BRITISH MEDICAL JOURNAL

454

21 FEBRUARY 1976

CORRESPONDE Emergency asthma services T J H Clark, FRCP, and others ............ 454 Long-term digoxin treatment in general practice J R Sewell, MRCP; W J F van der Vijgh, MD.. .454 Trental and peripheral vascular disease A J Barnes, MRCP ...................... 455 Aetiology of anencephaly and spina bifida Sir Cyril Clarke, PRCP, and others; P Malpas, FRCOG

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Asylums are still needed 456 M E Shariatmadari, MRCPSYCH . Thyroid cancer J E Richardson, FRCS, and others; H J Shaw, FRCS

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Multitudinous authorship .456 . D J Stoker, FRCR Venous thromboembolism in pregnancy 456 A Bergqvist, MD, and others . . Women in medicine Joan K Sutherland, MRCGP; Hazel O,Camp457 bell, MB; Margaret E Elmes, MB .. Women in psychiatry 457 Pamela M Ashurst, MRCPSYCH . . Not so double-blind? T W Anderson, BM, and others .......... 457 Plasticity in the nervous system 458 . . L S Illis, FRCP A place to be born 458 M Rosen, FFARCS, and others . . .....

Immunisation against whooping cough .............. 458 Rosemary Fox ............ Transcendental meditation K E Schmidt, MRCS ...................... 459 Ethics of the placebo Mary Rice, MB, DPM; Kirstine Adam, BSC, and I Oswald, MD ...................... 459 Effect of beta-blockade in chronic renal failure C P Swainson, MRCP, and R J Winney, MRCP

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SLE precipitated by antibiotics in Sj#gren's syndrome D M Grennan, MRCP .................... 460 High plasma calcitonin levels in breast cancer O L Silva, MD, and K L Becker, MD ........ 460 Tryptophan and depression B Rao, MRCPSYCH, and A D Broadhurst, MRCPSYCH

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Warfarin and Distalgesic interaction .............. 460 R V Jones, MRCP .......... Myasthenic syndrome during treatment with practolol R 0 Hughes, MRCP, and F J Zacharias, FRCP .......

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An unnecessary risk to children J S Anderson ............ .............. 461 Dukes classification of carcinoma of the rectum C G Lindstrom, MD .................... 461

Correspondents are urged to write briefly so that readers may be offered as wide a selection of letters as possible. So many are being received that the omission of some is inevitable. Letters should be signed personally by all their authors.

Emergency asthma services

SIR,-We read with interest the paper by Drs G K Crompton and I W B Grant (20 December, p 680) and can also report favourable results from a similar emergency service for the treatment of acute asthma at this hospital. Direct admission to a special care unit has been available for patients with acute asthma since January 1974 and by the end of December 1975 this unit had handled 437 such admissions; 379 patients were admitted once and a further 19 had 58 admissions among them. Among the 437 admissions in the two-year period there were two deaths attributable to asthma. The first was that of a man aged 51 who was being treated for a pneumothorax and had spent 80°,, of the previous year in hospital. The second death occurred in a 50-yearold man who also suffered from chronic bronchitis, with 30 admissions in the previous eight years. Controlled ventilation was considered unjustified in both patients and neither death was unexpected. Onlv two patients required controlled ventilation and one of these, aged 68, subsequently died of a cerebrovascular accident. Apart from these deaths, one man aged 50 was successfully resuscitated after a respiratory arrest and three other patients were transferred following an arrest on a general ward where they were treated for subacute asthma, having been admitted for revision of their outpatient treatment. They subsequently made uneventful recoveries. Unexpected death from acute asthma was

therefore not seen in patients normally diagnosed as being in status asthmaticus. We are continuing to study the natural history of both acute and subacute asthma in patients admitted to hospital but find our initial analysis both of interest and in accord with the results published by Drs Crompton and Grant. The practice of admitting patients in "status asthmaticus" to general wards will need to be reconsidered if these initial reports are substantiated. T J H CLARK M BRANTHWAITE M R HETZEL Brompton Hospital, London

Long-term digoxin treatment in general practice

SIR,-Dr P Curtis's peer review on long-term digoxin prescribing (27 December, p 747) is fascinating but is not a valid medical audit. He covertly points out that digoxin, once prescribed, is likely to be continued indefinitely but misses the vital point that what needs monitoring is not the quality of the doctors' records but whether the patient needs to be on digoxin at all. Digoxin toxicity is common (up to 290,,') in patients taking digoxin when admitted to hospital and carries a high mortality (up to 41° O'). The indications for initiation and continuation of digoxin therapy must be carefully

Folic acid deficiency during intensive therapy M Saary, MRCP, and A V Hoffbrand, DM .... 461 Neonatal jaundice in association with operative delivery O B Eden, MRCP ........................ 461 Computers and privacy J F N Sidebotham, MB, and others ........ 461 Clinical or administrative postal addresses ? T B Boulton, FFARCS .................... 462 Preventive medicine-House of Commons inquiry A W McIntosh, MFCM .................. 462 Consultants' ballot D H Teasdale, FRCS, and others ...... ...... 462 Doctors' wives and the Sex Discrimination Act Julie J Stafford, SRN .................... 462 Pay-beds in NHS hospitals F S A Doran, FRCS ...................... 462 Fair allocation of resources FMHall,MB .......................... 462 Points from letters Interview rooms (C C Smith); Pricing cigarettes off the market (Joan M Woodley); Higher medical accreditation (E N Wardle); Treatment of status epilepticus (P Donnelly); Departmental delays (D C Prior); Information contained in drug advertisements (D C Shenton); RCOG and abortion (H C McLaren); Axillary artery thrombosis and tuberculosis (K A Harden); Low sperm count and conception (B Sandler) .............. 463

considered in every patient because of the serious risks from digoxin cumulation in renal failure, hypokalaemia, and myocardial irritability. The "feeling of well-being" regarded by Dr Curtis as "a good outcome of long-term digoxin therapy" is not an adequate criterion of safe digoxin prescribing, as life-threatening arrhythmias may be the first and only evidence of digoxin toxicity. Of the patients studied by Dr Curtis, only five with atrial fibrillation had an unequivocal indication for continued digoxin therapy. In the other 37 (nine with left ventricular failure, 14 with ischaemic heart disease, two with rheumatic heart disease, eight with "no record," and three with cardiac failure) benefit from digoxin cannot be assumed. Digoxin does not significantly increase left ventricular contractility in patients with left ventricular disease,2 and Dr Curtis cites a study3 in which digoxin was safely withdrawn from 700,, of ambulant geriatric patients. Dr Curtis's point that inadequate records are not necessarily indicative of poor standards of care is valid, but proper medical audit is not possible without good records (this being the major reason for the widespread adoption of problem-orientated notes4). We should all evaluate our own indications for starting and maintaining patients in sinus rhythm on long-term digoxin therapy. JOIIN R SEWELL St Charles Hospital, London W10

Baller, G A, et al, New England J7ournal of Medicine, 1971, 284, 98a. Davidson, C, and Gibson, D, British Heart Journal, 1973, 35, 970. Thomas, J H, Gerontologia Clinica, 1971, 13, 285. 4Hurst, J W, New England Journal of Medicine, 1971,

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284, 51.

Letter: Long-term digoxin treatment in general practice.

BRITISH MEDICAL JOURNAL 454 21 FEBRUARY 1976 CORRESPONDE Emergency asthma services T J H Clark, FRCP, and others ............ 454 Long-term digoxin...
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