(25 November.) Cannulas and junior doctors. SIR,-Dr A M Zalin's letter points out the great increase in the number of cannulas inserted by junior staff in the past ...
recommended can be thwarted by political pressure to get the programme up and running-no matter what the long term consequences. Let me explain. North East Essex Health Authority covers 1250 km2 and includes four major conurbations. After careful deliberation we decided that women in the Colchester area would be screened by a static mammography unit and those in the peripheral towns (Clacton, Harwich, and Halstead) would be screened by a mobile unit. The 24 000 women eligible for screening would be divided by age so that 60 to 64 year olds would be screened in the first year, 55 to 60 year olds in the second year, and 50 to 55 year olds in the third year of each screening round. Our programme based on age rather than address was popular. An astute member of the community health council commented that breast screening was more likely to become an integral part of a healthy lifestyle if it was available every year. rhe general practitioners liked our plan: their enthusiasm for prevention is reflected by the highest vaccination rates in the region and attendance of more than 90% at our breast screening seminars. The workload of updating prior notification lists for a third of the women each year was acceptable, and there would be more time to counsel, encourage, and advise women if they were not all invited at once. The breast screening service was launched in June this year and has been running smoothly for six months. We have now been told by the regional breast screening team that, in spite of its previous enthusiasm for our method of call, all 50 to 64 year old women in one area should be screened before the programme moves on to the next. This will save about £4500-but will this outweigh the inconvenience to many women who may have to refer themselves between three yearly mobile visits to the static unit 30 km away? Transport between towns is virtually non-existent, and women in this age group are least likely to have cars. A screening programme will succeed only if it is acceptable to the public and if it suits the needs of the community. We need clear guidelines from national experts, but sometimes they are too late and too much at variance with local needs. MALA RAO North East Essex Health Authority,
Colchcster C04 SJR I Roberts MMNt. Breast screening: time for a rethink? Br Med ] 1989;299:1153-5. (4 November. )
SIR,-Professor Jocelyn Chamberlain pointed out that the number of randomised trials that have failed to show a benefit due to screening now outnumber those with positive results.' She then goes on to say that the Forrest committee would probably have reached the same conclusions if it were sitting there today. Surely the aim of the committee was to assess the cost benefit of screening? If the reproducibility of the benefits is in doubt, as it is now, then how could the same cost benefit equation be reached? A RODGERS
Medical School, University of Bristol, Bristol BS lrrH I Chamberlain J. Breast screening: a response to Dr Maureen Roberts. Br Med] 1989;299:1336-7. (25 November.)
Cannulas and junior doctors SIR,-Dr A M Zalin's letter points out the great increase in the number of cannulas inserted by junior staff in the past 10 years.' Britain is unusual among developed countries in that it expects its junior staff to put in cannulas, give all the intravenous antibiotics, and perform
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electrocardiography and phlebotomy out of hours. Surely, as happens in other European countries and the United States, these tasks could be carried out by the nursing staff, possibly by employing an extra nurse trained in such procedures. This would save the house officer what may be several hours of an "IV round" when on call in the evening, not to mention interrupted sleep to resite cannulas. Such a measure would considerably reduce the workload of the junior without altering the aim of Achieving a Balance in reducing the ratio of junior to consultant staff. Middlesbrough General Hospital, Mliddlesbrough lIS5 5AZ
articular steroid injection. Analysis of their table of results, however, shows that though the trend of improvement may have been better with the nerve block this was not borne out by their statistical analysis; their claim is therefore invalid. Treating pain in and around a chronic rheumatoid shoulder with steroid injection is both successful and rewarding, but the injection must be accurately placed into the site precriously diagnosed by sensory testing. This is a technique now routinely practised by most shoulder surgeons, and injecting steroid into the glenohumeral joint should no longer be considered as a panacea for all pain arising in and around the chronic rheumatoid shoulder.
I Zalin AM. Canntulas and junior doctors. BrAled_ 1989;299:1279. (18 November.)
Universitv Department of Orthopaedic Surgery, St James's University Hospital,
RICHARD WELLER
RAYMOND J NEWMAN
Leeds LS9 7TF
Chronic shoulder pain in rheumatoid arthritis SIR,-The paper by Dr P Emery and colleagues' comparing the efficacy of suprascapular nerve block and intra-articular injection for chronic shoulder pain in rheumatoid arthritis was interesting. For some time we have employed a neurolytic suprascapular nerve block, using 2 ml of 6% aqueous phenol after a therapeutic trial with 1-5% lignocaine, for prolonged pain relief and increased mobility for chronic shoulder pain in rheumatoid arthritis. It is difficult to understand why Dr Emery and colleagues included 40 mg of methylprednisolone with the local anaesthetic for the nerve block. It is true that the combination is often used epidurally for pain due to prolapsed intravertebral discs, but that is based on the assumption that pressure on the nerve roots is causing inflammation. There would seem to be no reason why the suprascapular nerve should be subject to inflammation at the suprascapular notch. JAMES M B BURN Pain Clinic, Royal South Hampshire Hospital, Southampton S09 4PE I Emery P, Bowman S, Wedderburn L, Graham R. Suprascapular nerve block for chronic shoulder pain in rheumatoid arthritis. Br MedJ 1989;299: 1079-80. (28 October.)
SIR, -Dr Paul Emery and his colleagues are to be congratulated for their prospective, randomised study' with patients with rheumatoid arthritis being defined according to the 1987 criteria of the American Rheumatism Association.2 It is to be regretted therefore that they did not attempt to categorise their patients according to the source of the shoulder pain. It can no longer be accepted that patients with chronic rheumatoid arthritis are suffering from "chronic shoulder pain": by selective injections of local anaesthetic the exact site of the pain can be attributed to the glenohumeral joint, the subacromial space, the acromioclavicular joint, the biceps tendon, or any combination of these. Subsequently a therapeutic injection of steroid can be instilled accurately into the site of the pain and most patients can be helped to a degree that surgery can be deferred.' To publish a study in which the only type of steroid injection was "a standard intra-articular injection" (presumably at the glenohumeral joint) ignores the fact that in most patients with chronic rheumatoid arthritis multiple parts of the shoulder joint complex are affected in addition to the true glenohumeral joint-for example, in 70% of patients whose shoulder is affected the acromioclavicular joint is also affected.' Finally, the authors state that suprascapular nerve block resulted in significant benefits in terms of the duration of pain relief, the pain index, and range of motion when compared with intra-
1 Emerv P, Bowman S, Wcdderbum L, Grahame R. Suprascapular nerve block for chronic shotilder paini in rhetumatoid arthritis.
Br Medj 1989;299:1079-80. (28 October.) 2 Arnett FC, Edworthv SMNI, Block DA. 'I'he American Rheumatism Association 1987 revised critcria for the classification ot' rheumatoid arthritis. Arthritis Rheum 1988;31:315-23. 3 Newman RJ. Surgery for rheumatoid arthritis. 1. Upper limb surgery of the shoulder. Current Orthop 1989;3:4-8. 4 Crossan JF, Vallance R. Clinical and radiiological features of the shoulder joint in rheumatoid arthritis. j Bone _o'int Surg [Br] 1980;62: 116. 5 Petersson CJ. The acromioclavicular joint in rlheumatoid arthritis. C/in Orthop 1987;223:86-93.
AUTHORS' REPLY,-We agree that it is usually possible to localise the exact site of pain in a shoulder, and that the pain can be treated locally. In patients with longstanding (mean 17 years) disease, however, the situation is more complicated. Our practice for chronic non-acromioclavicular shoulder pain is to give a divided in jection into the subacromial space and the glenohumeral joint. Whether this is necessary in longstanding rheumatoid arthritis, when the two synovial compartments may communicate, is not clear from published evidence. Many of our patients had in the past received acromioclavicular joint injections, and any patient who had localised acromioclavicular pain without evidence of the glenohumeral joint being affected or a specific response to such an injection was not included in the study. In these patients with very longstanding destructive shoulder disease several structures are inevitably affected and there are multiple tender sites. All these patients had clinical glenohumeral disease, which would not have been helped by a localised injection to the acromioclavicular joint. Our statement of significant benefit referred to the fact that nerve block produced a significant improvement in pain score (p
