(11) mm Hg; (p10
Brown and Adsett Perry et al'
10 29
41 43
36 21
13 7
Thus we agree that diastolic blood pressure audible to zero is uncommon in pregnancy, that muffling of Korotkoff sounds is evident in roughly three quarters of pregnant women, and that the difference between diastolic pressures measured at phase IV and at phase V during pregnancy has been overestimated previously. We do not agree, however, that these findings automatically justify the use of phase V recordings as the diastolic pressure in pregnancy. The median difference between phase IV and phase V pressures may have been only 5 mm Hg in our study, but this means that in half of the women the difference was greater, in 13% being more than 10 mm Hg. This is unlikely to be acceptable in the clinical management of conditions that have generally been diagnosed or treated on the basis of the phase IV sound. It is time for detailed comparisons of direct and indirect measurements of blood pressure in pregnancy and a subsequent international consensus on how to record blood pressure in pregnant women. MARK A BROWN JUDITH A WHITWORTH
Department of Renal Mcdicine, St George Hospital, Kogarah, New South Wales 2217, Australia I Perry IJ, Stewart BA, Brockwell J, Khan M, Davies P, Beevers DG, et al. Recording diastolic blood pressure in pregnancy. BMJ 1990;301:1198. 2 MacGillivray I, Thomas P. Recording diastolic blood pressure in pregnancy. BMJf 1991;302:179. (19 January.) 3 National High Blood Pressure Education Program Working Group. Consensus report on high blood pressure in pregnancy. Amj Obstet Gynecol 1990;163:1689-712. 4 Brown MA, Adsett D. Automated blood pressure recording in pregnancy. Clin Exp Hvpertens[B](in press).
Surgeons who undertake surgery for colorectal cancer SIR,-The paper by Messrs C S McArdle and D Hole on the variability of outcome of colorectal surgery performed by different surgeons is an object lesson in the value of audit.' Much as I support the authors' views on subspecialisation, I fear that their data do not support their contention that surgery for colorectal cancer should be undertaken only by surgeons with a special interest in it. Nor do I see how they conclude that trainee surgeons were being inadequately supervised. Only one of the teams that operated on more than 50 patients during the study featured in the top seven teams ranked according to adjusted hazard ratios for all patients. Indeed, the team doing the most operations was second bottom in this ranking. This does not suggest that increased workload or experience improves results. With respect to operations performed by trainees, five of the six surgical teams with the highest percentage of operations being done by trainees had adjusted hazard ratios for all patients of less than 10. The team with the second lowest percentage of operations performed by trainees had the worst results of all.
BMJ
VOLUME
303
13
JULY
1991
SIR,-The results of Messrs C S McArdle and D Hole's interesting audit of colorectal surgery do not justify their conclusions, in particular the conclusion that an improvement in overall survival might be achieved if such surgery was done by surgeons with a special interest in colorectal surgery or surgical oncology. ' The patients whom they studied were operated on by surgeons who, they say, had no such special interest in colorectal surgery. Whether surgeons with such a special interest would achieve better or worse results is not clear in their paper. If we are to believe their conclusions, however, none of the 13 surgeons who operated on the 645 patients in their study should now be undertaking such surgery. E J SHAXTED
Northampton Medical Consultancv Unit, Three Shires Hospital,
Cliftonville, Northampton NN 1 5DR I McArdle CS, Hole D. Impact of variability among surgeons on postoperative morbidity and mortality and ultimate survival.
BMJ 1991;302:1501-5. 122 June.)
Persistent vegetative state SIR, - Professor Bryan Jennett and Ms Clare Dyer's article on the right to die of patients in the persistent vegetative state rightly raised the issues surrounding this distressing condition. The authors make several assumptions. Firstly, they assume that persistent vegetative state is a diagnostic entity when in fact it is a syndrome. Indeed, Professor Jennett coined the term to avoid defining the underlying pathology or site of the damage. The condition is a description ofbehaviour responses. It is therefore not surprising that the outcome is so variable. Secondly, the authors seem to assume that persistent means permanent. Although they state that no recovery occurs after three months in a persistent vegetative state, our experience of patients referred to our brain injury unit is that about 15% of those still in coma between six months and one year after the injury recover to levels of communicating, using computers, walking, or, in one case, horse riding. Papers from the US show similar patterns of recovery. There are also several reports from elsewhere, admittedly not always well documented, of recovery occurring between one and eight years in "coma." The third assumption is that these patients are not recovering despite being adequately fed by nasogastric tube. As many as 80% of the patients in a persistent vegetative state admitted to our unit are suffering from undernutrition-not surprisingly, as it takes three hours of nursing time to feed a patient adequately through a nasogastric tube. One of the important contributions our unit makes to any recovery process is improving the nutritional state. Finally, it is assumed that patients in a persistent vegetative state have been given the chance to recover. In our experience few patients have had fully appropriate attention to their seating, posture, and bowel and bladder care or been provided with a coma arousal programme. If we are achieving improvement in those referred to us
KEITH ANDREWS
Putney,
London SW15 3SW I Jennett B, Dyer C. Persistent vegetative state and the right to die: the United States and Britain. BMJ 1991;302:1256-8.
(25 May.)
General practitioners' access to x ray services SIR,-Drs Jamie Bahrami and David Shoesmith seem to indicate that their access to radiological services and their clinical freedom are being curtailed by the reforms of the NHS.' It seems from their letter, however, that their request cards were returned on good clinical grounds. A general practitioner who refers a patient to a general surgical clinic does not ask a surgeon to perform a particular operation. He or she asks the surgeon for an opinion about further management. Similarly, when a general practitioner (or any other doctor) refers a patient to an x ray department he or she is requesting a radiological opinion, not demanding that some x ray pictures are obtained. The joint report of the National Radiological Protection Board and the Royal College of Radiologists stated that "at least 20% of x-ray examinations currently carried out in the UK are clinically unhelpful in the sense that the probability of obtaining information useful for patient management is extremely low."2 Therefore any attempt to cut out these unnecessary examinations can only benefit patients' care. Radiologists therefore have a responsibility to patients to ensure that appropriate examinations are being performed. The service provided by radiology departments is for the benefit of patients, not to satisfy the whims of referring doctors. The reforms of the NHS probably have much more serious implications for clinical freedom than that indicated by Drs Bahrami and Shoesmith. The use of radiological guidelines and good practice should be commended, not criticised, and the guidelines should be more widely used by referring doctors. J I ROBERTS Department of Radiology, Law Hospital, Carluke, Lanarkshire ML8 SER 1 Bahrami J, Shoesmith D. The new NHS: restnrcting GPs' access to x ray services. BMJ 1991;302:1541. (22 June.) 2 National Radiological Protection Board and Royal College of Radiologists. Patient dose reduction in diagnostic radiology. London: HMSO, 1990.
SIR,-Drs Jamie Bahrami and David Shoesmith question their access to diagnostic services.' Various guidelines are now available to help doctors requesting imaging services, notably those of the Royal College of Radiologists2 and South East Thames Regional Health Authority.' The health authority's guidelines were produced with the support of the regional medical audit advisory committee and medical committee after an extensive review and wide consultation with radiologists and clinicians. The college's guidelines were based on a similar experience in Wales. The regional document was distributed by
121
Brown and Adsett Perry et al'
10 29
41 43
36 21
13 7
Thus we agree that diastolic blood pressure audible to zero is uncommon in pregnancy, that muffling of Korotkoff sounds is evident in roughly three quarters of pregnant women, and that the difference between diastolic pressures measured at phase IV and at phase V during pregnancy has been overestimated previously. We do not agree, however, that these findings automatically justify the use of phase V recordings as the diastolic pressure in pregnancy. The median difference between phase IV and phase V pressures may have been only 5 mm Hg in our study, but this means that in half of the women the difference was greater, in 13% being more than 10 mm Hg. This is unlikely to be acceptable in the clinical management of conditions that have generally been diagnosed or treated on the basis of the phase IV sound. It is time for detailed comparisons of direct and indirect measurements of blood pressure in pregnancy and a subsequent international consensus on how to record blood pressure in pregnant women. MARK A BROWN JUDITH A WHITWORTH
Department of Renal Mcdicine, St George Hospital, Kogarah, New South Wales 2217, Australia I Perry IJ, Stewart BA, Brockwell J, Khan M, Davies P, Beevers DG, et al. Recording diastolic blood pressure in pregnancy. BMJ 1990;301:1198. 2 MacGillivray I, Thomas P. Recording diastolic blood pressure in pregnancy. BMJf 1991;302:179. (19 January.) 3 National High Blood Pressure Education Program Working Group. Consensus report on high blood pressure in pregnancy. Amj Obstet Gynecol 1990;163:1689-712. 4 Brown MA, Adsett D. Automated blood pressure recording in pregnancy. Clin Exp Hvpertens[B](in press).
Surgeons who undertake surgery for colorectal cancer SIR,-The paper by Messrs C S McArdle and D Hole on the variability of outcome of colorectal surgery performed by different surgeons is an object lesson in the value of audit.' Much as I support the authors' views on subspecialisation, I fear that their data do not support their contention that surgery for colorectal cancer should be undertaken only by surgeons with a special interest in it. Nor do I see how they conclude that trainee surgeons were being inadequately supervised. Only one of the teams that operated on more than 50 patients during the study featured in the top seven teams ranked according to adjusted hazard ratios for all patients. Indeed, the team doing the most operations was second bottom in this ranking. This does not suggest that increased workload or experience improves results. With respect to operations performed by trainees, five of the six surgical teams with the highest percentage of operations being done by trainees had adjusted hazard ratios for all patients of less than 10. The team with the second lowest percentage of operations performed by trainees had the worst results of all.
BMJ
VOLUME
303
13
JULY
1991
SIR,-The results of Messrs C S McArdle and D Hole's interesting audit of colorectal surgery do not justify their conclusions, in particular the conclusion that an improvement in overall survival might be achieved if such surgery was done by surgeons with a special interest in colorectal surgery or surgical oncology. ' The patients whom they studied were operated on by surgeons who, they say, had no such special interest in colorectal surgery. Whether surgeons with such a special interest would achieve better or worse results is not clear in their paper. If we are to believe their conclusions, however, none of the 13 surgeons who operated on the 645 patients in their study should now be undertaking such surgery. E J SHAXTED
Northampton Medical Consultancv Unit, Three Shires Hospital,
Cliftonville, Northampton NN 1 5DR I McArdle CS, Hole D. Impact of variability among surgeons on postoperative morbidity and mortality and ultimate survival.
BMJ 1991;302:1501-5. 122 June.)
Persistent vegetative state SIR, - Professor Bryan Jennett and Ms Clare Dyer's article on the right to die of patients in the persistent vegetative state rightly raised the issues surrounding this distressing condition. The authors make several assumptions. Firstly, they assume that persistent vegetative state is a diagnostic entity when in fact it is a syndrome. Indeed, Professor Jennett coined the term to avoid defining the underlying pathology or site of the damage. The condition is a description ofbehaviour responses. It is therefore not surprising that the outcome is so variable. Secondly, the authors seem to assume that persistent means permanent. Although they state that no recovery occurs after three months in a persistent vegetative state, our experience of patients referred to our brain injury unit is that about 15% of those still in coma between six months and one year after the injury recover to levels of communicating, using computers, walking, or, in one case, horse riding. Papers from the US show similar patterns of recovery. There are also several reports from elsewhere, admittedly not always well documented, of recovery occurring between one and eight years in "coma." The third assumption is that these patients are not recovering despite being adequately fed by nasogastric tube. As many as 80% of the patients in a persistent vegetative state admitted to our unit are suffering from undernutrition-not surprisingly, as it takes three hours of nursing time to feed a patient adequately through a nasogastric tube. One of the important contributions our unit makes to any recovery process is improving the nutritional state. Finally, it is assumed that patients in a persistent vegetative state have been given the chance to recover. In our experience few patients have had fully appropriate attention to their seating, posture, and bowel and bladder care or been provided with a coma arousal programme. If we are achieving improvement in those referred to us
KEITH ANDREWS
Putney,
London SW15 3SW I Jennett B, Dyer C. Persistent vegetative state and the right to die: the United States and Britain. BMJ 1991;302:1256-8.
(25 May.)
General practitioners' access to x ray services SIR,-Drs Jamie Bahrami and David Shoesmith seem to indicate that their access to radiological services and their clinical freedom are being curtailed by the reforms of the NHS.' It seems from their letter, however, that their request cards were returned on good clinical grounds. A general practitioner who refers a patient to a general surgical clinic does not ask a surgeon to perform a particular operation. He or she asks the surgeon for an opinion about further management. Similarly, when a general practitioner (or any other doctor) refers a patient to an x ray department he or she is requesting a radiological opinion, not demanding that some x ray pictures are obtained. The joint report of the National Radiological Protection Board and the Royal College of Radiologists stated that "at least 20% of x-ray examinations currently carried out in the UK are clinically unhelpful in the sense that the probability of obtaining information useful for patient management is extremely low."2 Therefore any attempt to cut out these unnecessary examinations can only benefit patients' care. Radiologists therefore have a responsibility to patients to ensure that appropriate examinations are being performed. The service provided by radiology departments is for the benefit of patients, not to satisfy the whims of referring doctors. The reforms of the NHS probably have much more serious implications for clinical freedom than that indicated by Drs Bahrami and Shoesmith. The use of radiological guidelines and good practice should be commended, not criticised, and the guidelines should be more widely used by referring doctors. J I ROBERTS Department of Radiology, Law Hospital, Carluke, Lanarkshire ML8 SER 1 Bahrami J, Shoesmith D. The new NHS: restnrcting GPs' access to x ray services. BMJ 1991;302:1541. (22 June.) 2 National Radiological Protection Board and Royal College of Radiologists. Patient dose reduction in diagnostic radiology. London: HMSO, 1990.
SIR,-Drs Jamie Bahrami and David Shoesmith question their access to diagnostic services.' Various guidelines are now available to help doctors requesting imaging services, notably those of the Royal College of Radiologists2 and South East Thames Regional Health Authority.' The health authority's guidelines were produced with the support of the regional medical audit advisory committee and medical committee after an extensive review and wide consultation with radiologists and clinicians. The college's guidelines were based on a similar experience in Wales. The regional document was distributed by
121
