enhanced magnetic resonance imaging in multiple sclerosis. Brain 1988;111:928-39. 9 Hawkins CP, Munro PMG, Mackenzie F, et al. Duration and selectisitv of blood-brain barrier breakdown in chronic relapsing experimental allergic encephalomvelitis studied by gadolinium-DTPA and protein markers. Brain 1990;113: 365-78. 10 Kappos L, Stadt D, Rohrbach E, et al. Gadolinium-DTPAenhanced magnetic resonance imaging in the evaluation of different disease courses and disease activity in MS. Neurologv 1988;38(suppl 1):255.
expect criticism. That is part of the natural process by which progress is made. Yet it is also important that we join together to provide the essential tool that can come only from the profession. Only in this way can we make it clear to systems suppliers our requirements for usable clinical information systems throughout the NHS. With determination and the right approach we can and should be leading the world. JAMES READ
Read clinical classification SIR,-The letters published from Dr R A Johnson' and Drs R G Jones and K B Page2 suggest a misunderstanding of the history behind, and the philosophy of, the Read codes.3 They also confuse the important distinction between the Read codes themselves and the software in which they are implemented. Thus, on this latter point, Dr Johnson is correct to focus on the importance of rapid entry of commonly occurring terms. This is entirely possible given well designed software. However, neither the NHS Centre for Coding and Classification (the body charged to develop the Read codes for use within the NHS) nor Computer Aided Medical Systems Limited (the company with the exclusive distribution rights within and without the NHS for the Read codes) has any direct control over the software within which the codes are implemented. It is up to the medical customer in hospital or general practice to choose a system which is adequate for the task. To this end, guidelines have been produced to assist in the choice. The Read codes have been designed to do precisely what Drs Johnson, Jones, and Page require-they have been designed specifically to be used in a consultation during which a doctor or other care provider is able quickly and simply to find and enter into the clinical computerised record the required term, represented in his or her own words. If the system is to be used retrospectively the same key word mnemonic method can be used or, if codes are to be entered from protocols and are known, the data can be entered directly using codes from either the Read classification or others -for example, the international classification of diseases, injuries, and causes of death and the Office of Population Censuses and Surveys classification of surgical operations and procedures. The Read codes are being used now in general practice by about 7000 general practitioners daily who are entering about 63 000 000 terms a year by this method. Many have been doing this for over four years and have given invaluable feedback. In the hospital sector the Read codes are being used in more and more systems for medical audit and resource management in a variety of software environments and on hardware varying from the smallest microcomputers to the largest
mainframes. The bold and inspired decision by the Department of Health to acquire the Read codes is only a starting point-but we have to start, and there is no other point that commands enough support at this time. The vital, crucial, and exciting ingredient is the supervisory board of the NHS Centre for Coding and Classification, on which will sit senior representatives of the Royal College of General Practitioners, the General Medical Services
Committee of the BMA, the Joint Formulary Committee, the Department of Health, the Office of Population Censuses and Surveys, and the Joint Consultants Committee and the chief medical officer's community care representative, with an independent chairman yet to be decided.. Under this framework and with the input from all the different specialties and interests in the field (many of which have already offered much help, support, and encouragement) we can progress together. Now that the codes have been acquired by the Secretary of State for Health it is only natural to
BMJ VOLUME 301
7 JULY 1990
NHS Centre for Coding and Classification, Leics LEI 1 2AG 1 Johnson RA. Read clinical classification. Br Med J 1990;300: 1467. (2 June.) 2 Jones RG, Page KB. Read clinical classification Br Med J 1990;300:1467. (2 June.) 3 Chisholm J. The Read clinical classification. Br MedJ7 1990;300: 1092. (28 April.)
Death by 1000 cuts: 5 Wales SIR,-With respect to cuts in Gwynedd Health Authority the article in the series "Death by 1000 cuts"' was accurate in all particulars but one. In the last paragraph Dr Tony Delamothe states that "The health authority acknowledged that the waiting time for abortions might increase from one month to three months after closure of the gynaecology annexe." I do not know where this information came from, but it is incorrect. It is true that the gynaecology annexe is being closed temporarily, but it is also true that this will have an effect on elective gynaecological procedures such as hysterectomy, pelvic repairs, etc, but emergency and urgent procedures including termination of pregnancy will be done speedily, as at present. R H DAVIES
Gwynedd Health Authority, Bangor, Gwynedd LL57 4TP 1 Delamothe T. Death by 1000 cuts: 5 Wales. Br Medj 1990;300: 1484. (9 June.)
*v- The information came from a document prepared by Gwynedd Health Authority that lists the responses of its officers to comments made about its consultation document, Measures Required to Reduce Overspending 1990-1. After summarising comments made about the proposed temporary closure of the gynaecology annexe ward at St David's Hospital the document reads: "Officers response to comments: Patients undergoing termination of pregnancy will not be housed near those who are due to give birth. It is acknowledged that waiting times may increase from one month to three months."-ED, BMJ'.
Signs of illness preceding sudden unexpected death in infants SIR,-The paper by Dr Ruth E Gilbert and colleagues on sudden unexpected death in infants' was discussed at the Journal Club of Public Health Medicine Trainees this week. We would like to comment on two points. Firstly, there was confusion in the paper between all sudden unexpected deaths in infants (mentioned in the title) and deaths assigned to the category of sudden infant death syndrome (mentioned in the objective of the abstract). The table distinguished the two categories only for major signs of illness 24 hours before death or interview. No distinction was made for major signs at other times or for minor signs at any time. Thus it was not possible from the data given to make conclusions about signs before death from the sudden infant death syndrome apart from major signs 24 hours before death. The paper would have been much more
useful if the seven fully explained deaths had been excluded and the data presented had been solely on deaths certified as being due to the sudden infant death syndrome. Secondly, it is interesting to note that there were as many as 88 deaths certified as being due to the sudden infant death syndrome in the four districts during two years. Based on the number of births in the four districts in 1986 and the national incidence of the syndrome of 2 28/1000 births in 19862 only 68 deaths due to the syndrome would have been expected in two years. These figures cast doubt on the validity of the diagnosis of the sudden infant death syndrome in these cases. The paper had the potential for providing some useful information on deaths due to the sudden infant death syndrome, but because of the two problems mentioned above it sadly loses its validity. DIANA FORREST PETER HAYWOOD
St George's Hospital Medical School, London SW 17 ORT 1 Gilbert RE, Fleming PJ, Azaz Y, Rudd PT. Signs of illness preceding sudden unexpected death in infants. Br Med JE 1990;300:1237-9. (12 May.) 2 Office of Population Censuses and Surveys. Sudden infant deaths 1985 to 1987. OPCS Monitor 1988;No 3. (DH3 88/3.)
AUTHORS' REPLY,-We are surprised that Drs Diana Forrest and Peter Haywood think that our study should have comprised only babies certified as having died of the sudden infant death syndrome. Many previous studies have emphasised the importance of studying all presentations of sudden unexpected death because of the difficulty in distinguishing between findings associated with death and those that explain death. '-5 We found an explanation for death in 8% of the victims of sudden unexpected death, a similar figure to that found in other studies in which necropsy was carried out by a paediatric pathologist (6-6% in the Scottish national study,' 10% in the Glasgow study,2 and 10% in the Newcastle study5). In contrast, in the Scottish national study, in which victims of sudden unexpected death were examined by a general pathologist, 26% of deaths were explained. This difference is thought to be due to equivocal findings such as milk aspiration or mild bronchiolitis being recorded as an explanation for death. Although Taylor and Emery attributed 39% (45/115) of sudden unexpected deaths to treatable disease,6 it is not clear whether they considered death to have been explained by or to have occurred during the course of a treatable disease.4 In our study deaths were classified as explained or unexplained at a multidisciplinary meeting that included a paediatric pathologist (Dr P J Berry), a microbiologist, a biochemist, an epidemiologist, and three paediatricians with wide experience of infant care. The effect of including all victims of sudden unexpected death, regardless of whether death was explained or not, would favour an excess of major signs of illness in the index infants compared with controls. Nevertheless, we found no differences in reported signs between index and control infants during the week before death. Only two of the seven infants whose deaths were explained had major signs for longer than 24 hours before death. We believe that, far from undermining the validity of our data, the fact that we studied all victims of sudden unexpected death was one of the main strengths of our study. Finally, Drs Forrest and Hayward cast doubt on the accuracy of figures for the incidence of the sudden infant death syndrome in Avon. These figures, recorded as part of the Avon infant mortality study, have been consistently higher than the national average of 2 24/1000 live births in 1987,1 being 2-83/1000 live births in 1984-7 and 3-0/1000, 4 0/1000, and 3 6/1000 in 1988 for the three of the four Avon districts included in their entirety in our
45
expect criticism. That is part of the natural process by which progress is made. Yet it is also important that we join together to provide the essential tool that can come only from the profession. Only in this way can we make it clear to systems suppliers our requirements for usable clinical information systems throughout the NHS. With determination and the right approach we can and should be leading the world. JAMES READ
Read clinical classification SIR,-The letters published from Dr R A Johnson' and Drs R G Jones and K B Page2 suggest a misunderstanding of the history behind, and the philosophy of, the Read codes.3 They also confuse the important distinction between the Read codes themselves and the software in which they are implemented. Thus, on this latter point, Dr Johnson is correct to focus on the importance of rapid entry of commonly occurring terms. This is entirely possible given well designed software. However, neither the NHS Centre for Coding and Classification (the body charged to develop the Read codes for use within the NHS) nor Computer Aided Medical Systems Limited (the company with the exclusive distribution rights within and without the NHS for the Read codes) has any direct control over the software within which the codes are implemented. It is up to the medical customer in hospital or general practice to choose a system which is adequate for the task. To this end, guidelines have been produced to assist in the choice. The Read codes have been designed to do precisely what Drs Johnson, Jones, and Page require-they have been designed specifically to be used in a consultation during which a doctor or other care provider is able quickly and simply to find and enter into the clinical computerised record the required term, represented in his or her own words. If the system is to be used retrospectively the same key word mnemonic method can be used or, if codes are to be entered from protocols and are known, the data can be entered directly using codes from either the Read classification or others -for example, the international classification of diseases, injuries, and causes of death and the Office of Population Censuses and Surveys classification of surgical operations and procedures. The Read codes are being used now in general practice by about 7000 general practitioners daily who are entering about 63 000 000 terms a year by this method. Many have been doing this for over four years and have given invaluable feedback. In the hospital sector the Read codes are being used in more and more systems for medical audit and resource management in a variety of software environments and on hardware varying from the smallest microcomputers to the largest
mainframes. The bold and inspired decision by the Department of Health to acquire the Read codes is only a starting point-but we have to start, and there is no other point that commands enough support at this time. The vital, crucial, and exciting ingredient is the supervisory board of the NHS Centre for Coding and Classification, on which will sit senior representatives of the Royal College of General Practitioners, the General Medical Services
Committee of the BMA, the Joint Formulary Committee, the Department of Health, the Office of Population Censuses and Surveys, and the Joint Consultants Committee and the chief medical officer's community care representative, with an independent chairman yet to be decided.. Under this framework and with the input from all the different specialties and interests in the field (many of which have already offered much help, support, and encouragement) we can progress together. Now that the codes have been acquired by the Secretary of State for Health it is only natural to
BMJ VOLUME 301
7 JULY 1990
NHS Centre for Coding and Classification, Leics LEI 1 2AG 1 Johnson RA. Read clinical classification. Br Med J 1990;300: 1467. (2 June.) 2 Jones RG, Page KB. Read clinical classification Br Med J 1990;300:1467. (2 June.) 3 Chisholm J. The Read clinical classification. Br MedJ7 1990;300: 1092. (28 April.)
Death by 1000 cuts: 5 Wales SIR,-With respect to cuts in Gwynedd Health Authority the article in the series "Death by 1000 cuts"' was accurate in all particulars but one. In the last paragraph Dr Tony Delamothe states that "The health authority acknowledged that the waiting time for abortions might increase from one month to three months after closure of the gynaecology annexe." I do not know where this information came from, but it is incorrect. It is true that the gynaecology annexe is being closed temporarily, but it is also true that this will have an effect on elective gynaecological procedures such as hysterectomy, pelvic repairs, etc, but emergency and urgent procedures including termination of pregnancy will be done speedily, as at present. R H DAVIES
Gwynedd Health Authority, Bangor, Gwynedd LL57 4TP 1 Delamothe T. Death by 1000 cuts: 5 Wales. Br Medj 1990;300: 1484. (9 June.)
*v- The information came from a document prepared by Gwynedd Health Authority that lists the responses of its officers to comments made about its consultation document, Measures Required to Reduce Overspending 1990-1. After summarising comments made about the proposed temporary closure of the gynaecology annexe ward at St David's Hospital the document reads: "Officers response to comments: Patients undergoing termination of pregnancy will not be housed near those who are due to give birth. It is acknowledged that waiting times may increase from one month to three months."-ED, BMJ'.
Signs of illness preceding sudden unexpected death in infants SIR,-The paper by Dr Ruth E Gilbert and colleagues on sudden unexpected death in infants' was discussed at the Journal Club of Public Health Medicine Trainees this week. We would like to comment on two points. Firstly, there was confusion in the paper between all sudden unexpected deaths in infants (mentioned in the title) and deaths assigned to the category of sudden infant death syndrome (mentioned in the objective of the abstract). The table distinguished the two categories only for major signs of illness 24 hours before death or interview. No distinction was made for major signs at other times or for minor signs at any time. Thus it was not possible from the data given to make conclusions about signs before death from the sudden infant death syndrome apart from major signs 24 hours before death. The paper would have been much more
useful if the seven fully explained deaths had been excluded and the data presented had been solely on deaths certified as being due to the sudden infant death syndrome. Secondly, it is interesting to note that there were as many as 88 deaths certified as being due to the sudden infant death syndrome in the four districts during two years. Based on the number of births in the four districts in 1986 and the national incidence of the syndrome of 2 28/1000 births in 19862 only 68 deaths due to the syndrome would have been expected in two years. These figures cast doubt on the validity of the diagnosis of the sudden infant death syndrome in these cases. The paper had the potential for providing some useful information on deaths due to the sudden infant death syndrome, but because of the two problems mentioned above it sadly loses its validity. DIANA FORREST PETER HAYWOOD
St George's Hospital Medical School, London SW 17 ORT 1 Gilbert RE, Fleming PJ, Azaz Y, Rudd PT. Signs of illness preceding sudden unexpected death in infants. Br Med JE 1990;300:1237-9. (12 May.) 2 Office of Population Censuses and Surveys. Sudden infant deaths 1985 to 1987. OPCS Monitor 1988;No 3. (DH3 88/3.)
AUTHORS' REPLY,-We are surprised that Drs Diana Forrest and Peter Haywood think that our study should have comprised only babies certified as having died of the sudden infant death syndrome. Many previous studies have emphasised the importance of studying all presentations of sudden unexpected death because of the difficulty in distinguishing between findings associated with death and those that explain death. '-5 We found an explanation for death in 8% of the victims of sudden unexpected death, a similar figure to that found in other studies in which necropsy was carried out by a paediatric pathologist (6-6% in the Scottish national study,' 10% in the Glasgow study,2 and 10% in the Newcastle study5). In contrast, in the Scottish national study, in which victims of sudden unexpected death were examined by a general pathologist, 26% of deaths were explained. This difference is thought to be due to equivocal findings such as milk aspiration or mild bronchiolitis being recorded as an explanation for death. Although Taylor and Emery attributed 39% (45/115) of sudden unexpected deaths to treatable disease,6 it is not clear whether they considered death to have been explained by or to have occurred during the course of a treatable disease.4 In our study deaths were classified as explained or unexplained at a multidisciplinary meeting that included a paediatric pathologist (Dr P J Berry), a microbiologist, a biochemist, an epidemiologist, and three paediatricians with wide experience of infant care. The effect of including all victims of sudden unexpected death, regardless of whether death was explained or not, would favour an excess of major signs of illness in the index infants compared with controls. Nevertheless, we found no differences in reported signs between index and control infants during the week before death. Only two of the seven infants whose deaths were explained had major signs for longer than 24 hours before death. We believe that, far from undermining the validity of our data, the fact that we studied all victims of sudden unexpected death was one of the main strengths of our study. Finally, Drs Forrest and Hayward cast doubt on the accuracy of figures for the incidence of the sudden infant death syndrome in Avon. These figures, recorded as part of the Avon infant mortality study, have been consistently higher than the national average of 2 24/1000 live births in 1987,1 being 2-83/1000 live births in 1984-7 and 3-0/1000, 4 0/1000, and 3 6/1000 in 1988 for the three of the four Avon districts included in their entirety in our
45
