ceased to beat, it is the time and accepted. Physicians' hands should stay their care; leave me in peace for I'm aware. Death, not unexpected at the end of this, a life so blessed with adventure, love and nothing missed.
Enough's enough; I've had my share no one should weep or even care; I died content, enjoyed my bones, may memories sing, I'm n'er alone. I need no choir or sad lament; so light the fire, drink well fo' me, I'm nae Hell bent but off wi' the birds to fly ag'in around the sun.
On Winters' nights you may hear my song or see me in the smoke; be not a'feared, I mean well to all, nae need fo' thee ta choke. The greatest thing about snuffing out like a light, is the favoured ability to avoid senility.
There's nothing morbid in this cry: Death has no fear for me, would others felt as I. EDWARD L MCNEIL
Tishlub House, Bedford, NY 10506-0507, USA
