the communities integrate. In the mean time it is clear that we should direct our attention towards ensuring that those women at increased risk of fetal malformations are offered preconceptual advice and, in the case of neural tube defects, perhaps periconceptual vitamin supplementation.' They should also be encouraged to book early for antenatal care so that the relevant screening tests are available to them should they wish. LYN CHITTY R M WINTER Kennedy Galton Centre, Northwick Park Hospital, Harrow HA I 3VJ
lasting longer than five minutes. This approach leads to difficulties where school nurseries and babysitters are concerned, and certainly does not replace the mainstay of management. That must continue to be the role of all physicians in the straightforward counselling of parents on the harmless yet understandably frightening nature of the condition with due emphasis on first aid. Parents will be most content with this approach as they maintain control and feel helpful to their child in his or her time of need, rather than hopeless and helpless. RICHARD W NEWTON
Royal M'\anchcster Children's Hospital, Pendleburv
7 1989;299: 1 Alberman E. Congenital malformations. Br 1416. (9 December.) 2 Cuckle H, Wald N. The impact of screening for open ncural defects in England and Wales. Prenatal Diagnosis 1987:7:91-9. 3 Lumb KM, Congdon PJ, Lealman GT. A comparative review of Asian and British-born patients in Bradford, 1974-8. J7 Epidemiol Communite Health 1981;35:106-9. 4 Modell B, Ward RHT, Fairweather DVI. Effect of introducing antenatal diagnosis on reproductive behaviour of f;amilies at risk for thalassaemia major. BrM ed7 1980;280:1347-5I. 5 Seller MJ, Nevin CG. Periconceptual vitamin supplementatiots and the prevention of neural tube defects in south-east England and Northern Ireland. J Mlfed Genet 1984;21:325-30.
1 V'alman HB. Convulsions in the older infant. BrMedJ 1989;299: 1331-3. (25 November.,) 2 Newton RW.. Randomised controlled trials of phenobarbitone and valproate in febrile convulsions. Arch Dis Child 1988;63: 1189-91. 3 McKinlav I, Newton RW. Intention to treat febrile convulsions with rcctal diazepam, valproate or phenobarbitone. Dete Med Child Neurol 1989;31:617-25. 4 Newton RW, McKinlay I. Subsequent management of children with febrile consulsions. Devled Child Neurol 1988;30:402-6.
Hearing problems of elderly people Effect of check ups every three years SIR,-Dr Gordon Hickish asks "Should the elderly SIR, -I am interested in the effect of check ups on patients every three years being drafted into general practitioners' contracts. My practice has offered check ups to patients for the past three years, and nearly all of the patients have attended them. Only two men did not take up our offer; they were insurance brokers, and their reasons were that they did not wish me to have information that would be used against them by insurance companies. At present, doctors can refuse to fill in information on lifestyle and other paragraphs on insurance forms, but in the light of the contract should it now be policy for doctors to protect their patients by not filling in forms on them? This might result in companies having more medicals performed by third parties, but it is a small price to pay to maintain a doctor-patient relationship. ANDREA M TREE Formbv L37 4AD
Convulsions in the older infant SIR,-As far as the measurement of blood concentrations 'of anticonvulsant drugs in older infants with febrile convulsions is concerned I believe that the venepuncture and the use of resources that thi entails could be justified only if seizures occur in spite of the anticonvulsant or there are side effects. I realise space is short in an article such as Dr H B Valman's, but his policy of advocating that the concentrations be estimated "three weeks after the first dose and then every six months" is hard to justify. Overall, the recurrence rate of febrile seizures is only 30%, and far more children have to receive anticonvulsant drugs than could ever benefit from them. My pooled analysis of the British experience showed that 100 children have to be treated with phenobarbitone to benefit but six.2 With side effects present in up to half of the children so treated we need seriously to question this as a best course of management. I fear also that studies have gone unpublished because they failed to show a beneficial effect of treatment, though there has been a recent useful report on this.' I would prefer to reserve the prescription of rectal diazepam for those children most at risk of recurrent convulsions and to use it for seizures
be screened for deafness?"' He does not answer the question but implies that the answer should be "yes." It seems that Dr Hickish, like Kenneth Clarke and many others, has fallen into the trap of justifying screening on the basis of case finding. We are all well aware that in the elderly population there is an immense amount of disease waiting to be unearthed, as will become obvious when the general practitioner contract unfolds, but case finding does not in itself validate the time and effort that screening absorbs. The only true justification for screening can be when actual outcomes are shown to be significantly different in the screened populations as compared with the unscreened population. With particular reference to deafness in the elderly, I am sure that every general practitioner has come across many patients who have been provided with hearing aids only to leave them unused. If Dr Hickish had shown a beneficial outcome for many of his patients I would agree with much of what he has written, but until those results are forthcoming the case must be at best be unproved. A large part of the general practitioner contract assumes that population screening from conception to cremation has some scientific basis-but in fact it is merely a political exercise with no sound basis whatsoever. The ensuing workload will be quite astounding and there is no sign of any additional funding to cope with this. The ideas may be superficially attractive, but far more work needs to be done before they are implemented. Sadly, once screening begins (whether in the elderly population for deafness or for any other pathological process) the clock cannot be put back-and that will be the end of scientific evaluation in general practice.
accommodated on a national basis. The main problem is and always has been that of making a worthy resource readily available to a large section of the population. The suggestion that every senior citizen should have audiological screening-let alone that screening should be repeated regularly -is purely utopian. This would simply overstretch a resource that in our department is severely understaffed. Dr Hickish suggests that audiometry should be performed in a general practitioner's surgery by a nurse, but it is generally agreed that to be meaningful audiometry should be performed by properly trained staff in a controlled audiometric environment. Harries et al argued the importance of expert screening and showed that 46% of patients were unsuitable for open access to a hearing aid clinic.2 They concluded that any method that avoids an expert opinion is unsatisfactory as it may prevent the recognition of treatable disease. Bellini et al found that for patients who had chronic otitis media no mention of this was made in 61% of referring letters.' The difficult delays highlighted in Dr Hickish's editorial are especially evident in Sheffield. To reduce these it has been the policy of our department to select suitable referrals and start a specific hearing aid clinic, thereby increasing the efficiency of the available resources and reducing the time to appointment. Also, all patients have their ears inspected by their general practitioner to ensure that they are clear of wax. In a prospective survey of 209 patients referred to this clinic we found that 28 had a treatable condition to which no reference had been made in the referring letter, and 23 patients had wax in one or both ears (unpublished data). This contrasts greatly with previous reports, and we believe that specificity of referral by selection will greatly improve the efficiency of this system. There are other ways to improve efficiency: the Central Nottingham Health Authority recently reduced the delay in obtaining an aid by 13 months by appointing an additional technician and providing funds for overtime.4 There is no doubt that well motivated general practitioners could dispense hearing aids, but does every general practitioner want to? We are sure that, with the correct use of available resources, the hospital based system is the only place that can continue to provide aids and give the excellent back up service for all hearing aid users. R W R FARRELL A PARKER J T BUFFIN
Department of Otolaryngology, Royal Hallmshire Hospital, Sheftfield S 10 2J F I Hickish G. Hearing problems of elderly people. Br Med J
1989;299:1415-6. (9 December.) 2 Harries MLL, Baguley I)M, Moffat DA. Hearing aids-a case for review. ] Larvngol Otol 1989;103:850-2. 3 Bellini MJ. Beesley 1P1 Perrett C, Pickles JM. Hearing-aids: can they be safely prescribed without medical supervision? An
analysis of patients referred for hearing-aids. Clin Otolaryngol 1989;14:415-8. 4 Anonymous. Authority blitz ends queue for hearing aids. Hospital Doctor 1989;9:6.
JOHN R HUGHES Havant Health Centre, Havant P09 2AZ
Incidence of rheumatic fever
I Hickish G. Hearing problems of elderly peoplc. Br Med J
1989;299:1415-6. (9 December.)
SIR,-Dr Gordon Hickish's editorial on hearing aids for the elderly' raises several interesting points worthy of comment. There is no doubt that there is an enormous requirement for hearing aids, though any calculation of the requirement is subject to many local variables, especially population profiles and regional industrial variation. These factors must be
SIR,-Minerva, reporting an outbreak of rheumatic fever in the United States, states that "it was common in all social classes as recently as the 1960s."' This is surely at variance with investigations into the social incidence of the disease from 1924 onwards. Savage showed that the incidence of the disease in urban Bristol was over three times that in the surrounding rural areas.2 Further studies of these cases showed that there was a significant association between the density of persons per room in the various city wards and the
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incidence of acute rheumatism. TFhere was no such correlation with the incidence of scarlet fever, indicating that the increase in acute rheumatism was not due to an increased incidence of infection by the haemolytic streptococcus. A further social study of children with rheumatic heart disease in 1937 led to the conclusion that if the living conditions of the 30% of the Bristol working class population with the most inadequate incomes were raised to the level of the highest 10% of all working class families the incidence of the disease would be roughly halved.4 Since the end of the 1939-45 war this has probably been more than achieved, and there has been a concomitant fall in the incidence of rheumatic fever so that it is now a rare disease. It is interesting that in Sri Lanka an increase in the disease with increasing urbanisation was reported as late as 1969.) C BRUCE PERRY
Bristol BS9 2RR I Minerva. Views. BrMledj 1989;299:1412. (2 December.) 2 Sasage WG. Inicidence of rheumatic heart disease in childhood (1927-19301) in Glouccstcrshire, Somerset, and Wilts. Br Medj It 1931 ;ii ( supph 37-4 1. 3 Perry CB, Roberts JAF. A study on the sariability in the incidence of rheumatic hcart disease withini the citv of Bristol.
BrAMedj 1937;ii,suppl: 154-8. 4 Daniel GH. Social and ccottotnic conditions and the incidence of rheumatic heart disease. 7ournial of the Roval Statistical Society 1942;105: 197-2 12. 5 Perry CB. Social aspects of acute rheumatism. Bristol iMedico-
Chirurgical Journal 1944;6 1:1- 0I. 6 Mirando EM. Presidential address. Ceylon Med J 1969;14: 159-72.
Interrelations in paediatric day stay surgery SIR,-The paper by Drs N McC Schofield and J B White' will go a long way towards improving the quality of surgical and anaesthetic management of children undergoing short stay surgery. Although children are superficially merely scaled down adults in terms of anaesthetic technique and drug dosage, their management as day cases is, we believe, more crucial than it is in adults. Many children are unaware of what their hospital stay will entail. They come into hospital with a parent, feeling well but apprehensive, and then receive various psychological insults, in particular their anaesthetic induction and postoperative pain. For this reason we have attempted to introduce several features in Chesterfield over the past three years to improve management of these patients. Before admission both parents and children are offered the opportunity to see a short video made in the hospital by the staff of the children's ward and operating theatre which explains, particularly in children's terms, what to expect from their forthcoming stay. The video emphasises the relaxed and friendly ward environment and the pleasant induction of anaesthesia, with a parent present, by a painless injection after the use of Emla cream (a eutectic mixture of prilocaine and lignocaine, Astra Pharmaceuticals). The child is admitted at 8 am and the operation performed as early as possible after the start of the list. The earlv admission time has not presented problems and allows time for a brief preoperative visit by both anaesthetist and surgeon. We have found that this visit invariably negates the need for premedication. Emla cream is used routinely, and its effectiveness has virtually abolished inhalational induction of anaesthesia. Parents are not pressured to come to the anaesthetic room, but many are aware of this option and invariably ask to. No problems have arisen as a result of a parent being at the induction. Indeed, unlike Drs Schofield and White, who reviewed only children never admitted to hospital before, we find that children who are frightened because of a previous traumatic hospital stay are more settled if a parent is present, and a parent is much more BMJ
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In women using epidural analgesia in labour in our hospital careful attention is paid to correcting inefficient uterine action early in labour, and allowance is made for the two phases of the second stage.2 The oxytocin infusion rate starts at 6 mU/min and reaches a maximum of 36 mU/min. We have just reviewed the outcome in primiparous women who have delivered to mid-December 1989. Of the 276 patients who used epidural analgesia in labour, 24 were delivered by caesarean section in the first stage. Of the 252 who entered the second stage, 67% received oxytocin in the first stage and 6% in the second stage of labour. In comparison to the study of Dr Saunders and colleagues, 63% delivered normally, 35% had a non-rotational forceps delivery, there were no rotational forceps deliveries, and 2% were delivered by caesarean section. This suggests that the use of oxytocin in primiM J WOLFE J M SIMMS paras earlier in labour and in higher dosage may Chesterfield and North Derbyshire Royal Hospital, minimise the incidence of rotational forceps Chesterfield S44 SBI deliveries associated with epidural analgesia. Such a policy has previously been associated with a 1 Schofield NM, White JB. Interrelations among children, parents, reduction in the overall incidence of instrumental premedication, and anaesthetists in paediatric day stay surdeliveries in a London population.' gery. BrMedJ 1989;299:1371-5. (2 December.) 2 Armitage EN. Analgesia after circumcision. Anaesthesia 1980;35: Furthermore, the dose of bupivacaine may be 77-8. critical. In a study of 517 patients using epidural analgesia in labour, including women of all parities, patients were randomly allocated to receive 6-8 ml SIR,-As both an anaesthetist and a parent, I was of 0 5%, 10-14 ml of 0 25%, or 6-8 ml of 0-25% particularly interested in the findings of Drs bupivacaine. Patients given the low volume, low N McC Schofield and J B White on the effects of concentration bupivacaine were less likely to need parental presence during the induction of anaes- either a low cavity (p