1150
unsigned
editorial alludes
to
the
same
unpublished
source.
If
The Lancet is to maintain its reputation for fairness it should review its editorial policy on this practice. Department of Neurology, Institute of Neurological Sciences, Southern General Hospital, Glasgow G51 4TF, and Department of Clinical Physics and Bio-Engineering, Glasgow
JOHN P. BALLANTYNE STIG HANSEN
THE NEW CONSULTANT CONTRACT
SIR,-It is interesting to see, in your review of Prof. James McCormick’s book The Doctor: Father Figure or Plumber (May 12, p. 1008), unprofessional conduct described as working to the clock, demanding overtime, and striking. This, it is stated, is likely to be seen in doctors whose incomes are continuing to fall in relative terms. Two of these features-working to the clock and demanding overtime-are to be seen in the proposed new so-called "work-sensitive" consultant contract. North Middlesex Hospital, London N18 1QX
M. G. REVILL
CLINICAL MEDICAL OFFICERS
SIR,-I write to support the view of Professor Forfar and the presidents of the Royal Colleges of Physicians and the British Pxdiatric Association in their letter of May 12, that the natural affiliation of most clinical medical officers "lies not with community medicine but with clinical paediatrics." This has been the expressed view of my Faculty from our beginning. We emphasise our abiding concern for the future of the child health service and acknowledge warmly our historical responsibility towards our clinical medical officer colleagues, who must have the same entitlement to vocational training and professional advancement in their chosen area of work as have those in other branches of medicine. Specialists in community medicine will, of course, continue to have an important role in the child health services in determining need for and facilitating the work of these services in the community. Faculty of Community Medicine of the Royal Colleges of Physicians of the United Kingdom, Royal College of Physicians, London NW1 4LE
JOHN BROTHERSTON, President
EDITORIAL INDEPENDENCE OF PRESCRIBERS’
JOURNAL SIR,-While applaud the publication of Prescribers’ journal and its circulation free of charge to all prescribing docwe
in the U.K., we feel we should draw attention to an incident which seems to indicate a form of censorship on the journal’s contents which may be unacceptable. One of us (J. H.) was invited to write a piece for Prescribers’ journal on the treatment of cardiac failure. In keeping with modern concepts and practice of treatment for this condition, the use of vasodilators such as nitrates was included in the discussion. To our surprise the manuscript was returned with a request that this section be omitted because cardiac failure has not yet been approved by the Committee on Safety of Medicines (C.S.M.) as an indication for use of drugs of this type, although they are well used for other cardiac indications such as angina and hypotension. After further correspondence, the Editorial Board of Prescribers’ Journal would not move from this
tors
which the Government-sponsored Prescribers’ Journal cannot publish guidance on the use of a medicine for a condition which has not been specifically approved by another Government body, the C.S.M. The C.S.M. itself does not initiate approval of a new indication unless requested to do so by the manufacturers of the medicine. Surely, doctors should not be deprived of advice on modern forms of drug treatment of which they may well be aware from other sources, nor should patients be deprived of their use, because of such censorship. The Editorial Board of Prescribers’ Journal should be freed from any restraints imposed by its Government sponsorship. Readers of the journal should be able to have confidence in the objectivity, impartiality, and excellence of its advice. St. Bartholomew’s Hospital Medical College, London EC1A 7BE
J. HAMER P. TURNER
NEUTROPENIA AFTER CONSECUTIVE TREATMENT COURSES WITH NAFCILLIN AND PIPERACILLIN
SIR,-Reversible neutropenia is an infrequent but wellknown complication of therapy with penicillin antibiotics and is most commonly associated with the administration of antistaphylococcal, semisynthetic penicillins. The administration of piperacillin sodium, a new semisynthetic penicillin with increased activity against gram-negative organisms, was associated with reversible leukopenia in 1 of 1266 patients who received the drug during Japanese trials (data on file of Lederle Laboratories). Dickinson et aU noted transient neutropenia in 1 of 16 patients studied in the United States. We have cared for a 46-year-old male with chronic osteomyelitis due to Staphylococcus aureus and Pseudomonas ceruginosa in whom neutropenia developed (absolute neutrophil-count 0 - 49 x 109/1) in association with relative eosinophilia (11%) on the 28th day of therapy with nafcillin and tobramycin. A bone-marrow biopsy done at that time showed a maturation arrest of the myeloid series. 4 days after nafcillin had been discontinued and while he was still receiving tobramycin, his peripheral blood contained 3.60 x 109/1 neutrophils and 0-42xl0’’/l eosinophils. Tobramycin was discontinued at this time because of ototoxicity. 10 days after nafcillin had been discontinued, treatment with piperacillin sodium, 4 g intravenously every 4 h, was started because of persistent pseudomonas osteomyelitis. At the start of therapy, the patient’s blood contained 5.50 x 109/1 neutrophils and no eosinophils. On the 17th day of therapy, his eosinophil-count (0.43x109/1) once again rose but his neutrophil-count (2.56 x 109/1) was still normal. 1 week later, his neutrophil-count was 0.07x109/1 and eosinophils had increased to 0.88x109/1. Piperacillin therapy was discontinued, and his neutrophil-count rose to 2.76x109/1 2 days later. His leucocyte-count subsequently returned to normal. All penicillin antibiotics may be associated with neutropenia. The neutropenia in our patient probably had an immune basis. This is suggested by the eosinophilia that accompanied neutropenia in association with the administration of two different penicillin antibiotics. Administration of any penicillin antibiotic to a patient who has previously had neutropenia in association with another penicillin antibiotic should be done with caution and careful hxmatological monitoring. C. WILSON G. GREENHOOD J. S. REMINGTON
Stanford
University Medical Center, Stanford, California 94305, U.S.A
K. L. VOSTI
position. It
seems
that
a
bureaucratic
impasse has been reached in
1.
Dickinson,
G.
M., Droller, D. G., Greenman, R. L., Hoffman, T. A. 18th on Antimicrobial Agents and Chemotherapy
interscience conference 1.
Lancet, 1978, i, 972.
(Atlanta, Oct. 1-4, 1978); abstr.
166.
unsigned
editorial alludes
to
the
same
unpublished
source.
If
The Lancet is to maintain its reputation for fairness it should review its editorial policy on this practice. Department of Neurology, Institute of Neurological Sciences, Southern General Hospital, Glasgow G51 4TF, and Department of Clinical Physics and Bio-Engineering, Glasgow
JOHN P. BALLANTYNE STIG HANSEN
THE NEW CONSULTANT CONTRACT
SIR,-It is interesting to see, in your review of Prof. James McCormick’s book The Doctor: Father Figure or Plumber (May 12, p. 1008), unprofessional conduct described as working to the clock, demanding overtime, and striking. This, it is stated, is likely to be seen in doctors whose incomes are continuing to fall in relative terms. Two of these features-working to the clock and demanding overtime-are to be seen in the proposed new so-called "work-sensitive" consultant contract. North Middlesex Hospital, London N18 1QX
M. G. REVILL
CLINICAL MEDICAL OFFICERS
SIR,-I write to support the view of Professor Forfar and the presidents of the Royal Colleges of Physicians and the British Pxdiatric Association in their letter of May 12, that the natural affiliation of most clinical medical officers "lies not with community medicine but with clinical paediatrics." This has been the expressed view of my Faculty from our beginning. We emphasise our abiding concern for the future of the child health service and acknowledge warmly our historical responsibility towards our clinical medical officer colleagues, who must have the same entitlement to vocational training and professional advancement in their chosen area of work as have those in other branches of medicine. Specialists in community medicine will, of course, continue to have an important role in the child health services in determining need for and facilitating the work of these services in the community. Faculty of Community Medicine of the Royal Colleges of Physicians of the United Kingdom, Royal College of Physicians, London NW1 4LE
JOHN BROTHERSTON, President
EDITORIAL INDEPENDENCE OF PRESCRIBERS’
JOURNAL SIR,-While applaud the publication of Prescribers’ journal and its circulation free of charge to all prescribing docwe
in the U.K., we feel we should draw attention to an incident which seems to indicate a form of censorship on the journal’s contents which may be unacceptable. One of us (J. H.) was invited to write a piece for Prescribers’ journal on the treatment of cardiac failure. In keeping with modern concepts and practice of treatment for this condition, the use of vasodilators such as nitrates was included in the discussion. To our surprise the manuscript was returned with a request that this section be omitted because cardiac failure has not yet been approved by the Committee on Safety of Medicines (C.S.M.) as an indication for use of drugs of this type, although they are well used for other cardiac indications such as angina and hypotension. After further correspondence, the Editorial Board of Prescribers’ Journal would not move from this
tors
which the Government-sponsored Prescribers’ Journal cannot publish guidance on the use of a medicine for a condition which has not been specifically approved by another Government body, the C.S.M. The C.S.M. itself does not initiate approval of a new indication unless requested to do so by the manufacturers of the medicine. Surely, doctors should not be deprived of advice on modern forms of drug treatment of which they may well be aware from other sources, nor should patients be deprived of their use, because of such censorship. The Editorial Board of Prescribers’ Journal should be freed from any restraints imposed by its Government sponsorship. Readers of the journal should be able to have confidence in the objectivity, impartiality, and excellence of its advice. St. Bartholomew’s Hospital Medical College, London EC1A 7BE
J. HAMER P. TURNER
NEUTROPENIA AFTER CONSECUTIVE TREATMENT COURSES WITH NAFCILLIN AND PIPERACILLIN
SIR,-Reversible neutropenia is an infrequent but wellknown complication of therapy with penicillin antibiotics and is most commonly associated with the administration of antistaphylococcal, semisynthetic penicillins. The administration of piperacillin sodium, a new semisynthetic penicillin with increased activity against gram-negative organisms, was associated with reversible leukopenia in 1 of 1266 patients who received the drug during Japanese trials (data on file of Lederle Laboratories). Dickinson et aU noted transient neutropenia in 1 of 16 patients studied in the United States. We have cared for a 46-year-old male with chronic osteomyelitis due to Staphylococcus aureus and Pseudomonas ceruginosa in whom neutropenia developed (absolute neutrophil-count 0 - 49 x 109/1) in association with relative eosinophilia (11%) on the 28th day of therapy with nafcillin and tobramycin. A bone-marrow biopsy done at that time showed a maturation arrest of the myeloid series. 4 days after nafcillin had been discontinued and while he was still receiving tobramycin, his peripheral blood contained 3.60 x 109/1 neutrophils and 0-42xl0’’/l eosinophils. Tobramycin was discontinued at this time because of ototoxicity. 10 days after nafcillin had been discontinued, treatment with piperacillin sodium, 4 g intravenously every 4 h, was started because of persistent pseudomonas osteomyelitis. At the start of therapy, the patient’s blood contained 5.50 x 109/1 neutrophils and no eosinophils. On the 17th day of therapy, his eosinophil-count (0.43x109/1) once again rose but his neutrophil-count (2.56 x 109/1) was still normal. 1 week later, his neutrophil-count was 0.07x109/1 and eosinophils had increased to 0.88x109/1. Piperacillin therapy was discontinued, and his neutrophil-count rose to 2.76x109/1 2 days later. His leucocyte-count subsequently returned to normal. All penicillin antibiotics may be associated with neutropenia. The neutropenia in our patient probably had an immune basis. This is suggested by the eosinophilia that accompanied neutropenia in association with the administration of two different penicillin antibiotics. Administration of any penicillin antibiotic to a patient who has previously had neutropenia in association with another penicillin antibiotic should be done with caution and careful hxmatological monitoring. C. WILSON G. GREENHOOD J. S. REMINGTON
Stanford
University Medical Center, Stanford, California 94305, U.S.A
K. L. VOSTI
position. It
seems
that
a
bureaucratic
impasse has been reached in
1.
Dickinson,
G.
M., Droller, D. G., Greenman, R. L., Hoffman, T. A. 18th on Antimicrobial Agents and Chemotherapy
interscience conference 1.
Lancet, 1978, i, 972.
(Atlanta, Oct. 1-4, 1978); abstr.
166.
