1595
Britain and Ireland, which are sustained by many strong influences, including history and local pride. Others (the Australasians for example) have managed things better, and have a single College which houses all the specialist associations under one roof. You seem to favour a similar arrangement here, and it would be interesting to have your advice as to where the roof should be. You will be pleased to know that the Royal College of Surgeons of England intends that the diploma of fellow should be awarded only on the completion of specialist training, as signalled by passing the intercollegiate test. This development is in line with the thinking of the Association of Surgeons, the British Orthopaedic Association, and the Association of Surgeons in Training. The European Community directives that affect medicine have been in place since 1976, and nothing new will happen with the introduction of the single market, except perhaps a change in attitude. We in this College are entirely ready for 1992. During the Eurochirurgie meeting in Paris this October we will, at the request of our French colleagues, be expounding the role of the Royal Colleges, and suggesting that the reconstructed FRCS might well provide a benchmark for a future European diploma in surgery, such as already exists in anaesthesia thanks to the efforts of our sister College. We do not consider the environment of an integrated Europe as "hostile". We welcome such integration as an opportunity both to learn from our peers and to contribute to the development of surgery. A free-standing medical Royal College, answerable to the profession and independent of Government, was of course an object of fear and loathing to the totalitarian regime of Bonaparte, which was why he suppressed it. Luckily, Wellington saw to it that our College was spared. Dialogues with Continental colleagues suggest that many would like to see such organisations reintroducedindeed a meeting was held in Strasbourg only last month to further the establishment of a European College of Surgeons. You should not dismiss the social advantages of a body which is charitable, forbidden to act in its members’ interests, is concerned with training, maintenance of standards, and protection of the public, furthers scientific advance, and commissions studies designed to improve the delivery of surgical care. Royal College of Surgeons of 35-43 Lincoln’s Inn Fields, London WC2A 3PN, UK
England,
Prevention of pressure
ADRIAN
MARSTON,
Chairman, External Affairs Board
sores
in your June 2 editorial that the document the King’s Fund Pressure Sore Study Group1 addressed itself "mainly to nurses and paramedical workers" suggests that you had given our document only a cursory glance. We clearly state that to be effective a strategy for pressure sore prevention and management "must be initiated at District level, with managerial endorsement, adequate funding, and the commitment of all health care professionals". Furthermore you conclude that, "Only when every patient with a suspected spinal cord injury, new stroke, or femoral neck fracture can be routinely admitted onto an APAM [alternating pressure air mattress] and nursed on it--or provided with an equivalent manual method of pressure relief-throughout the acute phase of his or her illness will we begin to see the end of pressure sores". This regretfully restricts pressure sore prevention and management to that of nursing care alone. It also shows a lack of awareness of the importance of medical assessment to identify and correct the cardiovascular and other factors predisposing to tissue hypoperfusion and hypoxia in acutely ill patients. Elderly people (the group most at risk) can lie in bed at home for long periods every night for many years without pressure sores developing. Extrinsic pressure may only become a clinically significant factor when acute illness has already reduced tissue perfusion. Then, appropriate surfaces upon which to rest patients have an important role in pressure sore prevention and management. Before APAMs are considered, however, the first step should be to review the quality of existing hospital mattresses. At the King’s Fund Centre we have received accounts that up to
SIR,-The
statement
produced by
40% of
mattresses in a hospital have proved useless if not dangerous, and of wards where as many as 20 of 24 mattresses have been known for many months to need replacement. It is for these and other concerns that we produced our strategy document for health districts. Our aim was to help to reduce avoidable human suffering and financial waste by offering guidelines by which all health professionals could work together to improve the prevention and management of pressure sores. It is gratifying that representatives from some fifty health districts in the UK have contacted us during the past eighteen months. Many of them have already defined or are now working on their own district policies on the basis of our guidelines.1 Academic Unit for the Care of the Charing Cross Hospital, London W6 8RF, UK
1.
Elderly,
BRIAN LIVESLEY
Livesley B The prevention and management of pressure sores in health districts. King’s Fund Centre for Health Services Development, a document produced by the Pressure Sore Study Group 1989. Available from the Academic Unit for the Care of the Elderly, Charing Cross Hospital, London.
Feminisation of medical
practice
SIR,—Those observers (May 12, p 1149) who believe that feminisation of medical practice would favourably affect the "veritable abattoir of hysterectomies" and the high rate of caesarean section would do well to look at India, where most obstetricians and gynaecologists are women. The two "wrongs", rather than being corrected, have got worse with the feminisation of obstetrics and gynaecology in India.1 An audit by us of one such "feminised" service in a private hospital revealed that the ratio of caesarean sections to vaginal deliveries rose from 1 in 19 in 1972 to 1 in 3 in 1988. The number of hysterectomies rose from 27 in 1983 to 121 by October, 1988, the number of beds and consultants in the specialty
remaining essentially unchanged. Whether women are "more empathic, and kinder and gentler altogether" in their dealings with other women is highly debatable. Our impression is that in India women are no different from men in their approach to patients-indeed, a prevalent belief among doctors is that women obstetricians tend to be brusque to the point of rudeness with patients in labour. One indulgent explanation offered is that, having gone through the experience themselves, such obstetricians believe the pain of childbirth to be quite bearable; and any empathy the obstetrician may have had with her patient rapidly diminishes with progression of the second stage. Surely, this aspect of human behaviour merits study rather than mere pious declarations by well-meaning feminists. SDM
Hospital,
Jaipur 302 015, India 1.
S. G. KABRA
RAMJI NARAYANAN
Pendey S, Jain M, Pandey LK. Ten year profile of caesarian section. J Obstet Gynaecol Ind 1986; 36: 448-51.
Centralised
laboratory services
SIR,-I was disappointed by Dr Webb’s (May 26, p 1284) interpretation of the Lothian Health Board’s review of its laboratory services. Unlike the arrangements you describe in your May 5 editorial on the Greater Glasgow Health Board, the review of laboratory services by the Lothian Health Board includes the heads of the laboratories, their senior technical colleagues, and doctors’ representatives. The Board has agreed, at least for the present, not to pursue competitive tendering of its laboratory services and to undertake this in-house review. There were two main reasons for this decision by the management team: firstly, I argued that effective National Health Service laboratories depend on close integration between their analytical, consultative, research, and teaching functions, which would be extremely vulnerable in a market based approach; and I secondly reported that I had been given assurances by all heads of laboratories that a review of their
1596
services would be timely and that some rationalisation and savings were possible. The amount to be saved is not predetermined and will emerge as the choices for change are presented. Your correspondent has drawn his conclusions about all laboratory services from an interim working document which relates only to clinical chemistry services: the Board has not yet begun its review of the other laboratory disciplines. This working document listed a range of possible options and each of these is being assessed against the stated requirements of users, and costed. An interim proposal to identify an area manager/director of clinical chemistry services was agreed by most of the review group to ensure better coordination of the laboratories than has been possible while each of the four laboratories is managed within a different unit. I expect that this person will be identified from among the senior staff in our clinical chemistry laboratories and that he or she will therefore have a wide understanding of the service. In the expectation that the Board’s management team will accept the recommendations of the review group-whatever their final choice may be---the clinical chemistry manager/director will be expected to implement them. Most heads of laboratories in Lothian Health Board have welcomed this opportunity to participate in the review and future planning of the services they provide. Department of Public Health Medicine, Lothian Health Board, Edinburgh EH3 7QQ, UK
HELEN ZEALLEY,
averaged electrocardiogram, are sensitive (94%) and specific (80%) for abnormalities on cardiac histology. These investigations are therefore necessary in patients with VT associated with a normal heart. The British Pacing and Electrophysiology Group is organising a nationwide database to study prognosis in such patients. Until more data are available clinicians should be aware that VT associated with a normal heart may not be a benign condition, and predictions about prognosis should be guarded in these circumstances.
J. S. GILL Cardiological Sciences, St George’s Hospital Medical School, University of London, London SW17 0RE, UK
D. E. WARD M. J. DAVIES A. J. CAMM
1. Mehta D, Odawara MD, Ward DE, McKenna WJ, Davies MJ, Camm AJ. Echocardiographic and histologic evaluation of the right ventricle in ventricular tachycardias of left bundle branch morphology without overt cardiac abnormality Am JCardiol 1989; 63: 939-44. 2. Mehta D, McKenna WJ, Ward DE, Davies MJ, Camm AJ. Significance of signal-averaged electrocardiography in relation to endomyocardial biopsy and ventricular stimulation studies in patients with ventricular tachycardia without clinically apparent heart disease. J Am Coll Cardiol 1989; 14: 372-79. 3. Mortality statistics: cause. Review of the Registrar General on deaths by cause, sex and age in England and Wales 1984, series DH2, no 11. London: HM Stationery Office, 1985. 4. Theine G, Nava A, Corrodo D, Rossi L, Penilli N. Right ventricular cardiomyopathy and sudden death in young people. N Eng l Med 1988; 318: 129-33.
Chief Administrative Medical Officer and Director of Public Health
Monoclonal
antibody to interleukin-2 graft rejection
receptor in liver Ventricular
extrasystoles and the healthy heart
SIR,—Although the main part of your April 14 editorial concerns the prognosis of isolated ventricular extrasystoles, whether these are at rest or at exercise, you infer that complex extrasystoles, including ventricular tachycardia (VT), in otherwise healthy individuals are benign. We suggest that this should be a guarded statement. VT in the absence of easily diagnosable underlying cardiac disease, such as ischaemic heart disease, cardiomyopathy, or congenital heart disease, is a fairly uncommon condition, arising in 5-10% of such cases seen in referral centres. During 3 years we have seen 50 patients with VT associated with a "normal" heart. The patients were young (mean age 39-7, SD 13-8 years) and a greater proportion were female (19) than usually seen in ischaemic heart disease. All our patients had documented attacks of VT. 40 had left-bundle-branch block-like morphology VT, inferring that these arise from the right ventricle, whereas 8 had right-bundle-branch block-like morphology VT suggesting a left ventricular origin. In 2 patients attacks have been of different morphology on various occasions. Although the episodes of tachycardia were non-sustained in some patients (n = 20), many did have sustained episodes (n==30), and some had syncope (n = 18). Detailed investigation showed that 19 had underlying histological abnormalities of the myocardium on cardiac biopsy, including fibrosis (the predominant abnormality), fatty infiltration, and myocyte hypertrophy; in none was arrhythmogenic right ventricular dysplasia indicated. Histological abnormalities were often associated with an abnormal echocardiogram (n = 16) (which included detailed right heart views) and the presence of late-potentials on signal-averaged
SIR,-Monoclonal antibodies to interleukin-2 (IL-2) receptor have to prevent and treat acute rejection in kidney transplantation.1-4 In a pilot study we have evaluated the monoclonal CD25 antibody BT5635in the prevention of acute rejection in liver transplantation. In six consecutive patients the antibody (10 mg) was infused intravenously 3-5 h before recirculation of the graft. Thereafter 10 mg was given over 24 h for 10 days; subsequently 10 mg was given intravenously every other day for 10 days. The controls were six patients transplanted immediately before the pilot study. Both groups were given methylprednisolone, azathioprine, and cyclosporin. Biopsy in the controls was done only if clinically indicated, whereas the patients on BT563 therapy underwent biopsies on days 7,14, and 21. The indications for treatment of acute rejection were an increase in bilirubin, concomitant with raised transaminases and histopathological changes. been used
One control died from recurrent tumour after 5 months. The other five are in good health 5-7 months after transplantation. All six patients given BT563 are alive and well at 2-4 months. In five
electrocardiogram (n = 11).2 In this group we have had 2 deaths during the 3 years, 1 related to surgery for severely symptomatic VT and the other sudden, both in patients with histological abnormalities of the myocardium. This rate exceeds the expected mortality in this age group. Other groups have also noted that VT in individuals with apparently normal hearts may be associated with a high mortality.’ This presents the clinician with a dilemma: should these patients who may have normal hearts and be at low risk of sudden death be intensively investigated and treated, or should few investigations be done, with the drawback that under-investigation may miss a patient with myocardial abnormality who may be at substantial risk? Our data suggest that two non-invasive investigations, an abnormal echocardiogram and the presence of late potentials on signal-
Greatest postoperative (days 5-14) increase in bilirubin and concomitant alteration in transaminases.
0 = control patients A-F (all but patient F treated for rejection). patients 1-6 (only patient 5 treated for rejection).
. = BT563 treated
Britain and Ireland, which are sustained by many strong influences, including history and local pride. Others (the Australasians for example) have managed things better, and have a single College which houses all the specialist associations under one roof. You seem to favour a similar arrangement here, and it would be interesting to have your advice as to where the roof should be. You will be pleased to know that the Royal College of Surgeons of England intends that the diploma of fellow should be awarded only on the completion of specialist training, as signalled by passing the intercollegiate test. This development is in line with the thinking of the Association of Surgeons, the British Orthopaedic Association, and the Association of Surgeons in Training. The European Community directives that affect medicine have been in place since 1976, and nothing new will happen with the introduction of the single market, except perhaps a change in attitude. We in this College are entirely ready for 1992. During the Eurochirurgie meeting in Paris this October we will, at the request of our French colleagues, be expounding the role of the Royal Colleges, and suggesting that the reconstructed FRCS might well provide a benchmark for a future European diploma in surgery, such as already exists in anaesthesia thanks to the efforts of our sister College. We do not consider the environment of an integrated Europe as "hostile". We welcome such integration as an opportunity both to learn from our peers and to contribute to the development of surgery. A free-standing medical Royal College, answerable to the profession and independent of Government, was of course an object of fear and loathing to the totalitarian regime of Bonaparte, which was why he suppressed it. Luckily, Wellington saw to it that our College was spared. Dialogues with Continental colleagues suggest that many would like to see such organisations reintroducedindeed a meeting was held in Strasbourg only last month to further the establishment of a European College of Surgeons. You should not dismiss the social advantages of a body which is charitable, forbidden to act in its members’ interests, is concerned with training, maintenance of standards, and protection of the public, furthers scientific advance, and commissions studies designed to improve the delivery of surgical care. Royal College of Surgeons of 35-43 Lincoln’s Inn Fields, London WC2A 3PN, UK
England,
Prevention of pressure
ADRIAN
MARSTON,
Chairman, External Affairs Board
sores
in your June 2 editorial that the document the King’s Fund Pressure Sore Study Group1 addressed itself "mainly to nurses and paramedical workers" suggests that you had given our document only a cursory glance. We clearly state that to be effective a strategy for pressure sore prevention and management "must be initiated at District level, with managerial endorsement, adequate funding, and the commitment of all health care professionals". Furthermore you conclude that, "Only when every patient with a suspected spinal cord injury, new stroke, or femoral neck fracture can be routinely admitted onto an APAM [alternating pressure air mattress] and nursed on it--or provided with an equivalent manual method of pressure relief-throughout the acute phase of his or her illness will we begin to see the end of pressure sores". This regretfully restricts pressure sore prevention and management to that of nursing care alone. It also shows a lack of awareness of the importance of medical assessment to identify and correct the cardiovascular and other factors predisposing to tissue hypoperfusion and hypoxia in acutely ill patients. Elderly people (the group most at risk) can lie in bed at home for long periods every night for many years without pressure sores developing. Extrinsic pressure may only become a clinically significant factor when acute illness has already reduced tissue perfusion. Then, appropriate surfaces upon which to rest patients have an important role in pressure sore prevention and management. Before APAMs are considered, however, the first step should be to review the quality of existing hospital mattresses. At the King’s Fund Centre we have received accounts that up to
SIR,-The
statement
produced by
40% of
mattresses in a hospital have proved useless if not dangerous, and of wards where as many as 20 of 24 mattresses have been known for many months to need replacement. It is for these and other concerns that we produced our strategy document for health districts. Our aim was to help to reduce avoidable human suffering and financial waste by offering guidelines by which all health professionals could work together to improve the prevention and management of pressure sores. It is gratifying that representatives from some fifty health districts in the UK have contacted us during the past eighteen months. Many of them have already defined or are now working on their own district policies on the basis of our guidelines.1 Academic Unit for the Care of the Charing Cross Hospital, London W6 8RF, UK
1.
Elderly,
BRIAN LIVESLEY
Livesley B The prevention and management of pressure sores in health districts. King’s Fund Centre for Health Services Development, a document produced by the Pressure Sore Study Group 1989. Available from the Academic Unit for the Care of the Elderly, Charing Cross Hospital, London.
Feminisation of medical
practice
SIR,—Those observers (May 12, p 1149) who believe that feminisation of medical practice would favourably affect the "veritable abattoir of hysterectomies" and the high rate of caesarean section would do well to look at India, where most obstetricians and gynaecologists are women. The two "wrongs", rather than being corrected, have got worse with the feminisation of obstetrics and gynaecology in India.1 An audit by us of one such "feminised" service in a private hospital revealed that the ratio of caesarean sections to vaginal deliveries rose from 1 in 19 in 1972 to 1 in 3 in 1988. The number of hysterectomies rose from 27 in 1983 to 121 by October, 1988, the number of beds and consultants in the specialty
remaining essentially unchanged. Whether women are "more empathic, and kinder and gentler altogether" in their dealings with other women is highly debatable. Our impression is that in India women are no different from men in their approach to patients-indeed, a prevalent belief among doctors is that women obstetricians tend to be brusque to the point of rudeness with patients in labour. One indulgent explanation offered is that, having gone through the experience themselves, such obstetricians believe the pain of childbirth to be quite bearable; and any empathy the obstetrician may have had with her patient rapidly diminishes with progression of the second stage. Surely, this aspect of human behaviour merits study rather than mere pious declarations by well-meaning feminists. SDM
Hospital,
Jaipur 302 015, India 1.
S. G. KABRA
RAMJI NARAYANAN
Pendey S, Jain M, Pandey LK. Ten year profile of caesarian section. J Obstet Gynaecol Ind 1986; 36: 448-51.
Centralised
laboratory services
SIR,-I was disappointed by Dr Webb’s (May 26, p 1284) interpretation of the Lothian Health Board’s review of its laboratory services. Unlike the arrangements you describe in your May 5 editorial on the Greater Glasgow Health Board, the review of laboratory services by the Lothian Health Board includes the heads of the laboratories, their senior technical colleagues, and doctors’ representatives. The Board has agreed, at least for the present, not to pursue competitive tendering of its laboratory services and to undertake this in-house review. There were two main reasons for this decision by the management team: firstly, I argued that effective National Health Service laboratories depend on close integration between their analytical, consultative, research, and teaching functions, which would be extremely vulnerable in a market based approach; and I secondly reported that I had been given assurances by all heads of laboratories that a review of their
1596
services would be timely and that some rationalisation and savings were possible. The amount to be saved is not predetermined and will emerge as the choices for change are presented. Your correspondent has drawn his conclusions about all laboratory services from an interim working document which relates only to clinical chemistry services: the Board has not yet begun its review of the other laboratory disciplines. This working document listed a range of possible options and each of these is being assessed against the stated requirements of users, and costed. An interim proposal to identify an area manager/director of clinical chemistry services was agreed by most of the review group to ensure better coordination of the laboratories than has been possible while each of the four laboratories is managed within a different unit. I expect that this person will be identified from among the senior staff in our clinical chemistry laboratories and that he or she will therefore have a wide understanding of the service. In the expectation that the Board’s management team will accept the recommendations of the review group-whatever their final choice may be---the clinical chemistry manager/director will be expected to implement them. Most heads of laboratories in Lothian Health Board have welcomed this opportunity to participate in the review and future planning of the services they provide. Department of Public Health Medicine, Lothian Health Board, Edinburgh EH3 7QQ, UK
HELEN ZEALLEY,
averaged electrocardiogram, are sensitive (94%) and specific (80%) for abnormalities on cardiac histology. These investigations are therefore necessary in patients with VT associated with a normal heart. The British Pacing and Electrophysiology Group is organising a nationwide database to study prognosis in such patients. Until more data are available clinicians should be aware that VT associated with a normal heart may not be a benign condition, and predictions about prognosis should be guarded in these circumstances.
J. S. GILL Cardiological Sciences, St George’s Hospital Medical School, University of London, London SW17 0RE, UK
D. E. WARD M. J. DAVIES A. J. CAMM
1. Mehta D, Odawara MD, Ward DE, McKenna WJ, Davies MJ, Camm AJ. Echocardiographic and histologic evaluation of the right ventricle in ventricular tachycardias of left bundle branch morphology without overt cardiac abnormality Am JCardiol 1989; 63: 939-44. 2. Mehta D, McKenna WJ, Ward DE, Davies MJ, Camm AJ. Significance of signal-averaged electrocardiography in relation to endomyocardial biopsy and ventricular stimulation studies in patients with ventricular tachycardia without clinically apparent heart disease. J Am Coll Cardiol 1989; 14: 372-79. 3. Mortality statistics: cause. Review of the Registrar General on deaths by cause, sex and age in England and Wales 1984, series DH2, no 11. London: HM Stationery Office, 1985. 4. Theine G, Nava A, Corrodo D, Rossi L, Penilli N. Right ventricular cardiomyopathy and sudden death in young people. N Eng l Med 1988; 318: 129-33.
Chief Administrative Medical Officer and Director of Public Health
Monoclonal
antibody to interleukin-2 graft rejection
receptor in liver Ventricular
extrasystoles and the healthy heart
SIR,—Although the main part of your April 14 editorial concerns the prognosis of isolated ventricular extrasystoles, whether these are at rest or at exercise, you infer that complex extrasystoles, including ventricular tachycardia (VT), in otherwise healthy individuals are benign. We suggest that this should be a guarded statement. VT in the absence of easily diagnosable underlying cardiac disease, such as ischaemic heart disease, cardiomyopathy, or congenital heart disease, is a fairly uncommon condition, arising in 5-10% of such cases seen in referral centres. During 3 years we have seen 50 patients with VT associated with a "normal" heart. The patients were young (mean age 39-7, SD 13-8 years) and a greater proportion were female (19) than usually seen in ischaemic heart disease. All our patients had documented attacks of VT. 40 had left-bundle-branch block-like morphology VT, inferring that these arise from the right ventricle, whereas 8 had right-bundle-branch block-like morphology VT suggesting a left ventricular origin. In 2 patients attacks have been of different morphology on various occasions. Although the episodes of tachycardia were non-sustained in some patients (n = 20), many did have sustained episodes (n==30), and some had syncope (n = 18). Detailed investigation showed that 19 had underlying histological abnormalities of the myocardium on cardiac biopsy, including fibrosis (the predominant abnormality), fatty infiltration, and myocyte hypertrophy; in none was arrhythmogenic right ventricular dysplasia indicated. Histological abnormalities were often associated with an abnormal echocardiogram (n = 16) (which included detailed right heart views) and the presence of late-potentials on signal-averaged
SIR,-Monoclonal antibodies to interleukin-2 (IL-2) receptor have to prevent and treat acute rejection in kidney transplantation.1-4 In a pilot study we have evaluated the monoclonal CD25 antibody BT5635in the prevention of acute rejection in liver transplantation. In six consecutive patients the antibody (10 mg) was infused intravenously 3-5 h before recirculation of the graft. Thereafter 10 mg was given over 24 h for 10 days; subsequently 10 mg was given intravenously every other day for 10 days. The controls were six patients transplanted immediately before the pilot study. Both groups were given methylprednisolone, azathioprine, and cyclosporin. Biopsy in the controls was done only if clinically indicated, whereas the patients on BT563 therapy underwent biopsies on days 7,14, and 21. The indications for treatment of acute rejection were an increase in bilirubin, concomitant with raised transaminases and histopathological changes. been used
One control died from recurrent tumour after 5 months. The other five are in good health 5-7 months after transplantation. All six patients given BT563 are alive and well at 2-4 months. In five
electrocardiogram (n = 11).2 In this group we have had 2 deaths during the 3 years, 1 related to surgery for severely symptomatic VT and the other sudden, both in patients with histological abnormalities of the myocardium. This rate exceeds the expected mortality in this age group. Other groups have also noted that VT in individuals with apparently normal hearts may be associated with a high mortality.’ This presents the clinician with a dilemma: should these patients who may have normal hearts and be at low risk of sudden death be intensively investigated and treated, or should few investigations be done, with the drawback that under-investigation may miss a patient with myocardial abnormality who may be at substantial risk? Our data suggest that two non-invasive investigations, an abnormal echocardiogram and the presence of late potentials on signal-
Greatest postoperative (days 5-14) increase in bilirubin and concomitant alteration in transaminases.
0 = control patients A-F (all but patient F treated for rejection). patients 1-6 (only patient 5 treated for rejection).
. = BT563 treated
