898 of their paper only 1

Letters

to

the Editor

patient in the heparin group who died due

pulmonary embolism, which was confirmed at necropsy. In Rem’s thesis,5 the results reported on pages 7 and 8 indicate that there was only 1 fatal and 3 contributory emboli among 107 patients allocated to receive heparin. (2) As already stated,3over half the patients submitted from the Basle centre had to be excluded because the random allocation of patients into heparin and control groups was not followed in this centre. The details of these patients and reasons for exclusion were fully explained to them during a meeting in Basle on June 24, 1975. Written confirmation that the mistake had been made in Basle was subsequently received by us.’7 (3) Gruber et al. ask about the duration of follow-up of patients in the trial. The protocol, and the original publication of July, 1975,8 clearly state that the patients were followed up until discharge, or death in hospital. (4) The relevant passage in Rem’s thesis’ is:

to

PREVENTION OF FATAL POSTOPERATIVE PULMONARY EMBOLISM BY LOW-DOSE HEPARIN

SIR,-We reported (Jan. 29, p.207) that the frequency of pulmonary emboli (P.E.) in Basle did not show the difference between the control and the heparin group found in the multicentre trial (M.C.T.).l The M.c.T. coordinating centre (March 12, p. 567) has now reanalysed the results, excluding all data from Basle. This procedure has not improved the necropsyrate (68.2%). 30 out of 31 fatal cases in our study did have necropsy examination. The coordinating centre is free to perform any sort of reanalysis, but the reasons given require some comments:

(1) The coordinating centre sees inconsistencies in our data, we find inconsistencies in table in the reanalysis. Here figures on total deaths, necropsy-rate, and number of P.E.s are said to come from our 1975 papery although death-rate, nec-

but

ropsy incidence, or number of fatal P.E.s are not mentioned in this publication. (2) One reason why our report appeared 18 months after publication of the results of the M.C.T.’ is that we had asked repeatedly which of our patients with P.E. at necropsy were included in the final evaluation and which patients were excluded and for what reason. We never received this information. The main question we asked in our Jan. 29 paper has not been answered in the reanalysis of the M.c.T.-namely, when, in the M.c.T., did the postoperative period end? (3) Reference 4 in the reanalysis paper looks unusual. Neither in the thesis of J.R. nor in the personal letter from F.D. dated Basle, June 30, 1975, can we trace the statement that "we had agreed that we had no more than 3 fatal P.E.". There are many more inconsistencies in the reanalysis. It is also clear that re-evaluation of the data of the M.C.T. after exclusion of the unfavourable results will not help to solve the problem of how to prevent fatal P.E. The coordinating centre has missed the point: it would have been interesting to know from all participating centres if they had any data on the follow-up of their patients. Our data do cast doubt on the conclusion drawn from the M.C.T., and we have started a new multicentre trial. ULRICH F. GRUBER FRANÇOIS DUCKERT RAIMUND FRIDRICH University of Basle, JOSEF REM Kantonsspital, CH-4031 Basle, Switzerland JOACHIM TORHORST _.

patients who were included in the studies up to 30th were in the control group and 105 patients in the heparin group: in the control group 5 patients died within the first postoperative week. At autopsy one patient showed an associated lung embolism. At a later date 5 more patients died in this group. Of these, 2 patients had a fatal lung embolism (one on the 8th and one on the 30th postoperative day), one patient showed a contnbutory lung embolism (he died on the 12th postoperative day). In the heparm group, one patient died on the first postoperative day. The autopsy confirmed lung embolism as a cause of death. After the first postoperative week 4 more casualties were recorded. 3 of these patients had contributory lung embolism (on the 14th, 15th day and at 3 months). The last 2 patients had their heparin treatment stopped, as they were quite hopeless carcinoma cases". "... of the 212

June, 1974, 107 patients

(5) The relevant points Basle

to

the

coordinating

in the letter from Dr F. Duckert in of the multicentre trial’ are:

centre

"... the randomization was correct but one or several assistants during the last period didn’t pay attention to the concordance between the envelope number and the proforma number. Since the names and numbers have been recorded by the assistants and noted on my randomization card a correction could be made. I believe the randomization was correct, unfortunately the proformas were uncorrectly chosen to record the data of the patient corresponding to the randomization en-

velope. "Another point, I believe that is the difference in the number of pulmonary embolism from center to center which is rather important since we had 2 or 3 fatal cases in Basle and also the discrepancy m the

bleeding frequency which it seemed higher in Basle than in other centers."

was

for the

heparm group

A copy of this letter and Rem’s thesis have been shown to the editor of The Lancet. V. V. KAKKAR T. P. CORRIGAN D. P. FOSSARD Co-ordinating Centre, I. SUTHERLAND Medical School, King’s College Hospital London SE5 8RX J. THIRLWELL

MALNUTRITION IN SURGICAL PATIENTS

***This letter has been shown

leagues,

to Professor Kakkar and his coland their reply follows.-ED. L.

SiR,-We have read the letter by Dr Gruber and his col-

leagues and our comments are: (1) Reference 3 in our paper of March 121 should have referred to the data presented in their publication in Schweizerische medizinische Wochenschrift and in the thesis of J. Rem.5 Unfortunately, this reference was misprinted; this mistake was corrected in the

following week’s issued Gruber et al.4 describe on p.

833

1. Kakkar, V. V., Corrigan, T. P., Fossard, D. P. Lancet, 1975, ii, 45. 2. Rem, J., Duckert, F., Fridrich, R., Gruber, U. F. Schweiz. med. Wschr.

1975, 105, 827. 3. International Multicentre Trial. Lancet, 1977, i, 567. 4. Rem, J., Duckert, F., Fridrich, R., Gruber, U. F. Schweiz. med. Wschr.

SIR,-Few will disagree with Mr Hill and his colleagues (March 26, p. 689) that the understanding of nutrition needs more emphasis in the medical curriculum. However, the findings in their nutritional survey cannot be accepted uncritically. The difference in numbers between the controls and the patients makes statistical comparisons difficult. They sampled their patients during a six-week winter period, which may itself influence the results; and they did not make serial measurements on individual patients before and after major surgery. How much did the condition for which the patient was being operated on contribute to the low nutritional indices recorded? I would also take issue with their rejection of comparisons between the observed values and generally accepted normal values. After all, a patient in Britain may be relatively overfed before admission to hospital, and weight loss, reduc-

1975, 105, 827. 5. Rem, J. A. Inaugural dissertation, Faculty of Medicine, 1975. (Translated by Isolde Harris.) 6. Kakkar, V. V. Lancet, 1977, i, 659.

University

of Basle,

7. Communication

centre from Basle. Letter received on before the publication of the M.C.T. results. 8. International Multicentre Trial Lancet, 1975, ii, 45. to

the

June 30, 1975, with

co-ordinating

comments

899 of arm muscle circumference, and a fall in serum-albumin themselves make protein-calorie malnutrition. do Over the past fifteen months we have been doing a similar, though less comprehensive, survey on patients under the care of one surgical firm. Those undergoing major surgery have been assessed serially during recovery, and although weight loss has at some stage been observed in about 40% of the major-surgery group, only about 5% of this group could be considered to have entered a state of protein-calorie malnutrition. Our findings, when compared with the Leeds data, may reflect differences in populations of surgical patients, but they do suggest that the position may not everywhere be as serious as it seems to be in Leeds. tion

not m

Department of Surgery, Guy’s Hospital, London SE1 9R1

M. H. JOURDAN

MENTAL HANDICAP: HOSPITAL AND COMMUNITY

S!R,—Your commentary (Feb. 26, p. 494) on Government policy on mental handicap highlights areas of concern for all those who work with the mentally handicapped in hospitals or m the community. Local authorities have been unable to carry out their plans or meet their commitments because of cutbacks in expenditure. The slow growth of hostel provision and the slow reduction in bed numbers in the large hospitals challenge us to find other ways of returning patients to the community and to improve the services of the large mental-handicap hospital. Group homes are proving successful and financially satisfactory, and they are frequently supported by voluntary bodies. However, they can only cater for the mildly handicapped, and the main advantage of these homes is that other patients can leave hospital to fill the hostel places left vacant by those moving into group homes. The patients who present the greatest

challenge are the profoundly handicapped, the multiply handicapped, and the behaviourally disturbed. They need all the skill the multidisciplmary team can muster, and I see the main role of the large hospital as providing a centre for the care of these patients and the training of staff who will then provide an effective community-care team. Prof. Peter Mittler is rightly concerned over the lack of progress, yet I feel that progress can still be made without further massive expenditure. The large hospital can easily become preoccupied with the problems of overcrowding, lack of staff, and threats of, industrial action. In an atmosphere of futility, rehabilitation schemes cease, contact with families is lost, and the short-stay patient becomes a long-stay probability. By contrast, the large hospital can make a valuable contribution if the staff see themselves as experts and are willing and able to move into the community, offering care in the home. The community nurse in mental handicap will surely become a key per-

providing a quality of care previously reserved for the hospital patient. Add to this nurse a psychologist, speech therapist, and occupational therapist, and you have a domiciliary team to meet the needs of many a hard-pressed and bewildered parent who wishes to keep their relative at home, given an adequate service. Such domiciliary teams should work with a consultant in mental handicap who will have a busy outpatient cliruc, beds for short, medium, and long term care, and daycare facilities. If only we bring our skills to the community, in particular to the family at their home, then the need for longstay beds will drop, short-term care will increase, and the smaller hospital serving one or two health districts of some 50-200 beds will meet most of the local needs, leaving the larger hospitals as centres for research, training, and special provision. Such small hospitals are being developed and should son in

’,e,.

f’’cnti31 part ot a local service. BB ’rhn? 1’1 a team ;s tor some people trving and tedmus but :ir. ’’