250

A postal questionnaire was sent to the deans of all 27 medical schools in the UK. The deans were asked to circulate copies to departments involved in teaching on chronic wounds (other than basic pathology and histology). The questionnaire was computer coded and was anonyrnised before analysis. There were 19 replies (70%). 2 medical schools indicated that there was definitely no formal teaching and 4 thought that there was probably no teaching. The average amount of teaching was 6 h (range 0-36 h). There were striking regional variations with England and Wales (excluding London) averaging less than 2 hours’ teaching, London 6 hours, and Scotland 17 hours. Two-thirds of responders indicated that all students received the teaching whereas one-third showed that only specific groups of students received the tuition. Most of the teaching took place in the first clinical year. There were 11 teachers for dermatology, 7 for health care of the elderly, 2 for general medicine, 7 for general surgery, 3 for vascular surgery, 4 for plastic surgery, 3 for orthopaedic surgery,1 for accident and emergency,1 for chiropody, and 2 for nursing. Thus, some students are taught this subject in more than one specialty though dermatology, health care of the elderly, and general surgery featured most often. 70% of students have some form of examination on the material taught but only 59 % have this work examined in the final MB or in continuous assessments. 81 % of teachers included preventive aspects; 62% mentioned the use of pressure-relieving equipment and aids, and 81% discussed wound dressings; only 50% covered bioengineering aspects, including physiological measurements. Some questionnaires were returned with detailed letters explaining why so little was taught about chronic open wounds. These ranged from the honest ("there is no structured teaching whatsoever on the management of wounds"), through the informative ("the General Medical Council will be issuing new guidelines about the medical curriculum late this year"), to the pompous ("the business of a medical school into the 1990s is learning rather than teaching... we do not think this task is about stuffing them with even more provision [data] for the journey: their canoe will sink"). Chronic open wounds may be an unglamorous aspect of medical life but the resultant morbidity and mortality are considerable. Doctors will not be able to join multidisciplinary teams dealing with such patients until the topic becomes a compulsory addition to the undergraduate medical course and is examined for (there is no shortage of patients). The survey was organised via the Tissue Viability Society (a multidisciplinary society involved in all aspects of wound care). My special thanks to the secretary, Mr John Gisby, and his assistant, Ms Dawn Roberts. Department of Health Care of the Elderly, Royal London Hospital, London E1 4DG, UK

G. C. J. BENNETT

1. Callam MJ, Dale JJ, Harper DR, Ruckley CV. Lothian & Forth Valley leg ulcer study.

Hawich: Buccleuch Pnnters, 1987. 2. Callam MJ, Ruckley CV, Harper DR, Dale JJ Chronic ulceration of the leg: extent of the problem and provision of care. Br Med J 1985; 290: 1855-56. 3. Wilson E Prevention and treatment of leg ulcers. Health Trends 1989; 21: 97. 4. Silver J. Letter to the editor Care Sci Pract 1987; 3 (suppl): 30.

Diet therapy in rheumatoid arthritis SIR,-Your correspondents (Jan 4, p 68), commenting on our study of fasting and one-year vegetarian diet in rheumatoid arthritis, reveal some serious misunderstandings. Dr Abuzakouk and Dr O’Farrelly claim that we required our patients to "spend a year on a health farm drinking decoctions of potatoes and parsley amongst other culinary enigmas". This is not so: the patients in the diet group only spent four weeks at the health farm. After 7-10 days of subtotal fasting patients were put on gluten-free vegan diet that they continued at home, and after 31months the food was gradually changed to a lactovegetarian diet. Professor Panayi wrongly states that "the test group had intensive personal contacts with dietitians and others while the controls did not". The controls had the same number of consultations with the dietitian-both personal and by telephone-as patients in the diet group. Abuzakouk and O’Farrelly believe that the patients were not randomly selected and therefore perhaps more susceptible to be influenced by placebo. Our patients were randomly allocated to either treatment group. We have never claimed, however, that they were representative of all patients with rheumatoid arthritis and we are aware of the possibility that some kind of selection may have taken place. Nevertheless we have shown that patients receptive to extensive changes in their diet can benefit from fasting and an

individually adjusted vegetarian diet. Clinical trials that include changes of lifestyle cannot be double blind. Therefore, we had to apply a single blind design. In such studies whether the observed effect is caused by the placebo effect or not, cannot be ruled out. However, in this respect we would emphasise that patients were included in the trial for 13 months. The placebo effect is usually short, and if all the improvements resulted from this effect alone, one would expect that the indices in the two groups would have converged during the 13 months. Furthermore, the placebo effect has the most pronounced effects on subjective indices, but we also found highly significant differences with respect to erythrocyte sedimentation rate, C-reactive protein, white blood cell count, and number of swollen joints. Other laboratory indices (unpublished data) such as calprotectin, complement factor C4, and complement factor C3 activation products also significantly favoured the diet group. We therefore find it unlikely that the placebo effect could account for all the improvements in the diet group. Finally, if we are wrong, a natural consequence of the apparently very potent placebo effect disclosed in our study would be to urge rheumatologists and general practitioners to take advantage of this effect in the management of patients with rheumatoid arthritis. Institute of Immunology and Rheumatology, National Hospital, 0172 Oslo, Norway, and Oslo Sanitetsforenings Rheumatism Hospital, Oslo

Platelet size and Patient referral and NHS reforms biR,—Froiessor Benjamin (Jan 4, p óU) when

reters to his experience was not agreed by the

extracontractual referral initially This has happened to me twice. The decisions were reversed, but only after further negotiation. Both patients had chronic fatigue syndrome, where supradistrict experience and research might be of benefit. One of the patients had been continually ill for ten years, making considerable demands on the NHS. I also share Benjamin’s fear of the implications for applied and basic research. One can add to this the reduced opportunities for teaching tomorrow’s doctors. We are now in the last quarter of the financial year. The likelihood is that extracontractual referrals will become even less frequent. Where is the "better health care and greater choice" for our patients? an

referring health authority.

Department of Psychological Medicine, St Bartholomew’s Hospital Medical College, London EC1A 7BE, UK

PETER D. WHITE

JENS KJELDSEN-KRAGH MARGARETHA HAUGEN ØYSTEIN FFØRRE

venous

disease

SIR,-Professor Martin and colleagues (Dec 7, p 1409) raise about the behaviour of platelets in patients with ischaemic heart disease. However, I should like to comment on the conclusions they draw from their work with respect to my data based on the investigation of patients with venous disease.1,2 I looked at the composition of venous blood in the legs of patients with chronic venous insufficiency and in controls after 60 min of leg

interesting questions

dependency. I found that the red cell count and whole blood viscosity were increased, indicating haemoconcentration, but that the white cell and the platelet counts were reduced. In the patient group there

was a

substantial increase in the

mean

volume of

platelets in venous blood samples from the long saphenous vein of the dependent limb (table). Further sampling after the supine position was resumed showed an increase in white cell but not platelet counts. This finding suggests that small platelets may be selectively retained in the dependent limb, or that morphological changes in platelets take place accompanied by an overall reduction in platelet numbers in veins.

Patient referral and NHS reforms.

250 A postal questionnaire was sent to the deans of all 27 medical schools in the UK. The deans were asked to circulate copies to departments involve...
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