86
2. Tweeddale
PM, Merchant S, Leslie M, Alexander F, McHardy GJR. variability in FEV1: relation to pretest activity, level of FEV1, and smoking habits. Thorax 1984; 39: 928-32. 3. Eliasson O, Degraff AC. The use of criteria for reversibility and obstruction to define patient groups for bronchodilator trials. Am Rev Respir Dis 1985; 132: 858-64. 4. Anthonisen NR, Wright EC, the IPPB Trial Group. Bronchodilator response in chronic obstructive pulmonary disease. Am Rev Respir Dis 1986; 133: 814-19. 5. Tweeddale PM, Alexander F, McHardy GJR. Short term variability of FEV1 and bronchodilator responsiveness in patients with obstructive ventilatory defect. Thorax 1987; 42: 487-90. 6. Weir DC, Burge PS. Measures of reversibility in response to Short
term
bronchodilators in chronic airflow obstruction: relation to airflow calibre. Thorax 1991; 46: 43-45. 7. Miller MR, Pincock AC. Predicted values: how should we use them? Thorax 1988; 43: 265-67. 8. Stourk RL, Nugent KM. Bronchodilator testing: confidence intervals derived from placebo inhalations. Am Rev Respir Dis 1983; 128: 153-57. 9. Strachan DP. Repeatability of ventilatory function measurements in a population survey of 7 year old children. Thorax 1989; 44: 474-79. 10. Editorial. Assessment of airflow obstruction. Lancet 1986; ii: 1255-56. 11. Guyatt GH, Townsend M, Pugsley SO, et al. Bronchodilators in chronic air flow limitation. Am Rev Respir Dis 1987; 135: 1069-74.
Medical schools and NHS reforms: death knell of the Universities Funding Council At the time of their introduction 3 years ago, the health service reforms in Britain were regarded as a substantial threat to medical education and research. The competitive market place and academic medicine are uneasy bedfellows at the best of times, and the original White Paper gave little cause for reassurance.i There are few short-term financial returns in teaching and research to encourage the entrepreneurial spirits of the Thatcherite revolution. However, the problems of academic medicine in the UK reflect much more than the clash of academic and commercial philosophies in teaching hospitals. The reforms are merely a response to an underlying malaise that affects both clinical and research communities-ie, the growing disparity between the needs of medical care and research as perceived by their practitioners and the resources that governments are prepared to apply to them. One has only to compare experience in a parallel field—eg, pharmaceutical investment in drug development, which has shown a progressive increase over the past decade-to recognise the tensions that develop when budgets are held under constraint.zAnother factor that has to be taken into account is the well-rehearsed issue of London and other metropolitan teaching hospitals which has been thrown into relief by the pressures of the market place. The Medical Sub-Committee of the Universities Funding Council has the unenviable task of advising on the allocation of government funds for medical schools. It is a body in its death throes, since a new much larger higher education funding council is about to be set up to embrace the former polytechnics. When this change takes place the special position of the medical schools is likely to be even further eroded.
as a terminal act, the Medical SubCommittee has reviewed the impact of the National Health Service reforms on academic activity.3 The result is a faintly disturbing yet curiously ambiguous document since the major consequences of the changes have yet to be seen. The final impression is of uncertain progress through no man’s land: minefields are clearly present, casualties so far are fewer than the pessimists had predicted, but it is impossible to see what lies ahead. In the battle some have clearly been more fortunate than others. In some teaching hospitals excessive clinical and administrative service work was noted to be impeding teaching and research; in others, market limitations on the flow of patients were felt to be creating difficulties. The negotiating posture can also prove helpful to academics. Thus, the Service Increment for Teaching and Research (SIFTR) attempts to compensate from NHS funds the excess costs incurred by these activities. The substantial sums involved have long been taken for granted in teaching hospital budgets: the money is used for maintaining the service in undefined ways. Without SIFTR the predicament of many teaching hospitals would be even worse than it is. Under the new dispensation the universities have a say in the way in which it is spent. Some medical schools have used their improved bargaining position to good effect. The market place offered clear
Meanwhile,
opportunities. There are important concerns that are only implicitly stated in this report. Overriding all is the inescapable fact that the money in the system is insufficient to meet all needs. An arrangement based on the market place defined by contracts may help to pinpoint what is happening and may change the balance, but it will not resolve the problem to the satisfaction of all parties responsible for clinical service, research, and teaching. In some ways it is unfortunate for the Universities Funding Council that their report was issued in the same week as the King’s Fund Commission proposals for acute medical services in London,4although the Council do point out that London’s difficulties are encountered in other large city teaching hospitals. The Council’s document is essentially concerned with preservation of the teaching and research status quo whereas the King’s Fund report presents a much more revolutionary approach, with its recommendations for a radical restructuring of both health services and medical schools into something more appropriate to the needs of the population and the opportunities afforded by modem medical science. If a teaching hospital is no longer providing a .sufficiently broad-based clinical service to support clinical teaching and research, the proposal for special protective contracts to ensure patient flows and case-mix is not especially appealing. This strategy is merely a desperate attempt to create a teaching hospital microenvironment that more closely mirrors the real if distant world of health need. Not only
87
does such
be swimming against a powerful tide but also it lacks conviction. No complaints were made about adequate case-mix in the 1950s and 1960s, when common medical and surgical conditions were conspicuous by their absence in metropolitan teaching hospitals. When academic bodies have used the case-mix argument it has occasionally been possible to read "humbug" on the lips of Department of Health representatives. The needs of teaching and clinical research have to be distinguished from the needs of teachers and researchers. This latest rather bland report gives no evidence that the Universities Funding Council has heard the tolling of the distant bell. a
policy
seem to
1. Working for patients. London: HM Stationery Office, 1989: 38. 2. Centre for Medicines Research. Annual Report 1991-1992. Carshalton, Surrey: Centre for Medicines Research, 1992: 11.
3. Universities Funding Council Medical Committee. Second Report on the Effects of the NHS Reforms on Medical and Dental Education and Research. London: Universities Funding Council, March, 1992. 4. King’s Fund Commission on the Future of London’s Acute Health Services. London Health Care 2010. London: King’s Fund, 1992.
Diagnosing recurrent suffocation of children The
capacity of adults to abuse children and the variety of techniques used continue to test our credulity. To beatings, emotional cruelty, and sexual abuse we must now add the more subtle phenomenon of repeated suffocation. Cases of deliberate and repeated suffocation have come to light during the investigation of children and infants with recurrent apnoeic attacks or cyanotic episodes.1-3 A thorough history may reveal that the onset of these episodes always occurs in the presence of one carer, usually the mother. The need for recurrent cardiopulmonary resuscitation started by a carer but continued by professionals is a suggestive feature.’ Episodes usually begin in infancy but may continue for months or years if the diagnosis is cyanotic delayed. There may be a history of recurrent episodes or unexpected deaths in siblings.44 The parents are often concerned and cooperative ("model parents"),1 but careful inquiry will elicit a history of factitious illness, eating disorder, or episodes of self harm in the majority of perpetrators.3 Physical examination of the child is usually unrevealing; petechiae or even bruises around the mouth,
nose, and neck may be detected. Most
investigations
are unhelpful, but long-term multichannel physiological recordings can provide essential diagnostic information. 1,3 If arterial oxygen saturation, breathing movements, electrocardiogram, heart rate, and nasal airflow are monitored simultaneously, a characteristic pattern of changes is observed during suffocation. "Usually the recording showed regular breathing which was suddenly interrupted by the onset of large movement artefact on the breathing movement signal in combination with a pattern of obstruction-that is, continued breathing
movements, absent airflow, and a gradual fall in Sa02. In addition, there was an initial sinus tachycardia, followed by a bradycardia when severe hypoxaemia
supervened. 113 This combination of personal and maternal history and polygraphic recordings may seem conclusive but will be insufficient to convince some people that seemingly ordinary folk are repeatedly suffocating their children. The diagnosis can be confirmed by covert video surveillance. To do this, medical personnel must cooperate with the police to arrange video observations of the carer and infant together in a specially prepared cubicle in hospital. Spying on people in this way is inherently distasteful but there can be no doubting its practical value. Perpetrators will usually deny their actions or intentions if confronted. A video record of a child struggling violently while the upper airway is occluded by hand or pad is a powerful image to bring home to professionals, courts, and perpetrators the gravity of the assault. There is a high mortality if the condition is not detected.4Ethical or legal objections to this approach have not been sustained. There is no legal right to privacy5 and the sharing of confidential medical information with police and social service departments is ethically acceptable if necessary for the child’s protection. Nevertheless, covert video surveillance is a complex, challenging, invasive, and expensive procedure and must be used sparingly if the confidence of staff and families is to be maintained. Proper case selection, confidentiality, and careful cooperation between agencies is essential. Repeated suffocation of children seems to be a rare condition-a British tertiary referral centre lately reported 14 cases collected over 5 years.Most paediatricians will therefore need to discuss possible cases with a specialist before they entertain the possibility of covert surveillance. Although this may mean that children have to be assessed in a specialist unit, the concept of permanently bugged cubicles in such units is surely unacceptable; such a policy would throw unwarranted suspicion on many families and threaten confidentiality. The necessary experience to establish such surveillance is widely available in the police service. If the case for video surveillance is agreed on the basis of history and polygraphic recordings, most paediatric units should be able to organise covert surveillance without referring parents and child elsewhere. 1. Rosen CL, Frost JD, Glaze DG. Child abuse and recurrent infant apnea. J Pediatr 1986; 109: 1065-67. 2. Southall DP, Stebbens VA, Rees SV, Lang MH, Warner JO, Shinebourne EA. Apnoeic episodes induced by smothering: two cases identified by covert video surveillance. BMJ 1987; 294: 1637-41. 3. Samuels MP, McClaughlin W, Jacobson RR, Poets CF, Southall DP. Fourteen cases of imposed upper airway obstruction. Arch Dis Child 1992; 67: 162-70. 4. Meadow R. Suffocation, recurrent apnea, and sudden infant death.
J Pediatr 1990; 117: 351-57. 5. Williams C, Bevan VT. The secret observation of children in Lancet 1988; i: 780-81.
hospital.
2. Tweeddale
PM, Merchant S, Leslie M, Alexander F, McHardy GJR. variability in FEV1: relation to pretest activity, level of FEV1, and smoking habits. Thorax 1984; 39: 928-32. 3. Eliasson O, Degraff AC. The use of criteria for reversibility and obstruction to define patient groups for bronchodilator trials. Am Rev Respir Dis 1985; 132: 858-64. 4. Anthonisen NR, Wright EC, the IPPB Trial Group. Bronchodilator response in chronic obstructive pulmonary disease. Am Rev Respir Dis 1986; 133: 814-19. 5. Tweeddale PM, Alexander F, McHardy GJR. Short term variability of FEV1 and bronchodilator responsiveness in patients with obstructive ventilatory defect. Thorax 1987; 42: 487-90. 6. Weir DC, Burge PS. Measures of reversibility in response to Short
term
bronchodilators in chronic airflow obstruction: relation to airflow calibre. Thorax 1991; 46: 43-45. 7. Miller MR, Pincock AC. Predicted values: how should we use them? Thorax 1988; 43: 265-67. 8. Stourk RL, Nugent KM. Bronchodilator testing: confidence intervals derived from placebo inhalations. Am Rev Respir Dis 1983; 128: 153-57. 9. Strachan DP. Repeatability of ventilatory function measurements in a population survey of 7 year old children. Thorax 1989; 44: 474-79. 10. Editorial. Assessment of airflow obstruction. Lancet 1986; ii: 1255-56. 11. Guyatt GH, Townsend M, Pugsley SO, et al. Bronchodilators in chronic air flow limitation. Am Rev Respir Dis 1987; 135: 1069-74.
Medical schools and NHS reforms: death knell of the Universities Funding Council At the time of their introduction 3 years ago, the health service reforms in Britain were regarded as a substantial threat to medical education and research. The competitive market place and academic medicine are uneasy bedfellows at the best of times, and the original White Paper gave little cause for reassurance.i There are few short-term financial returns in teaching and research to encourage the entrepreneurial spirits of the Thatcherite revolution. However, the problems of academic medicine in the UK reflect much more than the clash of academic and commercial philosophies in teaching hospitals. The reforms are merely a response to an underlying malaise that affects both clinical and research communities-ie, the growing disparity between the needs of medical care and research as perceived by their practitioners and the resources that governments are prepared to apply to them. One has only to compare experience in a parallel field—eg, pharmaceutical investment in drug development, which has shown a progressive increase over the past decade-to recognise the tensions that develop when budgets are held under constraint.zAnother factor that has to be taken into account is the well-rehearsed issue of London and other metropolitan teaching hospitals which has been thrown into relief by the pressures of the market place. The Medical Sub-Committee of the Universities Funding Council has the unenviable task of advising on the allocation of government funds for medical schools. It is a body in its death throes, since a new much larger higher education funding council is about to be set up to embrace the former polytechnics. When this change takes place the special position of the medical schools is likely to be even further eroded.
as a terminal act, the Medical SubCommittee has reviewed the impact of the National Health Service reforms on academic activity.3 The result is a faintly disturbing yet curiously ambiguous document since the major consequences of the changes have yet to be seen. The final impression is of uncertain progress through no man’s land: minefields are clearly present, casualties so far are fewer than the pessimists had predicted, but it is impossible to see what lies ahead. In the battle some have clearly been more fortunate than others. In some teaching hospitals excessive clinical and administrative service work was noted to be impeding teaching and research; in others, market limitations on the flow of patients were felt to be creating difficulties. The negotiating posture can also prove helpful to academics. Thus, the Service Increment for Teaching and Research (SIFTR) attempts to compensate from NHS funds the excess costs incurred by these activities. The substantial sums involved have long been taken for granted in teaching hospital budgets: the money is used for maintaining the service in undefined ways. Without SIFTR the predicament of many teaching hospitals would be even worse than it is. Under the new dispensation the universities have a say in the way in which it is spent. Some medical schools have used their improved bargaining position to good effect. The market place offered clear
Meanwhile,
opportunities. There are important concerns that are only implicitly stated in this report. Overriding all is the inescapable fact that the money in the system is insufficient to meet all needs. An arrangement based on the market place defined by contracts may help to pinpoint what is happening and may change the balance, but it will not resolve the problem to the satisfaction of all parties responsible for clinical service, research, and teaching. In some ways it is unfortunate for the Universities Funding Council that their report was issued in the same week as the King’s Fund Commission proposals for acute medical services in London,4although the Council do point out that London’s difficulties are encountered in other large city teaching hospitals. The Council’s document is essentially concerned with preservation of the teaching and research status quo whereas the King’s Fund report presents a much more revolutionary approach, with its recommendations for a radical restructuring of both health services and medical schools into something more appropriate to the needs of the population and the opportunities afforded by modem medical science. If a teaching hospital is no longer providing a .sufficiently broad-based clinical service to support clinical teaching and research, the proposal for special protective contracts to ensure patient flows and case-mix is not especially appealing. This strategy is merely a desperate attempt to create a teaching hospital microenvironment that more closely mirrors the real if distant world of health need. Not only
87
does such
be swimming against a powerful tide but also it lacks conviction. No complaints were made about adequate case-mix in the 1950s and 1960s, when common medical and surgical conditions were conspicuous by their absence in metropolitan teaching hospitals. When academic bodies have used the case-mix argument it has occasionally been possible to read "humbug" on the lips of Department of Health representatives. The needs of teaching and clinical research have to be distinguished from the needs of teachers and researchers. This latest rather bland report gives no evidence that the Universities Funding Council has heard the tolling of the distant bell. a
policy
seem to
1. Working for patients. London: HM Stationery Office, 1989: 38. 2. Centre for Medicines Research. Annual Report 1991-1992. Carshalton, Surrey: Centre for Medicines Research, 1992: 11.
3. Universities Funding Council Medical Committee. Second Report on the Effects of the NHS Reforms on Medical and Dental Education and Research. London: Universities Funding Council, March, 1992. 4. King’s Fund Commission on the Future of London’s Acute Health Services. London Health Care 2010. London: King’s Fund, 1992.
Diagnosing recurrent suffocation of children The
capacity of adults to abuse children and the variety of techniques used continue to test our credulity. To beatings, emotional cruelty, and sexual abuse we must now add the more subtle phenomenon of repeated suffocation. Cases of deliberate and repeated suffocation have come to light during the investigation of children and infants with recurrent apnoeic attacks or cyanotic episodes.1-3 A thorough history may reveal that the onset of these episodes always occurs in the presence of one carer, usually the mother. The need for recurrent cardiopulmonary resuscitation started by a carer but continued by professionals is a suggestive feature.’ Episodes usually begin in infancy but may continue for months or years if the diagnosis is cyanotic delayed. There may be a history of recurrent episodes or unexpected deaths in siblings.44 The parents are often concerned and cooperative ("model parents"),1 but careful inquiry will elicit a history of factitious illness, eating disorder, or episodes of self harm in the majority of perpetrators.3 Physical examination of the child is usually unrevealing; petechiae or even bruises around the mouth,
nose, and neck may be detected. Most
investigations
are unhelpful, but long-term multichannel physiological recordings can provide essential diagnostic information. 1,3 If arterial oxygen saturation, breathing movements, electrocardiogram, heart rate, and nasal airflow are monitored simultaneously, a characteristic pattern of changes is observed during suffocation. "Usually the recording showed regular breathing which was suddenly interrupted by the onset of large movement artefact on the breathing movement signal in combination with a pattern of obstruction-that is, continued breathing
movements, absent airflow, and a gradual fall in Sa02. In addition, there was an initial sinus tachycardia, followed by a bradycardia when severe hypoxaemia
supervened. 113 This combination of personal and maternal history and polygraphic recordings may seem conclusive but will be insufficient to convince some people that seemingly ordinary folk are repeatedly suffocating their children. The diagnosis can be confirmed by covert video surveillance. To do this, medical personnel must cooperate with the police to arrange video observations of the carer and infant together in a specially prepared cubicle in hospital. Spying on people in this way is inherently distasteful but there can be no doubting its practical value. Perpetrators will usually deny their actions or intentions if confronted. A video record of a child struggling violently while the upper airway is occluded by hand or pad is a powerful image to bring home to professionals, courts, and perpetrators the gravity of the assault. There is a high mortality if the condition is not detected.4Ethical or legal objections to this approach have not been sustained. There is no legal right to privacy5 and the sharing of confidential medical information with police and social service departments is ethically acceptable if necessary for the child’s protection. Nevertheless, covert video surveillance is a complex, challenging, invasive, and expensive procedure and must be used sparingly if the confidence of staff and families is to be maintained. Proper case selection, confidentiality, and careful cooperation between agencies is essential. Repeated suffocation of children seems to be a rare condition-a British tertiary referral centre lately reported 14 cases collected over 5 years.Most paediatricians will therefore need to discuss possible cases with a specialist before they entertain the possibility of covert surveillance. Although this may mean that children have to be assessed in a specialist unit, the concept of permanently bugged cubicles in such units is surely unacceptable; such a policy would throw unwarranted suspicion on many families and threaten confidentiality. The necessary experience to establish such surveillance is widely available in the police service. If the case for video surveillance is agreed on the basis of history and polygraphic recordings, most paediatric units should be able to organise covert surveillance without referring parents and child elsewhere. 1. Rosen CL, Frost JD, Glaze DG. Child abuse and recurrent infant apnea. J Pediatr 1986; 109: 1065-67. 2. Southall DP, Stebbens VA, Rees SV, Lang MH, Warner JO, Shinebourne EA. Apnoeic episodes induced by smothering: two cases identified by covert video surveillance. BMJ 1987; 294: 1637-41. 3. Samuels MP, McClaughlin W, Jacobson RR, Poets CF, Southall DP. Fourteen cases of imposed upper airway obstruction. Arch Dis Child 1992; 67: 162-70. 4. Meadow R. Suffocation, recurrent apnea, and sudden infant death.
J Pediatr 1990; 117: 351-57. 5. Williams C, Bevan VT. The secret observation of children in Lancet 1988; i: 780-81.
hospital.
