BRITISH MEDICAL JOURNAL
891
1 OCTOBER 1977
SIR,-In your leading article (3 September, p 594) concerning the prevention of amblyopia you do not seem to realise that very effective screening of infants and preschool children is done in the course of routine developmental examinations of all children seen in community health clinics. It is true that occasionally general practitioners fail to co-operate in further investigation, but with perseverance and tact full and adequate treatment is generally arranged. Community medical officers, with the co-operation of health visitors, are skilled in the detection of infant squints, and visual acuity in either eye can be accurately checked by 3) years of age with Sheridan cards. It is essential that developmental screening is not fragmented and that assessment is performed on the whole child. Squints may be bound up with questions of general muscular co-ordination, laterality, skull formation, and mental development. Such screening may be done by a community doctor or a general practitioner interested, trained, and willing to give time for developmental paediatrics such as is envisaged by the Court Committee. Do not let us proceed to a further fragmentation of preventive services for young children. Community Health Service, Mid-Surrey District, Surrey Area Health Authority,
Epsom, Surrey
low proportion of the nocturnal fracture group taking non-barbiturate hypnotics. Since 93 o of this group were already taking barbiturate hypnotics one would expect the scope for non-barbiturate hypnotics to be limited to about 7 °, even in this age of polypharmacy. Other aspects of his analysis rest on the assumption that the two groups-femoral fractures and geriatric outpatient referrals-are substantially similar. Referred patients, however, are likely to be iller and to be seeing their own doctors more frequently than patients admitted with femoral fracture, one-third of whom had no disease at the time of fracture. Thus one cannot extrapolate freely from one group to the other. We were a little surprised that no correspondent has commented on our finding of barbiturate-induced confusion in old people. We found that a sizeable proportion of our patients taking barbiturates had a clinically important degree of mental confusion which was reversible on stopping barbiturates. This would suggest that the lives of a substantial number of elderly people throughout the country could be made much less miserable and confused if their barbiturates were stopped. Also there may well be a sizeable number of old people in supervised accommodation and institutional care who need not be there. E M DAVIS Although the issue of barbiturates and nocturnal femoral fracture is more dramatic, the mental confusion caused by barbiturates probably affects the lives of more old people, and surely this is important.
Barbiturates and fractures SIR,-The letters following our recent paper on nocturnal femoral fracture and the use of barbiturate hypnotics (20 August, p 483) have raised several interesting points on which we would like to comment. Professor J C Brocklehurst and others (10 September, p 699) report a relatively low incidence of barbiturate usage in femoral fracture patients in London and Manchester. Dr F 0 Wells (p 700) shows that barbiturate prescriptions can be reduced very substantially by a local campaign. Thus there may well be considerable regional variation in barbiturate prescribing habits. We feel that it is important to know that this variation exists and not to assume that a slow decline in overall use implies less prescribing for all ages in all regions. We note that a significantly (P
891
1 OCTOBER 1977
SIR,-In your leading article (3 September, p 594) concerning the prevention of amblyopia you do not seem to realise that very effective screening of infants and preschool children is done in the course of routine developmental examinations of all children seen in community health clinics. It is true that occasionally general practitioners fail to co-operate in further investigation, but with perseverance and tact full and adequate treatment is generally arranged. Community medical officers, with the co-operation of health visitors, are skilled in the detection of infant squints, and visual acuity in either eye can be accurately checked by 3) years of age with Sheridan cards. It is essential that developmental screening is not fragmented and that assessment is performed on the whole child. Squints may be bound up with questions of general muscular co-ordination, laterality, skull formation, and mental development. Such screening may be done by a community doctor or a general practitioner interested, trained, and willing to give time for developmental paediatrics such as is envisaged by the Court Committee. Do not let us proceed to a further fragmentation of preventive services for young children. Community Health Service, Mid-Surrey District, Surrey Area Health Authority,
Epsom, Surrey
low proportion of the nocturnal fracture group taking non-barbiturate hypnotics. Since 93 o of this group were already taking barbiturate hypnotics one would expect the scope for non-barbiturate hypnotics to be limited to about 7 °, even in this age of polypharmacy. Other aspects of his analysis rest on the assumption that the two groups-femoral fractures and geriatric outpatient referrals-are substantially similar. Referred patients, however, are likely to be iller and to be seeing their own doctors more frequently than patients admitted with femoral fracture, one-third of whom had no disease at the time of fracture. Thus one cannot extrapolate freely from one group to the other. We were a little surprised that no correspondent has commented on our finding of barbiturate-induced confusion in old people. We found that a sizeable proportion of our patients taking barbiturates had a clinically important degree of mental confusion which was reversible on stopping barbiturates. This would suggest that the lives of a substantial number of elderly people throughout the country could be made much less miserable and confused if their barbiturates were stopped. Also there may well be a sizeable number of old people in supervised accommodation and institutional care who need not be there. E M DAVIS Although the issue of barbiturates and nocturnal femoral fracture is more dramatic, the mental confusion caused by barbiturates probably affects the lives of more old people, and surely this is important.
Barbiturates and fractures SIR,-The letters following our recent paper on nocturnal femoral fracture and the use of barbiturate hypnotics (20 August, p 483) have raised several interesting points on which we would like to comment. Professor J C Brocklehurst and others (10 September, p 699) report a relatively low incidence of barbiturate usage in femoral fracture patients in London and Manchester. Dr F 0 Wells (p 700) shows that barbiturate prescriptions can be reduced very substantially by a local campaign. Thus there may well be considerable regional variation in barbiturate prescribing habits. We feel that it is important to know that this variation exists and not to assume that a slow decline in overall use implies less prescribing for all ages in all regions. We note that a significantly (P
