favour in our resource conscious health service, particularly when an analysis of simple clinical factors reliably predicts the recurrence of seizures. The Royal College of Physicians' study showed that younger age, a family history of epilepsy or of febrile convulsions, and a seizure occurring between midnight and 8 59 am were factors associated with recurrence. If all three factors were present the recurrence rate at one year was 56% (95% confidence interval 42% to 70%); if two factors were present it was 43% (35% to 5 1%); if one factor was present 30% (25% to 36%); and if no factors were present 18% (7% to 28%). The study by Dr van Donselaar and colleagues also showed that younger age and seizures occurring at night or on waking were associated with recurrence. If these simple clinical questions can determine so well the probability of recurrence why bother with electroencephalography? The sensitivity of the first electroencephalogram in detecting epileptic discharges in patients after a first seizure in the study by Dr van Donselaar and colleagues was 16/151 (11%), and even if the recording was repeated after partial sleep deprivation (combined electroencephalograms) the number rose to only 35/151 (23%)-this with an interobserver agreement about epileptic discharges of only x=05. The authors were at pains to exclude all cases that were of doubtful idiopathic seizures. This low sensitivity (detection rate) of epileptic discharges in those who have had undoubted seizures should remind physicians that electroencephalography cannot be used to "diagnose" a doubtful event. The authors quote the specificity of combined electroencephalograms as being 91%-that is, a false positive rate of 9%. It is not clear what they mean by this as all patients in their study had truly had a first seizure. Neurologists traditionally interpret written electroencephalography reports in the light of the clinical history. Perhaps we should be more hard nosed. Clinical neurophysiologists would do us all a favour if they were more explicit about the sensitivity, specificity, and odds of being affected given a positive result5 for a variety of clinical disorders. Prior etalevaluated the use of sphenoidal electrodes in this way in 1975.6 Clinical neurophysiologists should surely build on this. ANTHONY HOPKINS Research Unit, Royal College of Physicians, London NWI 4LE I san Donselaar CA, Geerts AT, Schimsheimer R-J. Idiopathic first seizure in adult life: who should be treated? BMJ 1991;302:620-3. (16 March.) 2 Hauser WA, Rich SS, Annegers JF, Anderson ViE. Seizure recurrence after a first unprovoked seizure: an extended follow-up. Neurology 1990;40:1163-70. 3 Hopkins A, Garman A, Clarke CRA. The first seizure in adult life. Value of clinical features, electroencephalography and computerised tomographic scanning in prediction of seizure recurrence. Lancet 1988;i:721-6. 4 Salinsky M, Kanter R, Dashieff RM. Effectiveness of multiple EEGs in'supporting the diagnosis of epilepsy: an operational curve. Eptlepsia 1987;28:331-4. 5 Wald N. Rational use of investigations in clinical practice. In: Hopkins A, ed. Appropriate investigation anus treatment in clintcal practice. London: Royal College of Physicians, 1989. 6 Prior PF, Maynard DE, Scott DF. The value of sphenoidal EEG recording in patients with temporal lobe epilepsy. In: Epilepsologs. Proceedings of the seventh international svmposium on epilepss. Stuttgart: Georg Thieme, 1976.

SIR,-The well conducted hospital based study by Dr Cees A van- Donselaar and colleagues on the recurrence of a first idiopathic seizure' has replicated to some extent the results of a previous British survey.2 We would, however, make the following comment. The diagnosis of epileptic seizures is particularly difficult in its early stages. In 28% of patients enrolled in a community based study of epilepsy the diagnosis of the seizures was still unclear six months after entry.3 In the Mavo Clinic study, the time from the first seizure to diagnosis exceeded two years in more than 30% of patients.4 Dr van Donselaar and colleagues studied

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only patients attending hospital with a well defined single attack, and the overall recurrence rate in this group (40%) may be different from the true rate of recurrence in less selected patients in the general population (78% in a recent population based study5). J W A S SANDER S D SHORVON National Hospital-Chalfont Centre for Epilepsy, Chalfont St Peter, Buckinghamshire SL9 ORJ I van Donselaar CA, Geerts AT, Schimsheimer R-J. Idiopathic first seizure in adult life: who should be treated? BMl7 1991;302:620-3. (16 March.) 2 Hopkins A, Garman A, Clarke C. The first seizure in adult life: value of clinical features, electroencephalography, and computerised tomographic scanning in prediction of seizure recurrence. Lancet 1988;i:721-6. 3 Sander JWAS, Hart YM, Johnson AL, Shorson SD. The national general practice study of epilepsy: newly diagnosed seizures in a general population. Lancet 1990;336:1267-71. 4 Hauser WA, Kurland LT. The epidemiology of epilepsy in Rochester, Minnesota 1935 through 1967. Epilepsia 1975;16: 1-66. S Hart YM, Sander JWAS, Johnson AL, Shorson SD. The national general practice study of epilepsy: recurrence after a first seizure. Lancet 1990;336:1271-4.

Ovarian hyperstimulation SIR,-In the editorial by Dr Blair H Smith and Professor Ian D Cooke the only preventive measure mentioned for the avoidance of the ovarian hyperstimulation syndrome in assisted reproduction was aspiration of follicles. In their letter in response to the article Messrs Martin S Mills and Peter G Wardle mentioned an alternative possibility of proceeding to oocyte retrieval and freezing all the oocytes with none being replaced.2 This avoids the chance of pregnancy, which can aggravate any hyperstimulation syndrome. There is an alternative approach that in our hands has proved highly effective. The principle involved is that in cycles controlled by gonadotrophin releasing hormone antagonists it is possible to withdraw gonadotrophin stimulation and have confidence that the surge of luteinising hormone will not occur. We adopted this approach after having three patients with serious hyperstimulation syndrome in 1987. Since mid-1988 we have applied this policy and have had no cases of the hyperstimulation syndrome in an in vitro fertilisation clinic treating more than 500 cycles a year. By maintaining the gonadotrophin releasing hormone antagonist down regulation and restimulating with gonadotrophins when the ovarian follicles have regressed, good pregnancy rates are obtained in such cycles.3 DAVID H BARLOW

DECLAN EGAN JULIAN ROBINSON Nuffield Department of Obstetrics and Gynaecology, John Radcliffe Hospital, Oxford OX3 9DU I Smith BH, Cooke ID. Ovarian hvperstimulation: actual and theoretical risks. BX,7 1991;302:127-8. (19 January.) 2 Mills MS, Wardle PG. Ovarian hyperstimulation. BMJ 1991; 302:474. (23 February.) 3 Forman R, Frydman R, Egan D, Ross C, Barlow D. Severe ovarian hvperstimulation syndrome associating LHRH agonists and gonadotrophins in IVF: a review of a European series and a proposal for prevention. Fertil Stentl 1990;53:502.

I desperately needed to see my son SIR,-MS Sheila Awooner-Renner reminds us all that grief is a very personal experience.' Guidelines are written in journals and in hospitals to assist in the care of the bereaved person. The main role of staff, however, must be to follow the relatives' expression of grief to be uninhibited by the pressures of social acceptance. There is no proper way

to grieve: in this tragic situation the response that feels right to the individual is right. Death is probably the last of the great taboos in Western society. People are scared to talk of the dead-their language becomes an entanglement of euphemisms, and the recently bereaved are socially isolated. In hospital many feel the need to protect recently bereaved people from "any more distress" by guiding them through the grief process. We should be accompanying them through this difficult journey but not deciding their route. No one should be afraid to ask them, "Is there anything you want us to do? Is there anything you want to do?" With a simple question we can dispel the agony of the hospital routine and leave them to cope with their loss as their only agony. Relatives' wishes are diverse-some may want to see a tidy relative in a shroud, others may prefer to see him as they did earlier that day, in his usual clothes and with his hair untidy as usual. Their last memory is their lasting memory. We must not let our fear and embarrassment add to their misery. Doctors are often too formal and aloof, either in reality or in perception. At King's College Hospital accident and emergency department we have recently employed a community link worker and one of her roles is the care of the bereaved. Because she is introduced as being there to help relatives she is seen as a friend rather than a figure of authority. She is not thought to have other work to rush away to. Relatives are more open with her and ask her questions more freely. Discussion with an apparent lay person is often less clinical but more informative at this stage. Clinical detail may be added by medical and nursing staff. Her continued contact over the next few weeks allows the opportunity to ask those often forgotten questions. Our link worker has received many letters and calls of thanks from bereaved relatives. The only complaint, from a young spouse, questioned the need for such vigorous resuscitation and her exclusion at the time of death-the decision of a doctor, not the link worker. MATTHEW W COOKE

Accident and Emergency Department, King's College Hospital, London SE5 9RS I Awooner-Renner S. I desperately needed to see my son. BMJ7 1991 ;302:356. (9 February.)

Triage of x ray films? SIR,-Drs I G H Renwick and colleagues have identified that the early reporting of radiographs obtained in accident and emergency x ray departments is becoming increasingly difficult.' Their results show that radiographers should not be expected to take on the task because of a considerable error rate. I agree that triage of x ray films "can be of use to casualty officers." At this hospital the department of radiology provides a "red dot" system, whereby radiographers triage x ray films before their interpretation by casualty officers. All x ray films are reported by a radiologist and important diagnostic errors are identified and rectified by our audit process. Over a recent 10 day period 352 radiographs were ordered by casualty officers, of which 40 showed abnormalities. Casualty officers had a false positive error rate of 1-7% of all films. Of the 40 abnormal films, eight were judged to be normal by both the radiographer and the casualty officer, giving a combined false negative error rate of 20% of the abnormal films, and 2 3% of all the films. These figures compare favourably with those in other studies.2' All abnormalities detected by radiographers were confirmed and properly treated by casualty officers. Further discussion showed that the presence of a red dot focused the casualty officers' attention on the presence of an abnormality and was thought

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favour in our resource conscious health service, particularly when an analysis of simple clinical factors reliably predicts the recurrence of seizures...
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