58
Journal of the Royal Society of Medicine Volume 83 January 1990
major endemic sites for HTLV 1 infection. The virus was spread by breast feeding, by sexual contact and by contact with blood either through intravenous drug abuse or by transfusion. The lifetime risk for infected individuals of developing leukaemia was approximately 2% with a rather lower risk for developing myelopathy. Current assays for detecting anti HTLV 1 are of low specificity when used in low prevalence populations such as would be the case for UK donors. Though they are able also to detect antiHTLV 2, many of the serum samples (> 90%) giving positive reactions from UK donors have antibody profiles on Western Blot which suggest that the response is unrelated to exposure to HTLV. Before donor-screening is introduced in the UK, methods for confirmation and for differentiation between HTLV 1 and HTLV 2 infection will be needed especially if donor counselling of seropositives is to happen.
outlined the physical processes of plasma fractionation and showed that viruses tended to segregate in the albumin and cryoprecipitate fractions. Albumin was rendered safe by pasteurization and a variety of different heating methods had been applied to factor VIII to inactivate HIV, and possibly other viruses, without destroying this delicate protein. These included heating in solution, heating freeze-dried powder, steam treatment of freeze-dried powder, treatment with FB-propiolactone and ultraviolet light, extraction with lipid solvents and detergents, purification with monoclonal antibodies and hydrophobic adsorption chromatography. The relative merits of some of these procedures were discussed and the progress made towards eliminating viruses from blood products was described.
Finally, Dr Bruce Cuthbertson (Edinburgh)
Section of Pathology
Letters to the Editor Preference is given to letters commenting on contributions published recently in the JRSM. They should not exceed 400 words and should be typed double-spaced.
Hyperparathyroidism in a patient with myotonic dystrophy We read with interest the report from Middleton, Posen and Shannon of a woman with hyperparathyroidism and myotonic dystrophy (April 1989 JRSM, p 227). At the time we were investigating a similar case. A 56-year-old woman (CMH 269293) was admitted for investigation of poor balance and recurrent falls. She required bilateral cataract extraction aged 28, and was noted to have a peripheral pigmentary degeneration of the retina. Her mother also had bilateral cataracts. Examination showed muscle weakness, percussion myotonia and the typical facies of myotonic dystrophy, which was confirmed by electromyography. Hypercalcaemia was found on screening for endocrine disorder. Corrected serum calcium was 2.73 mmol/L, alkaline phosphatase 97 IU/L, creatinine 93 jimol/L. Immunoreactive parathormone, mixed terminal assay 0.18 pg/ml (normal < 0.5), midmolecule assay 1.5 pg/ml (normal < 1.0). Ultrasound of the neck did not demonstrate a parathyroid adenoma or hyperplasia. There were no symptoms directly attributable to hypercalcaemia, but the normal or high parathormone level in the presence of hypercalcaemia is strongly suggestive of hyperparathyroidism in this case. ANDREW DOWNIE E M JEPSON
Registrar Consultant Physician Department of General Medicine Central Middlesex Hospital London
P D Griffiths M Contreras
Early postoperative feeding - a continuing controversy in pyloric stenosis I enjoyed the paper by Foster and Lewis (September 1989 JRSM, p 532) on early postoperative feeding following pyloromyotomy and I think this is a valuable contribution. The authors do, however, appear to confuse two issues; firstly, the question of whether there is any need to delay the first feed, and secondly, whether there is any need to reduce or gradually increase feeds thereafter. I have always believed that the traditional graded postoperative feeding regimens are unnecessary and I would agree entirely with their conclusion in this respect. However, with respect of the question as to whether it is better to delay feeds for 18 h postoperatively - perhaps a prospective controlled trial is the only way of answering this. The main message of their paper, that it is unnecessary to withhold full feeds if the baby vomits postoperatively, is an important one and I hope that their recommendations on this will be widely accepted. R D SPICER Consultant Paediatric Surgeon The General Infirmary at Leeds
Review of medical audit The otherwise excellent review by Dr McKee and colleagues (August 1989 JRSM, p 474) should have been entitled 'medical audit in hospitals' as general practice is virtually ignored. Primary medical care is more diverse and decentralized than hospital medicine, so audit has to be performed differently'. To consider the various types of assessment mentioned in the article, as applied in general practice: (1) Case note review tends to be used as a tool for teaching and supervision in vocational training, and thus only indirectly for quality assessment.
Journal of the Royal Society of Medicine Volume 83 January 1990
Similar methods are used, however, to appraise referral letters (and the replies) for appropriateness, quantity of information and pre-referral management. (2) Analysis of health service data is widely used, either using practice microcomputers, or health authority or family practitioner committee systems (eg for cervical cytology or immunizations). The latter offers the bonus of comparative figures for the locality and feedback of such data is being developed in many areas, especially by family practitioner committees. (3) Population-based epidemiological studies may provide information about the quality of primary as well as secondary care. (4) Analysis of appropriate investigation and therapy can be performed, eg through using as a basis the Prescribing Analysis and Cost (PACT) feedback now sent to all practices. Important techniques particularly applicable in general practice include the following: (5) Analysis of doctor-patient- communication (mentioned by McKee et al) is performed using videotapes, especially in practices teaching undergraduates or trainees. (6) Practice Activity Analysis is the name for a series of instruments developed for clinical and operational audit by the Birmingham Research Unit ofthe Royal College of General Practitioners2. These range, for instance, from psychotropic prescribing (an encounter form) to rubella immunity (a grid for collecting data on preventive procedures in manual patient records). Rates are expressed in relation to numbers of patients or consultations over time, and a large database has now been assembled. (7) 'Rent-an-Audit' is a form of manual record assessment using check-lists to look for evidence of risk factor recording (eg blood pressure recording, noting smoking habit)3. (8) 'What sort ofDoctor?' was the title of two Royal College of General Practitioner working parties which developed a method of comprehensive practice appraisal4. This involves peers visiting one another to inspect premises and records, interview doctors and staff, view videotapes and examine preventive care. A development of this method is now being used for selection of prospective Fellows of the College. Wouldbe trainers already have to satisfy rather less stringent criteria for adequate practice facilities and quality of care, as well as teaching ability. These are just some of the methods used for medical audit within primary care, and some of these are directly relevant to work in hospitals too. JOHN WILMOT Senior Lecturer in General Practice, University of Warwick, Coventry References 1 Buckley EG. Quality assessment or quality control? JR Coll Gen Pract 1989;39:309-12 2 Crombie DL, Fleming DM. Practice activity analysis. Occasional paper 41, London: Royal College of General Practitioners, 1988 3 Gray M, O'Dwyer A, Fullard EM. Rent-an-audit. JR CoU Gen Pract 1987;37:177 4 Royal College of General Practitioners. What sort of doctor? Report from General Practice 23. London: Royal College of General Practitioners, 1985
Cat scratch disease Gallegos and Hobsley (July 1989 JRSM, p 442) highlight the problem of diagnosing ominous masses
in adolescents in and around the head and neck area. We commonly see such problems both related to the parotid and submandibular region and also find fine needle aspiration an invaluable means of excluding neoplasia. However, our experience of cat scratch disease is uncommon probably of the order of one case in 10 years whereas the same cat related age group commonly manifest toxoplasmosis. I am therefore surprised that the authors omitted to include the toxoplasma dye test or any mention ofthis more likely diagnosis. This protozoal infection transmitted by cats and readily picked up by vulnerable children appears to produce head and neck node enlargement of the order of three to five cases a year in our single outpatient department. DAVID RYAN Institute of Dental Surgery University of London The author replies: I would like to thank Mr Ryan for pointing out toxoplasmosis as a more common condition in the differential diagnosis of enlarged head and neck lymph nodes which should perhaps have been included in our discussion. However, the main aim of the paper was to illustrate an approach to masses within the parotid region on the basis of the presenting physical findings. In particular, we would counsel against fine needle aspiration biopsy in patients who present with clinically benign lumps in the parotid region. In such circumstances, and particularly in children, it is clearly important to exclude infective causes of enlarged lymph nodes as a cause for the lump and if possible this should be by serological tests in the first instance. N C GALLEGOS Surgical Registrar Department of Surgery University College London
Recognition and treatment of abdominal wall pain We agree entirely with Gallegos and Hobsley (June 1989 JRSM, p 343) that abdominal wall pain must be thought about in any patient with symptoms that do not fit a pattern suggestive of intraabdominal pathology and use the test that they attribute to Carnett. We have presented our own series of 24 patients', 10 of whom had not had previous surgery and in the other 14 the pain was not due to entrapment in the scar. We are sure that if the authors were to review the sites accurately identified as being the sites of maimum tenderness with 'one fingertip' that these would correspond to the surface markings of the anterior cutaneous branches of the intercostal nerves as they emerge through the rectus sheath just medial to the Linea Semilunaris. Tensing the recti often reveals a palpable dimple, which we believe to be the exit point ofthe nerve. This has been anatomically studied in depth2 and is common in patients attending pain clinics3. It is important to appreciate that the source of entrapment is deep to the anterior rectus sheath so that injections of local anaesthetic can be accurately placed, particularly in the obese. P N HALL A P B LEE
Senior House Officer in Plastic Surgery Queen Victoria Hospital, East Grinstead ConIsultant Anaesthetist, Pain Clinic West Suffolk Hospital, Bury St Edmunds
59
Journal of the Royal Society of Medicine Volume 83 January 1990
major endemic sites for HTLV 1 infection. The virus was spread by breast feeding, by sexual contact and by contact with blood either through intravenous drug abuse or by transfusion. The lifetime risk for infected individuals of developing leukaemia was approximately 2% with a rather lower risk for developing myelopathy. Current assays for detecting anti HTLV 1 are of low specificity when used in low prevalence populations such as would be the case for UK donors. Though they are able also to detect antiHTLV 2, many of the serum samples (> 90%) giving positive reactions from UK donors have antibody profiles on Western Blot which suggest that the response is unrelated to exposure to HTLV. Before donor-screening is introduced in the UK, methods for confirmation and for differentiation between HTLV 1 and HTLV 2 infection will be needed especially if donor counselling of seropositives is to happen.
outlined the physical processes of plasma fractionation and showed that viruses tended to segregate in the albumin and cryoprecipitate fractions. Albumin was rendered safe by pasteurization and a variety of different heating methods had been applied to factor VIII to inactivate HIV, and possibly other viruses, without destroying this delicate protein. These included heating in solution, heating freeze-dried powder, steam treatment of freeze-dried powder, treatment with FB-propiolactone and ultraviolet light, extraction with lipid solvents and detergents, purification with monoclonal antibodies and hydrophobic adsorption chromatography. The relative merits of some of these procedures were discussed and the progress made towards eliminating viruses from blood products was described.
Finally, Dr Bruce Cuthbertson (Edinburgh)
Section of Pathology
Letters to the Editor Preference is given to letters commenting on contributions published recently in the JRSM. They should not exceed 400 words and should be typed double-spaced.
Hyperparathyroidism in a patient with myotonic dystrophy We read with interest the report from Middleton, Posen and Shannon of a woman with hyperparathyroidism and myotonic dystrophy (April 1989 JRSM, p 227). At the time we were investigating a similar case. A 56-year-old woman (CMH 269293) was admitted for investigation of poor balance and recurrent falls. She required bilateral cataract extraction aged 28, and was noted to have a peripheral pigmentary degeneration of the retina. Her mother also had bilateral cataracts. Examination showed muscle weakness, percussion myotonia and the typical facies of myotonic dystrophy, which was confirmed by electromyography. Hypercalcaemia was found on screening for endocrine disorder. Corrected serum calcium was 2.73 mmol/L, alkaline phosphatase 97 IU/L, creatinine 93 jimol/L. Immunoreactive parathormone, mixed terminal assay 0.18 pg/ml (normal < 0.5), midmolecule assay 1.5 pg/ml (normal < 1.0). Ultrasound of the neck did not demonstrate a parathyroid adenoma or hyperplasia. There were no symptoms directly attributable to hypercalcaemia, but the normal or high parathormone level in the presence of hypercalcaemia is strongly suggestive of hyperparathyroidism in this case. ANDREW DOWNIE E M JEPSON
Registrar Consultant Physician Department of General Medicine Central Middlesex Hospital London
P D Griffiths M Contreras
Early postoperative feeding - a continuing controversy in pyloric stenosis I enjoyed the paper by Foster and Lewis (September 1989 JRSM, p 532) on early postoperative feeding following pyloromyotomy and I think this is a valuable contribution. The authors do, however, appear to confuse two issues; firstly, the question of whether there is any need to delay the first feed, and secondly, whether there is any need to reduce or gradually increase feeds thereafter. I have always believed that the traditional graded postoperative feeding regimens are unnecessary and I would agree entirely with their conclusion in this respect. However, with respect of the question as to whether it is better to delay feeds for 18 h postoperatively - perhaps a prospective controlled trial is the only way of answering this. The main message of their paper, that it is unnecessary to withhold full feeds if the baby vomits postoperatively, is an important one and I hope that their recommendations on this will be widely accepted. R D SPICER Consultant Paediatric Surgeon The General Infirmary at Leeds
Review of medical audit The otherwise excellent review by Dr McKee and colleagues (August 1989 JRSM, p 474) should have been entitled 'medical audit in hospitals' as general practice is virtually ignored. Primary medical care is more diverse and decentralized than hospital medicine, so audit has to be performed differently'. To consider the various types of assessment mentioned in the article, as applied in general practice: (1) Case note review tends to be used as a tool for teaching and supervision in vocational training, and thus only indirectly for quality assessment.
Journal of the Royal Society of Medicine Volume 83 January 1990
Similar methods are used, however, to appraise referral letters (and the replies) for appropriateness, quantity of information and pre-referral management. (2) Analysis of health service data is widely used, either using practice microcomputers, or health authority or family practitioner committee systems (eg for cervical cytology or immunizations). The latter offers the bonus of comparative figures for the locality and feedback of such data is being developed in many areas, especially by family practitioner committees. (3) Population-based epidemiological studies may provide information about the quality of primary as well as secondary care. (4) Analysis of appropriate investigation and therapy can be performed, eg through using as a basis the Prescribing Analysis and Cost (PACT) feedback now sent to all practices. Important techniques particularly applicable in general practice include the following: (5) Analysis of doctor-patient- communication (mentioned by McKee et al) is performed using videotapes, especially in practices teaching undergraduates or trainees. (6) Practice Activity Analysis is the name for a series of instruments developed for clinical and operational audit by the Birmingham Research Unit ofthe Royal College of General Practitioners2. These range, for instance, from psychotropic prescribing (an encounter form) to rubella immunity (a grid for collecting data on preventive procedures in manual patient records). Rates are expressed in relation to numbers of patients or consultations over time, and a large database has now been assembled. (7) 'Rent-an-Audit' is a form of manual record assessment using check-lists to look for evidence of risk factor recording (eg blood pressure recording, noting smoking habit)3. (8) 'What sort ofDoctor?' was the title of two Royal College of General Practitioner working parties which developed a method of comprehensive practice appraisal4. This involves peers visiting one another to inspect premises and records, interview doctors and staff, view videotapes and examine preventive care. A development of this method is now being used for selection of prospective Fellows of the College. Wouldbe trainers already have to satisfy rather less stringent criteria for adequate practice facilities and quality of care, as well as teaching ability. These are just some of the methods used for medical audit within primary care, and some of these are directly relevant to work in hospitals too. JOHN WILMOT Senior Lecturer in General Practice, University of Warwick, Coventry References 1 Buckley EG. Quality assessment or quality control? JR Coll Gen Pract 1989;39:309-12 2 Crombie DL, Fleming DM. Practice activity analysis. Occasional paper 41, London: Royal College of General Practitioners, 1988 3 Gray M, O'Dwyer A, Fullard EM. Rent-an-audit. JR CoU Gen Pract 1987;37:177 4 Royal College of General Practitioners. What sort of doctor? Report from General Practice 23. London: Royal College of General Practitioners, 1985
Cat scratch disease Gallegos and Hobsley (July 1989 JRSM, p 442) highlight the problem of diagnosing ominous masses
in adolescents in and around the head and neck area. We commonly see such problems both related to the parotid and submandibular region and also find fine needle aspiration an invaluable means of excluding neoplasia. However, our experience of cat scratch disease is uncommon probably of the order of one case in 10 years whereas the same cat related age group commonly manifest toxoplasmosis. I am therefore surprised that the authors omitted to include the toxoplasma dye test or any mention ofthis more likely diagnosis. This protozoal infection transmitted by cats and readily picked up by vulnerable children appears to produce head and neck node enlargement of the order of three to five cases a year in our single outpatient department. DAVID RYAN Institute of Dental Surgery University of London The author replies: I would like to thank Mr Ryan for pointing out toxoplasmosis as a more common condition in the differential diagnosis of enlarged head and neck lymph nodes which should perhaps have been included in our discussion. However, the main aim of the paper was to illustrate an approach to masses within the parotid region on the basis of the presenting physical findings. In particular, we would counsel against fine needle aspiration biopsy in patients who present with clinically benign lumps in the parotid region. In such circumstances, and particularly in children, it is clearly important to exclude infective causes of enlarged lymph nodes as a cause for the lump and if possible this should be by serological tests in the first instance. N C GALLEGOS Surgical Registrar Department of Surgery University College London
Recognition and treatment of abdominal wall pain We agree entirely with Gallegos and Hobsley (June 1989 JRSM, p 343) that abdominal wall pain must be thought about in any patient with symptoms that do not fit a pattern suggestive of intraabdominal pathology and use the test that they attribute to Carnett. We have presented our own series of 24 patients', 10 of whom had not had previous surgery and in the other 14 the pain was not due to entrapment in the scar. We are sure that if the authors were to review the sites accurately identified as being the sites of maimum tenderness with 'one fingertip' that these would correspond to the surface markings of the anterior cutaneous branches of the intercostal nerves as they emerge through the rectus sheath just medial to the Linea Semilunaris. Tensing the recti often reveals a palpable dimple, which we believe to be the exit point ofthe nerve. This has been anatomically studied in depth2 and is common in patients attending pain clinics3. It is important to appreciate that the source of entrapment is deep to the anterior rectus sheath so that injections of local anaesthetic can be accurately placed, particularly in the obese. P N HALL A P B LEE
Senior House Officer in Plastic Surgery Queen Victoria Hospital, East Grinstead ConIsultant Anaesthetist, Pain Clinic West Suffolk Hospital, Bury St Edmunds
59
