chart. Once treatment for acute asthma has been started how does the doctor or the patient know when the attack is over without some form of objective measurement? In my experience of using home monitoring of peak flow for this purpose it takes from one to 20 days for the diurnal variation to settle below 15%. A 47 year old woman consulted her general practitioner with severe acute asthma. She was distressed and had pulsus paradoxus of 20 mm Hg and a peak flow rate of 1301/min. After 10mg nebulised salbutamol, oxygen, and 40 mg oral prednisolone her reading had increased to only 140 1/min. The hospital medical registrar was asked to admit her. She returned to the surgery later that day, having been discharged by the registrar and told to take another 30mg prednisolone. The peak flow rate had not been measured, and the decision to discharge her had been based on normal findings on examination and a clear chest x ray film. She was treated in the community with high dose inhaled budesonide, terbutaline, and 60 mg prednisolone tablets daily and home monitoring of peak expiratory flow. It took nine days of treatment with high doses of oral prednisolone for her diurnal readings to settle within 15% of her best attainable value. Doctors working in hospitals often state that most deaths due to asthma occur in the community. The risk resulting from the early discharge of patients with uncontrolled acute asthma and the stress that their management puts on general practitioners may not be so well known. The British Thoracic Society's guidelines recommended that patients should be discharged to their general practitioner if their condition has improved one hour after treatment,2 but doctors may be lulled into a false sense of security during the early relief phase after nebulised treatment in patients with acute asthma. The guidelines also suggested that a peak flow meter should be provided in addition to the general practitioner following up the patient the next day, and I believe that this advice has the potential to considerably reduce readmissions to hospital and deaths from asthma. MARK LEVY GPs in Asthma Group, Kenton, Middlesex HA3 5JZ
1 Vathenen AS, Cooke NJ. Home peak flow meters. BMJ 1991; 302:738. (30 March.) 2 British Thoracic Societv. Guidelines for managcment of asthma in adults: II-acute severe asthma. BMJ7 1990;301:797-800.
Triage of x ray films? SIR,-I should like to reply to several points made by H J Nawrocka and J D Nawrocki' about our paper.2 I believe that the extra category of "insignificantly abnormal" is valid. The study was set up to see whether radiographers could take over instant casualty reporting from radiologists. As radiologists, we are continually being asked by clinicians whether an abnormality is significant. Radiographers providing a casualty reporting service should be able to make these distinctions as the decision is not always clinical. We emphasised that we were comparing the radiographers with the current reporting arrangements, which are partly provided by junior radiologists. An instant reporting system provided entirely by experienced consultants would be ideal, but to compare radiographers with such a system would be unrealistic. To claim that radiographers' seniority has been shown to affect their accuracy is overstating the case. Berman et al said that "performance correlated reasonably well with seniority" but did not back this up with any
figures.3 Finally, however, I am pleased that we agree that radiographers are an underused resouce in the casualty department, as shown by Mr I K
1210
Dukes.' I firmly believe that radiographers should be offered the opportunity of extra training in interpreting x ray films obtained in casualty departments. Our department is currently trying to obtain funding for a formal assessment of such training. I G H RENWICK
Department of Radiology, St James's University Hospital, Leeds LS9 7TF 1 Nawrocka HJ, Nawrocki JD. Triage of x ray films? BMl7 1991;302:1024. (27 April.) 2 Renwick IGH, Butt WP, Steele B. How well can radiographcrs triage x ray films in accidenit and emergency departments? BMVJ 1991;302:568-9. (9 March.) Ebar 3 Berman L, de Lacey G, Twomey E, Twomey B, Welch T, R. Reducing errors in the accident and emergency department: a simple method using radiographers. B.IJr 1985;290:421-2. 4 Dukes IK. Triage of x ray films? BlMJ 1991;302:1023-4. (27 April.)
Misuse of temazepam SIR,-As chairman of the Advisory Council on the Misuse of Drugs, I am writing to express the council's serious concern about the illicit misuse of temazepam. It seems that there is a significant diversion of temazepam into the illicit drug market. As a result of commendable cooperation from the pharmaceutical industry the liquid filled capsules of temazepam have now been phased out after a reformulation by the manufacturers. It was hoped that this would prevent drug misusers injecting the contents of such capsules. There is evidence, however, that the new gel filled capsules are now being used by determined misusers, who liquefy the contents by heating before injecting. The council would be pleased if doctors would take this information into account when prescribing temazepam, be aware of how much temazepam is being prescribed to a patient, and assess whether a new patient requesting a prescription for temazepam is acting in good faith. D G GRAHAME-SMITH Chairman
Advisory Council on the Misuse of Drugs, Home Office, London SW I H 9AT
with the need for a continuing high standard of daily care. A "healthy" child with the disease is not necessarily one who does not require an allowance; he or she has probably benefited from comprehensive treatment. Among paediatric patients this treatment is provided primarily by the parents. We have conducted a survey of patients attending the Cardiff cystic fibrosis clinic to see whether they have been granted an attendance allowance. Among the 59 patients who have applied for the allowance 54 have been successful eventually, some after several applications, which for one family included correspondence with their member of parliament. Forty two receive the day allowance and 12 the combined day and night allowance. This success rate of 92% makes a convincing case for the allowance to be available automatically to all who apply. Although the allowance relates to treatment needed (not necessarily to treatment given), we compared the degree of disease among those in our clinic who do and those who do not receive the allowance (using the Schwachman score for general health and the Chrispin-Norman score for features in chest x ray films). The table shows the results. No differences were found in any of the values between any of the groups (Mann-Whitney U test). A report of the Royal College of Physicians on cystic fibrosis in adults stated that, "Certain statutory benefits and allowances are payable in particular situations: these include mobility allowance and attendance allowance, but the success rate of applications is notoriously variable."2 Parents who work hard to preserve and prolong the lives of their children with cystic fibrosis should not be subjected to the harassment of applications, reapplications, and reviews (which for some patients result in the allowance being removedthe disease is, after all, progressive) and the feelings of grievance that these engender. Cystic fibrosis is the most common inherited chronic disease in the United Kingdom; it results in considerable morbidity and limited life expectancy. An attendance allowance (or its equivalent, as it is currently being reviewed) should be available as of right. GWYNETH OWEN SABINE MAGUIRE HENRY RYLEY MARY C GOODCHILD
Attendance allowance for patients with cystic fibrosis
Cystic Fibrosis Unit, Department of Child Health, University Hospital of Wales, Cardiff CF4 4XW
SIR,-We agree wholeheartedly with most of the sentiments expressed by Drs S A Peters and C J Rolles in their letter on the attendance allowance with respect to patients with cystic fibrosis.' We also believe that the allowance should be granted to all paediatric patients with cystic fibrosis, at least at the lower rate (usually synonymous with the day allowance). In our opinion, only some patients would qualify for the higher- rate (day and night allowance), and for these applicants a medical assessment would be appropriate, preferably done by a doctor thoroughly familiar with the disease and the consequences of its treatment. As Drs Peters and Rolles say, "Good health and improving life expectancy in cystic fibrosis are directly linked to diligent daily treatment." There is a natural variation in the manifestations and severity of cystic fibrosis, which is governed to some degree by genetic factors, but such considerations are of secondary importance compared
1 IPeters SA, Rolles CJ. Attendance allowance. BAM 1991;302:966. 20 April.') 2 Royal College of Physicians. C(vstic fibrosis in adults. Recornmendations for care of patients in the UK. Londoni: Royal Collegc of Physicians, 1990:10.
Obtaining a postgraduate qualification in Italy SIR,-Having gained postgraduate specialist qualifications in my country of origin, Italy, and having worked in the United Kingdom for a while, I know that Dr Jammi N Rao's interpretation of the specialist qualifications obtained in countries in the European Community' is incorrect, to say the least. In Italy, to obtain a postgraduate qualification
Degree of disease in all patients with cystic fibrosis at Cardiff clinic and in those receiving attendance allowance. Figures are mean (SD) values (and ranges)
All patients with cystic fibrosis Patients with day allowance (n=42) Patients with day and night allowance (n= 12)
Schwachman score (general health)
Chrispin-Norman score (features in chest x ray films)
Age (years)
84-2 (11-0) (43-98) n=93 84-3 (12-6) (43-98) 79-5 (11 -2) (60-91)
8-6 (5-0) (1-24) n=95 8-4 (5 0) (2-24) 11-3 (6-4) (5-23)
8-9 (5-3) (1-27) n=98 8 8 (4-2) (3-18) 9-5 (2-8) (4-14)
BMJ
VOLUME 302
18 MAY 1991
1 Vathenen AS, Cooke NJ. Home peak flow meters. BMJ 1991; 302:738. (30 March.) 2 British Thoracic Societv. Guidelines for managcment of asthma in adults: II-acute severe asthma. BMJ7 1990;301:797-800.
Triage of x ray films? SIR,-I should like to reply to several points made by H J Nawrocka and J D Nawrocki' about our paper.2 I believe that the extra category of "insignificantly abnormal" is valid. The study was set up to see whether radiographers could take over instant casualty reporting from radiologists. As radiologists, we are continually being asked by clinicians whether an abnormality is significant. Radiographers providing a casualty reporting service should be able to make these distinctions as the decision is not always clinical. We emphasised that we were comparing the radiographers with the current reporting arrangements, which are partly provided by junior radiologists. An instant reporting system provided entirely by experienced consultants would be ideal, but to compare radiographers with such a system would be unrealistic. To claim that radiographers' seniority has been shown to affect their accuracy is overstating the case. Berman et al said that "performance correlated reasonably well with seniority" but did not back this up with any
figures.3 Finally, however, I am pleased that we agree that radiographers are an underused resouce in the casualty department, as shown by Mr I K
1210
Dukes.' I firmly believe that radiographers should be offered the opportunity of extra training in interpreting x ray films obtained in casualty departments. Our department is currently trying to obtain funding for a formal assessment of such training. I G H RENWICK
Department of Radiology, St James's University Hospital, Leeds LS9 7TF 1 Nawrocka HJ, Nawrocki JD. Triage of x ray films? BMl7 1991;302:1024. (27 April.) 2 Renwick IGH, Butt WP, Steele B. How well can radiographcrs triage x ray films in accidenit and emergency departments? BMVJ 1991;302:568-9. (9 March.) Ebar 3 Berman L, de Lacey G, Twomey E, Twomey B, Welch T, R. Reducing errors in the accident and emergency department: a simple method using radiographers. B.IJr 1985;290:421-2. 4 Dukes IK. Triage of x ray films? BlMJ 1991;302:1023-4. (27 April.)
Misuse of temazepam SIR,-As chairman of the Advisory Council on the Misuse of Drugs, I am writing to express the council's serious concern about the illicit misuse of temazepam. It seems that there is a significant diversion of temazepam into the illicit drug market. As a result of commendable cooperation from the pharmaceutical industry the liquid filled capsules of temazepam have now been phased out after a reformulation by the manufacturers. It was hoped that this would prevent drug misusers injecting the contents of such capsules. There is evidence, however, that the new gel filled capsules are now being used by determined misusers, who liquefy the contents by heating before injecting. The council would be pleased if doctors would take this information into account when prescribing temazepam, be aware of how much temazepam is being prescribed to a patient, and assess whether a new patient requesting a prescription for temazepam is acting in good faith. D G GRAHAME-SMITH Chairman
Advisory Council on the Misuse of Drugs, Home Office, London SW I H 9AT
with the need for a continuing high standard of daily care. A "healthy" child with the disease is not necessarily one who does not require an allowance; he or she has probably benefited from comprehensive treatment. Among paediatric patients this treatment is provided primarily by the parents. We have conducted a survey of patients attending the Cardiff cystic fibrosis clinic to see whether they have been granted an attendance allowance. Among the 59 patients who have applied for the allowance 54 have been successful eventually, some after several applications, which for one family included correspondence with their member of parliament. Forty two receive the day allowance and 12 the combined day and night allowance. This success rate of 92% makes a convincing case for the allowance to be available automatically to all who apply. Although the allowance relates to treatment needed (not necessarily to treatment given), we compared the degree of disease among those in our clinic who do and those who do not receive the allowance (using the Schwachman score for general health and the Chrispin-Norman score for features in chest x ray films). The table shows the results. No differences were found in any of the values between any of the groups (Mann-Whitney U test). A report of the Royal College of Physicians on cystic fibrosis in adults stated that, "Certain statutory benefits and allowances are payable in particular situations: these include mobility allowance and attendance allowance, but the success rate of applications is notoriously variable."2 Parents who work hard to preserve and prolong the lives of their children with cystic fibrosis should not be subjected to the harassment of applications, reapplications, and reviews (which for some patients result in the allowance being removedthe disease is, after all, progressive) and the feelings of grievance that these engender. Cystic fibrosis is the most common inherited chronic disease in the United Kingdom; it results in considerable morbidity and limited life expectancy. An attendance allowance (or its equivalent, as it is currently being reviewed) should be available as of right. GWYNETH OWEN SABINE MAGUIRE HENRY RYLEY MARY C GOODCHILD
Attendance allowance for patients with cystic fibrosis
Cystic Fibrosis Unit, Department of Child Health, University Hospital of Wales, Cardiff CF4 4XW
SIR,-We agree wholeheartedly with most of the sentiments expressed by Drs S A Peters and C J Rolles in their letter on the attendance allowance with respect to patients with cystic fibrosis.' We also believe that the allowance should be granted to all paediatric patients with cystic fibrosis, at least at the lower rate (usually synonymous with the day allowance). In our opinion, only some patients would qualify for the higher- rate (day and night allowance), and for these applicants a medical assessment would be appropriate, preferably done by a doctor thoroughly familiar with the disease and the consequences of its treatment. As Drs Peters and Rolles say, "Good health and improving life expectancy in cystic fibrosis are directly linked to diligent daily treatment." There is a natural variation in the manifestations and severity of cystic fibrosis, which is governed to some degree by genetic factors, but such considerations are of secondary importance compared
1 IPeters SA, Rolles CJ. Attendance allowance. BAM 1991;302:966. 20 April.') 2 Royal College of Physicians. C(vstic fibrosis in adults. Recornmendations for care of patients in the UK. Londoni: Royal Collegc of Physicians, 1990:10.
Obtaining a postgraduate qualification in Italy SIR,-Having gained postgraduate specialist qualifications in my country of origin, Italy, and having worked in the United Kingdom for a while, I know that Dr Jammi N Rao's interpretation of the specialist qualifications obtained in countries in the European Community' is incorrect, to say the least. In Italy, to obtain a postgraduate qualification
Degree of disease in all patients with cystic fibrosis at Cardiff clinic and in those receiving attendance allowance. Figures are mean (SD) values (and ranges)
All patients with cystic fibrosis Patients with day allowance (n=42) Patients with day and night allowance (n= 12)
Schwachman score (general health)
Chrispin-Norman score (features in chest x ray films)
Age (years)
84-2 (11-0) (43-98) n=93 84-3 (12-6) (43-98) 79-5 (11 -2) (60-91)
8-6 (5-0) (1-24) n=95 8-4 (5 0) (2-24) 11-3 (6-4) (5-23)
8-9 (5-3) (1-27) n=98 8 8 (4-2) (3-18) 9-5 (2-8) (4-14)
BMJ
VOLUME 302
18 MAY 1991
