Clinically pseudo-seizures may be mistaken for genuine fits as they are usually tonic-clonic in appearance, although occasionally manifesting as complex partial seizures. Certain features are helpful in differentiation, including gaze aversion, resistance to passive limb movement or eye opening, prevention of the hand falling on to the face, and induction by suggestion.3 Previously normal electroencephalograms, particularly during an attack, or normal serum prolactin concentrations during a pseudo-seizure can be useful in supporting the diagnosis.4 Status epilepticus is a medical emergency that requires prompt treatment with anticonvulsants. Patients with pseudo-status epilepticus, however, are more at risk from medical treatment than from their condition, and early recognition of pseudoseizures would avoid iatrogenic complications. This might be facilitated by rapid access to a register of patients with pseudo-seizures. The register should be held in local accident and emergency departments in the region as these patients may attend many hospitals. T B HASSAN T J UNDERHILL D JEFFERSON Derbyshire Royal Infirmary, Derby DE l 2QY 1 O'Brien MD. Management of status epilepticus in adults. BMJ 1990;301:918. (20 October.) 2 King DW, Callagher BB, Murvin AJ, et al. Pseudo-seizure:
diagnostic evaluation. Neurology 1982;32: 18-23. 3 Howell SJ, Owen L, Chadwick DW. Pseudo-status epilepticus. QJ Med 1989;266:507-19. 4 Collins WCJ, Lanigan 0, Callaghan N. Plasma prolactin concentrations following epileptic and pseudo-seizures.
J Neurol Neurosurg Psychiatry 1983;45:505-8.
The Ministry of Defence has assured us that in Northern Ireland currently only the above size of plastic bullet is being used with one size of charge, giving a muzzle velocity of roughly 250 km/h. R TOUQUET
St Mary's Hospital, London W2
I.AM BRENNAN
Trauma in pregnancy
JULIE HALFACRE
SIR,-Dr Pamela Nash and Mr Peter Driscoll quite rightly stress the priority of resuscitating the pregnant woman, assessment of the fetus forming part of the secondary survey.' One aspect that they only touched on is the need for caesarean section after maternal death or when maternal death seems imminent. There can surely be few tragedies greater than the delivery of a cerebrally damaged orphan secondary to maternal death and fetal anoxia. I would therefore be interested in their views on the cases in which women have major trauma during pregnancy and then have a cardiac arrest. It seems unlikely that external cardiac massage could maintain an adequate placental circulation for long, even in a normovolaemic patient. Prolonged unsuccessful attempts at resuscitation must clearly jeopardise fetal viability. At what stage and on what indication should caesarean section be undertaken if it is to result in the successful delivery of a healthy infant? P S WILKINS
West Middlesex University Hospital, Middlesex TW7 6AF 1 Nash P, Driscoll P. Trauma in pregnancy. BMJ7 1990;301:974-6.
(27 October.)
Plastic bullets in Northern Ireland SIR,-The article by Mr Robin Touquet and Dr Teresa Challoner is factually incorrect and requires comment.' Plastic bullets were first introduced in 1973 and replaced rubber bullets completely in 1975. In that time three people were killed by rubber bullets and 14 by plastic bullets, including seven children. The fatality rate is therefore one per 3857 bullets fired. The bullet comes in two sizes. The most commonly used is the 25 grain Teflon bullet, which weighs 135 g. We would disagree that the plastic bullet quickly loses its speed and kinetic energy because it is small and fairly light. It is far heavier and more accurate than the rubber bullet it replaced and was designed for short range use in an effort to immobilise rather than kill. It is important that doctors commenting on this controversial subject should at least be factually correct, and a film criticised for being "unsophisticated" should not be met by an equally unsophisticated review. A J RITCHIE
J R P GIBBONS Royal Victoria Hospital, Belfast BT12 6BA
AUTHORS' REPLY,-Before attempting a postmortem caesarean section it is essential to attain signs of fetal viability and confirm that the estimated gestational age is greater than 26 to 28 weeks. Fetal prognosis is based on the time interval between maternal death and delivery, with delivery within five minutes being associated with best fetal outcome and caesarean section at greater than 20 minutes being unlikely to produce a live fetus. Before a caesarean section is performed fetal viability must be ascertained and maternal cardiopulmonary resuscitation continued throughout. A vertical mid-line incision should be made through the abdominal layers into the uterus. The fetus is then removed from the uterine cavity and resuscitated by the paediatric team. The cord is clamped and the placenta removed. There have been occasional reported cases in which the mother has revived after delivery of the fetus, so it is worth continuing cardiopulmonary resuscitation after delivery of the child to assess the mother for signs of life. PAMELA NASH
Hillingdon Hospital, Middlesex UB8 3NN
PETER DRISCOLL
Hope Hospital, 1 Touquet R, Challoner T. Plastic bullets in Northern Ireland.
Salford M6 8HD
BMJ 1990;301:1053. (3 November.)
AUTHOR'S REPLY,-Messrs Ritchie and Gibbons are correct about the plastic bullet's weight: we meant to say that the bullet is large and fairly light. But the other statistics that we used, including those on fatalities, came from the army, and clarifying any discrepancies is difficult because the Ministry of Defence is reluctant to discuss details. We were told that there is one size of plastic bullet-3-7 cm by 10 cm, weighing 135 g. Rubber bullets were of a different size and had a different size of charge and thus a different muzzle velocity. They are no longer in use.
1332
We are currently studying the resuscitation skills of obstetric and midwifery staff and have found that the misconception that caesarean section is performed only to increase fetal survival to be commonplace. We would therefore commend readers to refresh their knowledge of resuscitation of pregnant women by reference to recently published reviews of the'subject such as that by Rees and Willis.2
SIR,-Dr Pamela Nash and Mr Peter Driscoll state that caesarean section is indicated when a pregnant woman has died after major trauma. ' We would like to emphasise the current view that caesarean section should not be regarded as a last ditch effort to save the fetus but as an important part of the armamentarium in maternal cardiopulmonary resuscitation.2 The mechanism for improved maternal survival probably includes complete resolution of aortocaval compression associated with emptying the uterus rather than partial relief brought about by using the lateral
position.'
Queen Charlotte's and Chelsea Hospital, London W6 OXG 1 Nash P, Driscoll P. Trauma in pregnancy. BMJ 1990;301:974-6.
(27 October.) 2 Rees GA, Willis BA. Resuscitation in pregnancy. In: Evanis FR, ed. ABC of Resuscitation. 2nd ed. London: BMJ, 1990:50-3. 3 Kerr MG, Scott DB, Samuel E. Studies of the inferior vena cava in late pregnancy. BMJ 1964;i:532-3.
Readmission rates SIR, -Certain points in the triad of papers by Dr Alan Clarke and colleagues'3 require further clarification. In calculating rates of readmission the inclusion of planned readmissions and day cases in the numerator and the use of live discharges as a denominator (rather than total deaths and discharges) may lead to artificial differences between specialties and services-for example, those where patients are routinely admitted to die. When audit of a sample of case notes of patients readmitted was undertaken as a means of determining avoidability of readmission, it should be remembered that this was in part an audit of the completeness of the documentation of those notes. In addition, a substantial proportion of notes were not obtainable, and one explanation might be that this group represented a subset of patients with chronic relapsing conditions whose case notes were required at day hospital or outpatient clinics, thus excluding a sizeable group with chronic or recurrent illness who would have been classified as unavoidable readmissions. At this juncture it would seem that no single measure is a reliable or robust indicator of outcome. Any combination of indices used for this purpose will require some estimation of case mix to be included. Until complete readmission data are available and responsive to case mix and severity it will not be possible properly to assess their potential role as part of an outcome indicator profile for an individual unit, hospital, or district. It is difficult to perceive a useful outcome indicator that is not subject to the "perverse incentive," whether by admission or discharge controls as well as the confounding factors of variability in community and primary care services. MARTIN SANDLER PETER MAYER
Family Services Unit, Selly Oak Hospital, Birmingham B29 6JD 1 Chambers C, Clarke A. Measuring readmission rates. BMJ 1990;301:1134-6. (17 November.) 2 Clarke A. Are readmissions avoidable? BMJ 1990;301:1136-8. (17 November.) 3 Milne R, Clarke A. Can readmission rates be used as an outcome indicator? BMJ 1990;301:1139-40. (17 November.)
Delayed detection of congenital hearing loss SIR,-We agree with Dr N J Wild and colleagues that hearing impairment in infants should be diagnosed as early as possible. ' We were interested that they found that no children were misdiagnosed as hearing impaired or unaffected by brain stem evoked audiometry. This technique assesses the
BMJ VOLUME 301
8 DECEMBER 1990
higher frequency range of the hearing spectrum, and there is therefore a theoretical risk that a child with appreciable low frequency deafness (which could adversely affect speech and language development) may have a normal result with this test. Such a child could be passed as having normal hearing. We performed a retrospective analysis of brain stem evoked audiometry carried out in Wolverhampton since 1985. We found two children in whom low frequency loss was not initially detected as the test gave a normal result. Both children had speech and language delay and required amplification, they were eventually fitted with hearing aids. We suggest that infants who are considered at high risk for deafness should be followed up until it is established that their hearing is normal, irrespective of the result of brain stem evoked audiometry. R T SHORTRIDGE N BULMER
Royal Hospital,
Wolverhampton WV2 I BT I Wild NJ, Sheppard S, Smithells RW, Holzel H, Jones G. Delayed detection of congenital hearing loss in high risk
infants. BMJ 1990;301:903-4. (20 October.)
Free tobacco promotion SIR,-Dr Martin Raw finds it odd that the Health Education Authority should propose extending the voluntary agreement between the government and the tobacco industry on sports sponsorship "when it has been shown that such agreements don't work."' The report's purpose is to show that the present voluntary agreement is both being breached and defective. The government is, at present, committed to voluntary agreements, and thus the report recommends that action should be taken to remedy the breaches and defects in the agreement to curtail the promotion of tobacco on BBC television programmes. Our longer term aim, however, is that there should be a total ban on all advertising, promotion, and sponsorship of cigarettes, tobacco products, and products bearing their brand names. To really work, this ban must be worldwide. SPENCER HAGARD Health Education Authority, London WCIH 9TX I Raw M. Massise free BBC tobacco promotion.
BMJ 1990;301:
1061. (10 November.)
Do streptococci cause toxic shock? SIR,-Dr Phillip Sanderson's editorial highlights several recent reports from the United States that implicate streptococcal pyrogenic exotoxin in the pathogenesis of a toxic shock syndrome.' In contrast a United Kingdom based survey found that severe streptococcal infection was usually associated with group A strains that produce exotoxin B; none of the strains tested produced exotoxin A.2 We suggest that strains producing exotoxin B are also capable of producing a toxic shock syndrome, which in the United Kingdom may be an important form of this condition. Septic scarlet fever was defined by Christie and Bisno as extrafaucial scarlet fever associated with septicaemia."4 We recently reported three such cases that were associated with cellulitis due to Streptococcus pyogenes group A (serotype Ml/Tl/OF-) in healthy young adults.' Organ failure occurred in each case, and despite prompt treatment two of the patients died. The crucial early clinical sign in all of the cases was punctate
BMJ
VOLUME
301
8
DECEMBER
1990
erythema, which spread rapidly to cover the entire body and which was most intense in the folds of the axilla, elbows, and knees; the rash was typical of scarlet fever. Desquamation of the skin over the palms of the hands and the soles of the feet as well as desquamation of the tongue also occurred but at a much later stage. Such a fine punctate erythema can easily be missed, be labelled as a toxic erythema, or be misclassified as a drug rash. As a result the appropriate serological streptococcal investigations may not be pursued. Streptococcal pyogenic exotoxin B was subsequently detected in the plasma from two of the three patients. No exotoxin A was detected. The minimum pyrogenic dose of exotoxin B is at least four times higher than that of either exotoxin A or exotoxin C, and exotoxin B does not enhance lethal endotoxin shock as well as exotoxins A and C.6 This suggests that exotoxin B is intrinsically or biologically less active than exotoxins A and C, and that it may thus produce a much wider spectrum of clinical syndromes than that associated with exotoxin A. We followed the standard recommendation and used high dose intravenous benzylpenicillin (12 million units/day) as primary treatment. Nevertheless, in one patient S pyogenes group A was isolated from a blood culture taken 48 hours after starting benzylpenicillin. Although toxin production undoubtedly contributed to the epithelial changes, conjunctivitis, and multiorgan failure in our patients, the Eagle effect may also have contributed to the high mortality. Eagle showed that the efficacy of penicillin falls as the number of S pyogenes organisms in muscle increases, such that it can become ineffective.7"9 Clindamycin and to a lesser extent erythromycin are not adversely affected by the Eagle effect. We suggest that doctors should consider changing from benzylpenicillin to clindamycin or erythromycin at an early stage of treatment with benzylpenicillin if the patient does not show a prompt improvement. SUNIL SHAUNAK St Mary's Hospital Medical School, LondonW2 lPG A M GORDON All Saint's Hospital,
Chatham ME4 5NG I Sanderson P. Do streptococci cause toxic shock? BM3r 1990;301: 1006-7. (3 November.) 2 Gaworzewska ET, Hallas G. Group A streptococcal infections and a toxic shock like syndrome. N EnglJ7 Med 1989;321:1546. 3 Christie AB. Infectious diseases. Edinburgh: Churchill Livingstone, 1987:1281-8. 4 Bisno AL. Streptococcus pyogenes. In: Mandell GL, Douglas RG, Bennett JE, eds. Principles and practice of infectos diseases. New York: Wiley, 1985:1124-33. 5 Shaunak S, Wendon J, Monteil M, Gordon AM. Septic scarlet fever due to Streptococcus pyogenes cellulitis. Q J Med
6 7
8
9
1988;69:921-5. Barsumian EL, Cunningham CM, Schlievert PM, Watson DW. Heterogeneity of group A streptococcal pyrogenic exotoxin B. Infect Immun 1978;20:512-8. Eagle H. Experimental approach to the problem of treatment failure with penicillin. 1. Group A streptococcal infection in mice. AmJ7 Med 1952;13:389-99. Stevens DL, Gibbons AE, Bergstrom R, Winn V. The Eagle effect revisited: efficacy of clindamycin, erythromycin, and penicillin in the treatment of streptococcal myositis. J Infect Dis 1988;158:23-8. Fried M, Rudensky B, Golan J, et al. Severe cellulitis caused by Group A streptococcus. _X Infect Dis 1990;161:155.
A painful process SIR,-Dr A Nicol recommends that necropsy should become routine practice. Although most pathologists recognise the value of the necropsy,2 the rate of necropsy remains low.3 In Peterborough, where the rate is 15%, a questionnaire was sent to all consultants in medicine, surgery, and geriatrics, and to their house officers, including senior house officers. The questionnaire included questions about attitudes to necropsy and to the requesting of permission
from relatives of the deceased. Fourteen consultants and 25 juniors took part. Of the consultants (six surgeons, five physicians, three geriatricians), all said that necropsy was important; one believed that it was important in only some cases. Six said that they wanted necropsies after all deaths, most said that they would like necropsies after around half, and one said only if the diagnosis was in doubt. Eight thought that juniors experienced difficulties in asking for necropsies, five thought that juniors had received some instruction in these matters, nine said that they offered tuition or guidance, and nine thought juniors would like or needed more instruction. All thought requests for necropsy should be made by medical staff; all but two said the house officer, with or without senior staff. Only one thought a bereavement councillor should be included. All 25 juniors recognised the value of the necropsy. Most requested two or three a month, and estimates of refusal rates ranged from none to 100% with an average of 48%. Twelve thought that necropsies should be requested by the house officer alone, seven by the house officer or senior staff, or both, four by senior staff alone, and one by a bereavement councillor alone. Many thought that, as house officers, they had the closest relationship with the patient's relatives. Eleven house officers experienced some difficulty in requesting necropsy. Seventeen said that they had received no help or instruction, and 18 said that they would like more guidance. Two, both Moslems, had religious objections to necropsy, and one of them actively discouraged relatives. The main point to emerge is that although both house officers and consultants acknowledged the value of the necropsy and accepted the role of junior staff in seeking permission, a need exists for more structured guidance and support by senior staff if a higher necropsy rate is to be attained. M D HARRIS Addenbrooke's Hospital, Cambridge CB2 2QQ 1 Nicol A. A painful process. BM, 1990;301:1165. (17 November.) 2 McGoogan E. The autopsy and clinical diagnosis. J R Coll Physicians Lond 1984;18:240-3. 3 Chana J, Rhys-Maitland R, Hon P, Scott P, Thomas C, Hopkins A. Who asks permission for an autopsy? J R Coll Physicians Lond 1990;24:185-8.
Using the citation index to assess performance SIR,-We would like to endorse the cautionary remarks regarding citation analyses made by Dr Bernard Dixon. I As librarians we are aware of the value of citation indices for judging the importance of a journal when faced with decisions for "deselection" because of shrinking budgets.2 We are, however, alarmed at the misuse of citation analyses in making value judgments on individuals. The main danger lies in extrapolating from the importance of a cited article or journal to the importance of the author or authors. It is the contents of a particular article that have prompted others to cite it, and the reasons for citing it are numerous.`- Citation behaviour is, on the whole, "uneven, unpredictable, and biased."6 Citation analyses are a measure of past performance for a particular year. They do not necessarily reflect the present ability or future potential of all the authors who have published in that year. It may even be misleading to judge a journal's importance or future impact by citation performance unless its performance is examined over several years. We have found that doctors and researchers, prodded by administrators and accreditation committees, use the impact factor for the previous year as a method for choosing the journal to which they will send their articles. This approach engenders a
1333
diagnostic evaluation. Neurology 1982;32: 18-23. 3 Howell SJ, Owen L, Chadwick DW. Pseudo-status epilepticus. QJ Med 1989;266:507-19. 4 Collins WCJ, Lanigan 0, Callaghan N. Plasma prolactin concentrations following epileptic and pseudo-seizures.
J Neurol Neurosurg Psychiatry 1983;45:505-8.
The Ministry of Defence has assured us that in Northern Ireland currently only the above size of plastic bullet is being used with one size of charge, giving a muzzle velocity of roughly 250 km/h. R TOUQUET
St Mary's Hospital, London W2
I.AM BRENNAN
Trauma in pregnancy
JULIE HALFACRE
SIR,-Dr Pamela Nash and Mr Peter Driscoll quite rightly stress the priority of resuscitating the pregnant woman, assessment of the fetus forming part of the secondary survey.' One aspect that they only touched on is the need for caesarean section after maternal death or when maternal death seems imminent. There can surely be few tragedies greater than the delivery of a cerebrally damaged orphan secondary to maternal death and fetal anoxia. I would therefore be interested in their views on the cases in which women have major trauma during pregnancy and then have a cardiac arrest. It seems unlikely that external cardiac massage could maintain an adequate placental circulation for long, even in a normovolaemic patient. Prolonged unsuccessful attempts at resuscitation must clearly jeopardise fetal viability. At what stage and on what indication should caesarean section be undertaken if it is to result in the successful delivery of a healthy infant? P S WILKINS
West Middlesex University Hospital, Middlesex TW7 6AF 1 Nash P, Driscoll P. Trauma in pregnancy. BMJ7 1990;301:974-6.
(27 October.)
Plastic bullets in Northern Ireland SIR,-The article by Mr Robin Touquet and Dr Teresa Challoner is factually incorrect and requires comment.' Plastic bullets were first introduced in 1973 and replaced rubber bullets completely in 1975. In that time three people were killed by rubber bullets and 14 by plastic bullets, including seven children. The fatality rate is therefore one per 3857 bullets fired. The bullet comes in two sizes. The most commonly used is the 25 grain Teflon bullet, which weighs 135 g. We would disagree that the plastic bullet quickly loses its speed and kinetic energy because it is small and fairly light. It is far heavier and more accurate than the rubber bullet it replaced and was designed for short range use in an effort to immobilise rather than kill. It is important that doctors commenting on this controversial subject should at least be factually correct, and a film criticised for being "unsophisticated" should not be met by an equally unsophisticated review. A J RITCHIE
J R P GIBBONS Royal Victoria Hospital, Belfast BT12 6BA
AUTHORS' REPLY,-Before attempting a postmortem caesarean section it is essential to attain signs of fetal viability and confirm that the estimated gestational age is greater than 26 to 28 weeks. Fetal prognosis is based on the time interval between maternal death and delivery, with delivery within five minutes being associated with best fetal outcome and caesarean section at greater than 20 minutes being unlikely to produce a live fetus. Before a caesarean section is performed fetal viability must be ascertained and maternal cardiopulmonary resuscitation continued throughout. A vertical mid-line incision should be made through the abdominal layers into the uterus. The fetus is then removed from the uterine cavity and resuscitated by the paediatric team. The cord is clamped and the placenta removed. There have been occasional reported cases in which the mother has revived after delivery of the fetus, so it is worth continuing cardiopulmonary resuscitation after delivery of the child to assess the mother for signs of life. PAMELA NASH
Hillingdon Hospital, Middlesex UB8 3NN
PETER DRISCOLL
Hope Hospital, 1 Touquet R, Challoner T. Plastic bullets in Northern Ireland.
Salford M6 8HD
BMJ 1990;301:1053. (3 November.)
AUTHOR'S REPLY,-Messrs Ritchie and Gibbons are correct about the plastic bullet's weight: we meant to say that the bullet is large and fairly light. But the other statistics that we used, including those on fatalities, came from the army, and clarifying any discrepancies is difficult because the Ministry of Defence is reluctant to discuss details. We were told that there is one size of plastic bullet-3-7 cm by 10 cm, weighing 135 g. Rubber bullets were of a different size and had a different size of charge and thus a different muzzle velocity. They are no longer in use.
1332
We are currently studying the resuscitation skills of obstetric and midwifery staff and have found that the misconception that caesarean section is performed only to increase fetal survival to be commonplace. We would therefore commend readers to refresh their knowledge of resuscitation of pregnant women by reference to recently published reviews of the'subject such as that by Rees and Willis.2
SIR,-Dr Pamela Nash and Mr Peter Driscoll state that caesarean section is indicated when a pregnant woman has died after major trauma. ' We would like to emphasise the current view that caesarean section should not be regarded as a last ditch effort to save the fetus but as an important part of the armamentarium in maternal cardiopulmonary resuscitation.2 The mechanism for improved maternal survival probably includes complete resolution of aortocaval compression associated with emptying the uterus rather than partial relief brought about by using the lateral
position.'
Queen Charlotte's and Chelsea Hospital, London W6 OXG 1 Nash P, Driscoll P. Trauma in pregnancy. BMJ 1990;301:974-6.
(27 October.) 2 Rees GA, Willis BA. Resuscitation in pregnancy. In: Evanis FR, ed. ABC of Resuscitation. 2nd ed. London: BMJ, 1990:50-3. 3 Kerr MG, Scott DB, Samuel E. Studies of the inferior vena cava in late pregnancy. BMJ 1964;i:532-3.
Readmission rates SIR, -Certain points in the triad of papers by Dr Alan Clarke and colleagues'3 require further clarification. In calculating rates of readmission the inclusion of planned readmissions and day cases in the numerator and the use of live discharges as a denominator (rather than total deaths and discharges) may lead to artificial differences between specialties and services-for example, those where patients are routinely admitted to die. When audit of a sample of case notes of patients readmitted was undertaken as a means of determining avoidability of readmission, it should be remembered that this was in part an audit of the completeness of the documentation of those notes. In addition, a substantial proportion of notes were not obtainable, and one explanation might be that this group represented a subset of patients with chronic relapsing conditions whose case notes were required at day hospital or outpatient clinics, thus excluding a sizeable group with chronic or recurrent illness who would have been classified as unavoidable readmissions. At this juncture it would seem that no single measure is a reliable or robust indicator of outcome. Any combination of indices used for this purpose will require some estimation of case mix to be included. Until complete readmission data are available and responsive to case mix and severity it will not be possible properly to assess their potential role as part of an outcome indicator profile for an individual unit, hospital, or district. It is difficult to perceive a useful outcome indicator that is not subject to the "perverse incentive," whether by admission or discharge controls as well as the confounding factors of variability in community and primary care services. MARTIN SANDLER PETER MAYER
Family Services Unit, Selly Oak Hospital, Birmingham B29 6JD 1 Chambers C, Clarke A. Measuring readmission rates. BMJ 1990;301:1134-6. (17 November.) 2 Clarke A. Are readmissions avoidable? BMJ 1990;301:1136-8. (17 November.) 3 Milne R, Clarke A. Can readmission rates be used as an outcome indicator? BMJ 1990;301:1139-40. (17 November.)
Delayed detection of congenital hearing loss SIR,-We agree with Dr N J Wild and colleagues that hearing impairment in infants should be diagnosed as early as possible. ' We were interested that they found that no children were misdiagnosed as hearing impaired or unaffected by brain stem evoked audiometry. This technique assesses the
BMJ VOLUME 301
8 DECEMBER 1990
higher frequency range of the hearing spectrum, and there is therefore a theoretical risk that a child with appreciable low frequency deafness (which could adversely affect speech and language development) may have a normal result with this test. Such a child could be passed as having normal hearing. We performed a retrospective analysis of brain stem evoked audiometry carried out in Wolverhampton since 1985. We found two children in whom low frequency loss was not initially detected as the test gave a normal result. Both children had speech and language delay and required amplification, they were eventually fitted with hearing aids. We suggest that infants who are considered at high risk for deafness should be followed up until it is established that their hearing is normal, irrespective of the result of brain stem evoked audiometry. R T SHORTRIDGE N BULMER
Royal Hospital,
Wolverhampton WV2 I BT I Wild NJ, Sheppard S, Smithells RW, Holzel H, Jones G. Delayed detection of congenital hearing loss in high risk
infants. BMJ 1990;301:903-4. (20 October.)
Free tobacco promotion SIR,-Dr Martin Raw finds it odd that the Health Education Authority should propose extending the voluntary agreement between the government and the tobacco industry on sports sponsorship "when it has been shown that such agreements don't work."' The report's purpose is to show that the present voluntary agreement is both being breached and defective. The government is, at present, committed to voluntary agreements, and thus the report recommends that action should be taken to remedy the breaches and defects in the agreement to curtail the promotion of tobacco on BBC television programmes. Our longer term aim, however, is that there should be a total ban on all advertising, promotion, and sponsorship of cigarettes, tobacco products, and products bearing their brand names. To really work, this ban must be worldwide. SPENCER HAGARD Health Education Authority, London WCIH 9TX I Raw M. Massise free BBC tobacco promotion.
BMJ 1990;301:
1061. (10 November.)
Do streptococci cause toxic shock? SIR,-Dr Phillip Sanderson's editorial highlights several recent reports from the United States that implicate streptococcal pyrogenic exotoxin in the pathogenesis of a toxic shock syndrome.' In contrast a United Kingdom based survey found that severe streptococcal infection was usually associated with group A strains that produce exotoxin B; none of the strains tested produced exotoxin A.2 We suggest that strains producing exotoxin B are also capable of producing a toxic shock syndrome, which in the United Kingdom may be an important form of this condition. Septic scarlet fever was defined by Christie and Bisno as extrafaucial scarlet fever associated with septicaemia."4 We recently reported three such cases that were associated with cellulitis due to Streptococcus pyogenes group A (serotype Ml/Tl/OF-) in healthy young adults.' Organ failure occurred in each case, and despite prompt treatment two of the patients died. The crucial early clinical sign in all of the cases was punctate
BMJ
VOLUME
301
8
DECEMBER
1990
erythema, which spread rapidly to cover the entire body and which was most intense in the folds of the axilla, elbows, and knees; the rash was typical of scarlet fever. Desquamation of the skin over the palms of the hands and the soles of the feet as well as desquamation of the tongue also occurred but at a much later stage. Such a fine punctate erythema can easily be missed, be labelled as a toxic erythema, or be misclassified as a drug rash. As a result the appropriate serological streptococcal investigations may not be pursued. Streptococcal pyogenic exotoxin B was subsequently detected in the plasma from two of the three patients. No exotoxin A was detected. The minimum pyrogenic dose of exotoxin B is at least four times higher than that of either exotoxin A or exotoxin C, and exotoxin B does not enhance lethal endotoxin shock as well as exotoxins A and C.6 This suggests that exotoxin B is intrinsically or biologically less active than exotoxins A and C, and that it may thus produce a much wider spectrum of clinical syndromes than that associated with exotoxin A. We followed the standard recommendation and used high dose intravenous benzylpenicillin (12 million units/day) as primary treatment. Nevertheless, in one patient S pyogenes group A was isolated from a blood culture taken 48 hours after starting benzylpenicillin. Although toxin production undoubtedly contributed to the epithelial changes, conjunctivitis, and multiorgan failure in our patients, the Eagle effect may also have contributed to the high mortality. Eagle showed that the efficacy of penicillin falls as the number of S pyogenes organisms in muscle increases, such that it can become ineffective.7"9 Clindamycin and to a lesser extent erythromycin are not adversely affected by the Eagle effect. We suggest that doctors should consider changing from benzylpenicillin to clindamycin or erythromycin at an early stage of treatment with benzylpenicillin if the patient does not show a prompt improvement. SUNIL SHAUNAK St Mary's Hospital Medical School, LondonW2 lPG A M GORDON All Saint's Hospital,
Chatham ME4 5NG I Sanderson P. Do streptococci cause toxic shock? BM3r 1990;301: 1006-7. (3 November.) 2 Gaworzewska ET, Hallas G. Group A streptococcal infections and a toxic shock like syndrome. N EnglJ7 Med 1989;321:1546. 3 Christie AB. Infectious diseases. Edinburgh: Churchill Livingstone, 1987:1281-8. 4 Bisno AL. Streptococcus pyogenes. In: Mandell GL, Douglas RG, Bennett JE, eds. Principles and practice of infectos diseases. New York: Wiley, 1985:1124-33. 5 Shaunak S, Wendon J, Monteil M, Gordon AM. Septic scarlet fever due to Streptococcus pyogenes cellulitis. Q J Med
6 7
8
9
1988;69:921-5. Barsumian EL, Cunningham CM, Schlievert PM, Watson DW. Heterogeneity of group A streptococcal pyrogenic exotoxin B. Infect Immun 1978;20:512-8. Eagle H. Experimental approach to the problem of treatment failure with penicillin. 1. Group A streptococcal infection in mice. AmJ7 Med 1952;13:389-99. Stevens DL, Gibbons AE, Bergstrom R, Winn V. The Eagle effect revisited: efficacy of clindamycin, erythromycin, and penicillin in the treatment of streptococcal myositis. J Infect Dis 1988;158:23-8. Fried M, Rudensky B, Golan J, et al. Severe cellulitis caused by Group A streptococcus. _X Infect Dis 1990;161:155.
A painful process SIR,-Dr A Nicol recommends that necropsy should become routine practice. Although most pathologists recognise the value of the necropsy,2 the rate of necropsy remains low.3 In Peterborough, where the rate is 15%, a questionnaire was sent to all consultants in medicine, surgery, and geriatrics, and to their house officers, including senior house officers. The questionnaire included questions about attitudes to necropsy and to the requesting of permission
from relatives of the deceased. Fourteen consultants and 25 juniors took part. Of the consultants (six surgeons, five physicians, three geriatricians), all said that necropsy was important; one believed that it was important in only some cases. Six said that they wanted necropsies after all deaths, most said that they would like necropsies after around half, and one said only if the diagnosis was in doubt. Eight thought that juniors experienced difficulties in asking for necropsies, five thought that juniors had received some instruction in these matters, nine said that they offered tuition or guidance, and nine thought juniors would like or needed more instruction. All thought requests for necropsy should be made by medical staff; all but two said the house officer, with or without senior staff. Only one thought a bereavement councillor should be included. All 25 juniors recognised the value of the necropsy. Most requested two or three a month, and estimates of refusal rates ranged from none to 100% with an average of 48%. Twelve thought that necropsies should be requested by the house officer alone, seven by the house officer or senior staff, or both, four by senior staff alone, and one by a bereavement councillor alone. Many thought that, as house officers, they had the closest relationship with the patient's relatives. Eleven house officers experienced some difficulty in requesting necropsy. Seventeen said that they had received no help or instruction, and 18 said that they would like more guidance. Two, both Moslems, had religious objections to necropsy, and one of them actively discouraged relatives. The main point to emerge is that although both house officers and consultants acknowledged the value of the necropsy and accepted the role of junior staff in seeking permission, a need exists for more structured guidance and support by senior staff if a higher necropsy rate is to be attained. M D HARRIS Addenbrooke's Hospital, Cambridge CB2 2QQ 1 Nicol A. A painful process. BM, 1990;301:1165. (17 November.) 2 McGoogan E. The autopsy and clinical diagnosis. J R Coll Physicians Lond 1984;18:240-3. 3 Chana J, Rhys-Maitland R, Hon P, Scott P, Thomas C, Hopkins A. Who asks permission for an autopsy? J R Coll Physicians Lond 1990;24:185-8.
Using the citation index to assess performance SIR,-We would like to endorse the cautionary remarks regarding citation analyses made by Dr Bernard Dixon. I As librarians we are aware of the value of citation indices for judging the importance of a journal when faced with decisions for "deselection" because of shrinking budgets.2 We are, however, alarmed at the misuse of citation analyses in making value judgments on individuals. The main danger lies in extrapolating from the importance of a cited article or journal to the importance of the author or authors. It is the contents of a particular article that have prompted others to cite it, and the reasons for citing it are numerous.`- Citation behaviour is, on the whole, "uneven, unpredictable, and biased."6 Citation analyses are a measure of past performance for a particular year. They do not necessarily reflect the present ability or future potential of all the authors who have published in that year. It may even be misleading to judge a journal's importance or future impact by citation performance unless its performance is examined over several years. We have found that doctors and researchers, prodded by administrators and accreditation committees, use the impact factor for the previous year as a method for choosing the journal to which they will send their articles. This approach engenders a
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