109
dependent
on overseas
doctors
can we
afford
to waste
this
potential ? It is wasteful not only in terms of educational opportunity for these able young people themselves but also because Great Britain continues to absorb the medical graduates of other countries who can surely ill afford to lose them. The Chief Medical Officer of the Department of Health has stated in his annual report that in 1973 the number of N.H.S. doctors rose by 3%, half of them born abroad. Perhaps 50% of doctors at present working in National Health Service hospitals come from abroad. A further relevant and sad statistic revealed by the 197273 U.C.C.A. report is that of 2120 overseas applicants for places in British medical schools only 116 were admitted, If existing medical schools an acceptance rate of 5%. cannot further increase their intake then there seems to be much logic in the proposalby the members of the National Association of Clinical Tutors for a working-party to examine the possibility of utilising the resources of the Open University for preclinical training and those in postgraduate teaching centres in district general hospitals for clinical training. Even post-Illich ! 38 Magdalen Road, Norwich,
JAMES
Norfolk NOR 57P.
BEVERIDGE.
SEASONAL VARIATION OF PATENT DUCTUS ARTERIOSUS
SIR,-Dr Rothman and Dr Fyler reported a seasonal variation in ventricular septal defect (V.S.D.), especially when associated with patent ductus arteriosus (P.D.A.).2 However, Dr Rosenberg and Dr Heinonen (Oct. 12, p. 903) could not demonstrate such a seasonal trend for last menstrual periods in mothers of offspring with either
simple
or
complex
v.s.D.
These contradictory findings prompt me to report a study which did not demonstrate a seasonal variation in P.D.A., as had been suggested by other workers. 3,4 The records of 421 patients, over the age of one month with P.D.A., confirmed by surgery, catheterisation, or necropsy, were reviewed. 135 such patients were treated at the Massachusetts General Hospital of Boston and 286 at the YaleNew Haven Hospital, between 1947 and 1966. Their years of birth ranged from 1893 to 1966. These patients were classified: as (a) having only a P.D.A., (b) as having a P.D.A. associated with another anomaly, (c) as presenting a chromosomal aberration and P.D.A., and (d) as patients known to have been affected in utero by rubella virus. There was no statistically significant seasonal variation in births of patients with P.D.A. of any of the above groups, with the exception of the rubella syndrome. This does not accord with Record and McKeown3 who found that P.D.A. was increased among girls born between May and December, with a peak in July and August. Polani and Campbell4 reached similar conclusions. However, by combining Record’s figures with their own, they found that more girls were born during May to November, with the peak in August, and fewer from December to April. They also found that births of affected boys were equally distributed through the year, except that fewer were born in January, February, and March. Finally, Rutstein et al.5 described an increase in the births of patients with P.D.A. between October and January and correlated these with the high incidence of rubella seven months earlier. My results do not agree with those of the above workers. I believe that the season of birth does not significantly 1. Times, Nov. 8, 1974, p. 17. 2. Rothman, K. J., Fyler, D. C. Lancet, 1974, ii, 193. 3. Record, R. G., McKeown, T. Br. Heart J. 1953, 15, 376. 4. Polani, P. E., Campbell, M. Ann. hum. Genet. 1960, 24, 343. 5. Rutstein, D. D., Nickerson, R. J., Heald, F. P. Am. J. Dis. Child.
1952, 84, 199.
affect the incidence of P.D.A., with the exception of the P.D.A. caused by the rubella virus. The incidence of births of affected infants should reflect the season of the epidemic as in the cases reported (November to January), which followed a spring epidemic. I thank Dr W. W. L. Glenn for his assistance in
allowing
the
study of the Yale records. B. Department of Pediatrics, University of Athens, P.O. Box 3064, Athens, Greece.
CHRISTOS S. BARTSOCAS.
CHEMOPROPHYLAXIS OF MENINGOCOCCAL INFECTION SIR,-I am perturbed by your editorial (Dec. 14, p. 1431) in which you state that minocycline cannot be recommended as a prophylactic agent, firstly because experience is "
limited, and,
more
seriously, because toxic vestibular to 90% of those receiving
effects have been reported in up
the drug." The first criticism may be pertinent when considering British evidence, but is certainly not true of worldwide publications referring to the prophylactic treatment of over
20,000 subjects.1-5 Regarding your second point I agree that minocycline can cause giddiness. However, our own extensive review of the published and unpublished literature has provided us with an estimated overall incidence of about 5%. Guttler,l for example, in his study of 14,800 subjects, did not even consider the incidence of dizziness worthy of special mention, but classified it together with headache and nausea, quoting a total incidence of 7%. In some series,6.? " vestibular " side-effects were totally lacking in patients treated with minocycline. Masterton 8 reported that of 349 patients treated with single doses of 300 mg. and 400 mg. of minocycline for acute gonorrhoea, only 2 (0-6%) complained of giddiness. These figures are totally at variance with those of Williams 9 who in any case treated only 19 patients, 7 of whom received doses far above those recommended. Lederle Laboratories, Fareham Road, Gosport, P.O. Box 7, Hants P013 0AS.
A. YEADON, Medical Director.
TREATMENT OF MALIGNANT MELANOMA
SIR,-Grant et al., 10 reporting results with B.C.G. immunotherapy in malignant melanoma, describe such complications as fever, granulomatous hepatitis, mycobacterial pneumonia, and splenomegaly, suggesting that they are the These and other result of systemic B.C.G. infection. complications have also been attributed to a hypersensitivity reaction.ll Neurological symptoms have, as far as we know, not been reported. A 28-year-old woman with malignant melanoma developed Guillain-Barré syndrome after B.C.G. immunotherapy by the multiple puncture technique. She had melanoma Guttler, R. B. Antimicrob. Ag. Chemother. 1972, 1, 397. Devine, L. F. Am. J. Epidem. 1971, 93, 337. Guttler, R. B. J. infect. Dis. 1971, 124, 199. Devine, L. F. Am. J. Epidem. 1973, 97, 394. 5. Munford, R. S. J. infect. Dis. 1974, 129, 644. 6. Pines, A. Practitioner, 1974, 213, 727. 7. Fowler, W. Br. J. clin. Pract. 1974, 28, 347. 8. Masterton, G., Schofield, C. B. S. Lancet, 1974, ii, 1139. 9. Williams, D. N. ibid. p. 744. 10. Grant, R. M., Cochran, A. J., Hoyle, D., Mackie, R., Murray, E. L., Ross, C. Lancet, 1974, ii, 1096. 11. Sparks, F. C., Silverstein, M. J., Hunt, J. S., Haskell, C. M., Pitch, Y. M., Morton, D. L. New Engl. J. Med. 1973, 289, 827. 1. 2. 3. 4.
dependent
on overseas
doctors
can we
afford
to waste
this
potential ? It is wasteful not only in terms of educational opportunity for these able young people themselves but also because Great Britain continues to absorb the medical graduates of other countries who can surely ill afford to lose them. The Chief Medical Officer of the Department of Health has stated in his annual report that in 1973 the number of N.H.S. doctors rose by 3%, half of them born abroad. Perhaps 50% of doctors at present working in National Health Service hospitals come from abroad. A further relevant and sad statistic revealed by the 197273 U.C.C.A. report is that of 2120 overseas applicants for places in British medical schools only 116 were admitted, If existing medical schools an acceptance rate of 5%. cannot further increase their intake then there seems to be much logic in the proposalby the members of the National Association of Clinical Tutors for a working-party to examine the possibility of utilising the resources of the Open University for preclinical training and those in postgraduate teaching centres in district general hospitals for clinical training. Even post-Illich ! 38 Magdalen Road, Norwich,
JAMES
Norfolk NOR 57P.
BEVERIDGE.
SEASONAL VARIATION OF PATENT DUCTUS ARTERIOSUS
SIR,-Dr Rothman and Dr Fyler reported a seasonal variation in ventricular septal defect (V.S.D.), especially when associated with patent ductus arteriosus (P.D.A.).2 However, Dr Rosenberg and Dr Heinonen (Oct. 12, p. 903) could not demonstrate such a seasonal trend for last menstrual periods in mothers of offspring with either
simple
or
complex
v.s.D.
These contradictory findings prompt me to report a study which did not demonstrate a seasonal variation in P.D.A., as had been suggested by other workers. 3,4 The records of 421 patients, over the age of one month with P.D.A., confirmed by surgery, catheterisation, or necropsy, were reviewed. 135 such patients were treated at the Massachusetts General Hospital of Boston and 286 at the YaleNew Haven Hospital, between 1947 and 1966. Their years of birth ranged from 1893 to 1966. These patients were classified: as (a) having only a P.D.A., (b) as having a P.D.A. associated with another anomaly, (c) as presenting a chromosomal aberration and P.D.A., and (d) as patients known to have been affected in utero by rubella virus. There was no statistically significant seasonal variation in births of patients with P.D.A. of any of the above groups, with the exception of the rubella syndrome. This does not accord with Record and McKeown3 who found that P.D.A. was increased among girls born between May and December, with a peak in July and August. Polani and Campbell4 reached similar conclusions. However, by combining Record’s figures with their own, they found that more girls were born during May to November, with the peak in August, and fewer from December to April. They also found that births of affected boys were equally distributed through the year, except that fewer were born in January, February, and March. Finally, Rutstein et al.5 described an increase in the births of patients with P.D.A. between October and January and correlated these with the high incidence of rubella seven months earlier. My results do not agree with those of the above workers. I believe that the season of birth does not significantly 1. Times, Nov. 8, 1974, p. 17. 2. Rothman, K. J., Fyler, D. C. Lancet, 1974, ii, 193. 3. Record, R. G., McKeown, T. Br. Heart J. 1953, 15, 376. 4. Polani, P. E., Campbell, M. Ann. hum. Genet. 1960, 24, 343. 5. Rutstein, D. D., Nickerson, R. J., Heald, F. P. Am. J. Dis. Child.
1952, 84, 199.
affect the incidence of P.D.A., with the exception of the P.D.A. caused by the rubella virus. The incidence of births of affected infants should reflect the season of the epidemic as in the cases reported (November to January), which followed a spring epidemic. I thank Dr W. W. L. Glenn for his assistance in
allowing
the
study of the Yale records. B. Department of Pediatrics, University of Athens, P.O. Box 3064, Athens, Greece.
CHRISTOS S. BARTSOCAS.
CHEMOPROPHYLAXIS OF MENINGOCOCCAL INFECTION SIR,-I am perturbed by your editorial (Dec. 14, p. 1431) in which you state that minocycline cannot be recommended as a prophylactic agent, firstly because experience is "
limited, and,
more
seriously, because toxic vestibular to 90% of those receiving
effects have been reported in up
the drug." The first criticism may be pertinent when considering British evidence, but is certainly not true of worldwide publications referring to the prophylactic treatment of over
20,000 subjects.1-5 Regarding your second point I agree that minocycline can cause giddiness. However, our own extensive review of the published and unpublished literature has provided us with an estimated overall incidence of about 5%. Guttler,l for example, in his study of 14,800 subjects, did not even consider the incidence of dizziness worthy of special mention, but classified it together with headache and nausea, quoting a total incidence of 7%. In some series,6.? " vestibular " side-effects were totally lacking in patients treated with minocycline. Masterton 8 reported that of 349 patients treated with single doses of 300 mg. and 400 mg. of minocycline for acute gonorrhoea, only 2 (0-6%) complained of giddiness. These figures are totally at variance with those of Williams 9 who in any case treated only 19 patients, 7 of whom received doses far above those recommended. Lederle Laboratories, Fareham Road, Gosport, P.O. Box 7, Hants P013 0AS.
A. YEADON, Medical Director.
TREATMENT OF MALIGNANT MELANOMA
SIR,-Grant et al., 10 reporting results with B.C.G. immunotherapy in malignant melanoma, describe such complications as fever, granulomatous hepatitis, mycobacterial pneumonia, and splenomegaly, suggesting that they are the These and other result of systemic B.C.G. infection. complications have also been attributed to a hypersensitivity reaction.ll Neurological symptoms have, as far as we know, not been reported. A 28-year-old woman with malignant melanoma developed Guillain-Barré syndrome after B.C.G. immunotherapy by the multiple puncture technique. She had melanoma Guttler, R. B. Antimicrob. Ag. Chemother. 1972, 1, 397. Devine, L. F. Am. J. Epidem. 1971, 93, 337. Guttler, R. B. J. infect. Dis. 1971, 124, 199. Devine, L. F. Am. J. Epidem. 1973, 97, 394. 5. Munford, R. S. J. infect. Dis. 1974, 129, 644. 6. Pines, A. Practitioner, 1974, 213, 727. 7. Fowler, W. Br. J. clin. Pract. 1974, 28, 347. 8. Masterton, G., Schofield, C. B. S. Lancet, 1974, ii, 1139. 9. Williams, D. N. ibid. p. 744. 10. Grant, R. M., Cochran, A. J., Hoyle, D., Mackie, R., Murray, E. L., Ross, C. Lancet, 1974, ii, 1096. 11. Sparks, F. C., Silverstein, M. J., Hunt, J. S., Haskell, C. M., Pitch, Y. M., Morton, D. L. New Engl. J. Med. 1973, 289, 827. 1. 2. 3. 4.
