May 11, 1985 - on developing, in consultation with other service providers and the ... I Parliamentary Social Services Committee. ... London: HMSO, 1985.
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where these qualities are to be found is at present uncertain. As a first step, central government, regional and district health authorities, and local authorities should concentrate on developing, in consultation with other service providers and the consumers, "a pattern of service which will enable all those involved to work together and relate to the changing needs of mentally ill and mentally handicapped people and their families."4 The general practitioner and the primary care team have a critical part to play in these developments.
GREG WILKINSON Honorary Lecturer, General Practice Research Unit, Institute of Psychiatry, London SE5 8AF I Parliamentary Social Services Committee. House ofCommons. Community care with special reference to adult mentally ill and mentally handicapped people: second report from the Social Services Committee. London: HMSO, 1985. (HC 13 I, II, III.) 2 Acheson ED. That over used word Community! Health Trends 1985;17:3. 3 Richmond A, Barry A. More and more is less and less: the myth of massive psychiatric need. BrJ Psychiatry 1985;146: 164-8. 4 Department of Health and Social Security. Mental illness: policies for prevention, treatment, rehabilitation, and care. A note distributed within the NHS. London: DHSS, 1983.
Endoscopic ultrasonography: a new look from within Standard techniques of ultrasound imaging through the skin surface have rapidly become of diagnostic importance, notably in the investigation of abdominal, cardiac, thyroid, and testicular diseases, and in obstetrics. The techniques are non-invasive and appear to be safe. Unfortunately there are physical limits to the quality of the image. The characteristics of external probes are a compromise, since the best resolution demands the highest frequencies, and these penetrate poorly. Furthermore, bone and gas are absolute barriers to transmission of a diagnostic beam. These two drawbacks have led to the development of invasive ultrasound probes, which may be placed directly in contact with internal organs. These are, for example, being used at open operation to scan the biliary tree,' 2 pancreas,' 2 and blood vessels,2 and through the rectum and urethra to scan the prostate and bladder.3 Endoscopic ultrasonography is a further extension of this principle. The ultrasound transducer is incorporated into the tip of a standard type of fibreoptic endoscope so that the mediastinum may be scanned from within the oesophagus and the abdominal organs examined from within the stomach and duodenum. Manufacturers have approached this goal in different ways, some using mechanically driven sector probes,4 others electronic linear5 and phased array systems.6 All systems have had problems during development, but equipment for upper gastrointestinal application will be commercially available this year. Endoscopic ultrasonography has many potential uses, and several centres have been assessing the prototype equipment enthusiastically. Most work in the thorax has concerned the heart. The technique has proved an acceptable alternative to conventional echocardiography in those patients (up to 10%) who have a poor "echo window." The images are also complementary to conventional echocardiography as they are obtained from a unique orientation. Endoscopic ultrasonography gives particular detailed views of the posterior
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structures of the heart. Slight angulation of the transducer can provide complete tomographic cuts of the whole heart from one continuous "echo window"-the left atrium. The intra-atrial septum is viewed en face. Two studies have already claimed to show the superiority of endoscopic ultrasonography over conventional echocardiography in detecting atrial septal defects and assessing their size, with and without contrast injections.6 7 The detection rate of intraatrial thrombi (and other tumours) should be higher by endoscopic ultrasonography, since conventional echocardiography has a reported sensitivity for thrombus detection of only 59% in patients with rheumatic heart disease.8 The transoesophageal approach also allows continuous echocardiographic monitoring of left ventricular function during exercise9 and open heart surgery.'0 It should prove useful in the prevention of air embolism associated with cardiac bypass by detecting air trapped in the ventricles before disconnecting the apparatus. "I Endoscopic ultrasonography provides superb views of the wall of the upper gastrointestinal tract. It has been used to stage oesophageal cancer'2 and fully to document oesophageal varices. In the stomach the method has been used to define submucosal lesions, the depth and penetration of gastric ulcers and tumours, and spread to the local lymph nodes.'2 13 Scanning of organs outside the stomach requires considerable practice and skill.5 1' '5 The stomach is floppy and bears inconstant relationships with other organs. Scans are performed without direct endoscopic vision since air must be aspirated or replaced by water. Orientation may be helped by x ray screening or by applying a conventional transducer to the abdominal wall and observing "crosstalk" between the two instruments. Passing the endoscope into the second part of the duodenum gives a more predictable orientation, but this is not always possible with some prototype instruments with relatively long rigid tips.5 The pancreas may be viewed through the wall of the stomach and through the duodenum, and experts claim to be able to see most of the pancreas in almost all patients.'6 '7 The potential resolution is better than 1 mm. Tiny liver metastases may be detected which cannot be seen on standard scans. Endoscopic ultrasonography is valuable in detecting the earliest changes of chronic pancreatitis and its findings are rarely equivocal in differentiating chronic pancreatitis from the normal organ or from pancreatic cancer. The concept of being able to examine the entire mucosa of the upper gut, its walls, and all contiguous organs in one examination is a challenging dream. By the standards of conventional abdominal ultrasound the present equipment for endoscopic ultrasonography is primitive, but it will be improved substantially. These techniques are already spreading rapidly in Europe and Japan, but realistic clinical evaluation will take many years. P B COTTON Consultant physician,
department of gastroenterology P J SHORVON Senior registrar in radiology
W R LEES Consultant radiologist Middlesex Hospital, London WIN 8AA I Lane RJ, Glazer G. Intra-operative B-mode ultrasound scanning of the extra hepatic biliary system and pancreas. Lancet 1980;ii:334-7. 2 Sigel B, Coelho JCU, Machi J, et al. The application of real-time ultrasound imaging during
surgical procedures. Surg Gynecol Obswt 1983;157:33-7.
1374 3 Peeling WB, Griffiths GI. Imaging of the prostate by ultrasound. 7 Urol 1984;132:217-22. 4 Lux G, Heyder N, Lutz H, Demling L. Endoscopic ultrasonographv-technique, orientation and diagnostic possibilities. Endoscopv 1982;14:220-5. 5 DiMagno EP, Regan PT, Clain JE, James EM, Buxton JL. Human endoscopic ultrasonography. Gastroenterology 1982;83:824-9. 6 Hanrath P, Schluter M, Langerstein BA, et al. Detection of ostium secundum atrial septal defects by transoesophageal cross-sectional echocardiographv. Br Heartj7 1983;49:350-8. 7 Reifart N, Strohm WD, Classen M. Detection of atrial and ventricular septal defects by transoesophageal two-dimensional echocardiography with a mechanical sector scanner. Scand3' Gastroenterol (Suppi) 1982;19:101-6. 8 Shrestha NK, Moreno FL, Narciso FV, Torres L, Calleja HB. Two-dimensional echocardiographic diagnosis of left atrial thrombus in rheumatic heart disease. A clinico-pathologic study. Circulation 1983;67:341-7. 9 Matsumoto M, Hanrath P, Kremer P, et al. The evaluation of left ventricular function by transoesophageal M-Mode exercise echocardiography. In: Hanrath P, Bleifeld W, Souquet J, eds. Cardiovascular diagnoqis hy ultrasound. London: Martinus Nijhoff, 1982:227-36. 10 Matsumoto M, Oka Y, Strom J, et al. Application of transoesophageal echocardiography to
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continuous intraoperative monitoring of left ventricular performance. Am J Cardtol 1980;46:95-105. 11 Duff HJ, Bada AJ, Krarner R, Strauss HD, David TE, Berman ND. Detection of entrapped intracardiac air with intra-operative echocardiography. Am Cardiol 1980;46:255-60. 12 Tio TL, T ytgat GN. Endoscopic ultrasonography in the assessment of intra- and transmural infiltration of tumours in the oesophagus, stomach and papilla of Vater and in the detection of extraoesophageal lesions. Endoscopy 1984;16:203-10. 13 Caletti G, Bolondi L, Labo G. Ultrasonic endoscopy-the gastrointestinal wall. Scand J Gastroenterol(Suppl) 1984;19:5-8. 14 Rifkin MD, Gordon SJ, Goldberg BB. Sonographic examination of the mediastinum and upper abdomen by fibreoptic gastroscope. Radiology 1984;151:175-80. 15 Sivak MV, George C. Endoscopic ultrasonography: preliminary experience. ScandJ7 Gastroenterol (Suppl) 1984;19:51-9. 16 Yasada K, Tanaka Y, Fujimoto S, Nakajima M, Kawai K. Use of endoscopic ultrasonography in small pancreatic cancer. ScandJ7 Gastroenterol 1984;19:9-17. 17 Strohm WD, Kurtz W, Hagenmuller F, Classen M. Diagnostic efficiency of endoscopic ultrasound tomography in pancreatic cancer and cholestasis. Scand J Gastroenterol (Suppl} 1984;19: 18-23.
Regular Review Benzodiazepines in general practice: time for a decision J CATALAN, D H GATH The government's regulations restricting the range of benzodiazepines prescribable under the NHS have focused fresh concern on the use of these drugs in general practice. The intensity of the debate was reflected in a long correspondence in the BM7'-3 after a report of an alleged new syndrome attributed to benzodiazepine withdrawal4 and a leading article advocating cautious prescribing.9 At the same time, television's top consumer programme criticised doctors for overhasty and excessive prescribing of these drugs.6 How far could or should the prescribing of benzodiazepines in general practice be reduced? Here we examine three questions. Firstly, are there good reasons for trying to reduce the prescribing of benzodiazepines in general practice? Secondly, would such an attempt be harmful to patients? and, thirdly, would such an attempt be feasible in the working conditions of general practice? Without doubt many doctors are worried about the scale on which benzodiazepines have been prescribed in general practice. Precise data cannot be cited since official statistics do not list benzodiazepines separately. Nevertheless, in England annual prescriptions for tranquillisers and sedatives (including benzodiazepines) in the NHS amounted to about 21 million in the late 1970s and about 18 million in the early 1980s.6 In these same two periods prescriptions for hypnotics (mostly benzodiazepines) ran steadily at about 14 million a year. These prescriptions were largely issued in general practice. A recent survey in five group practices showed that diazepam was the most frequently prescribed of all drugs.4 During one year sedative or hypnotic drugs were prescribed at least once to 16% of women and 7% of men registered in the five practices; in women aged over 45 the figure was about 25%. These drugs are prescribed mainly to patients with minor affective disorders, which make up a large part of a general practitioner's case load and commonly present with symptoms of anxious or depressed mood or insomnia.10-12 They are called minor disorders to distinguish them from the major mood disorders (depressive disorders, anxiety
neuroses, mania) seen in psychiatric practice. These minor disorders often seem to be associated with social problems 13-15 and physical morbidity,'6 and they usually improve within six to 12 months." 13'7
Arguments for and against Three main arguments have been put forward to justify the use of benzodiazepines for such disorders. Firstly, they are said to be effective.'8 20 Secondly, benzodiazepines are said to be safer in standard doses than other drugs that might be used, safer in overdosage than other drugs,2' and safer than alcohol, tobacco, or non-prescribed drugs which patients might take if benzodiazepines were withheld.22 Thirdly, benzodiazepines are relatively cheap: anxiolytic drugs account for only a small proportion of the total health bill in Britain and cost far less than the beer, wine, and spirits consumed by the population.2 The critics of benzodiazepines dispute all three arguments. On efficacy much depends on our interpretation of the many published drug trials. Benzodiazepines are generally accepted to be superior to placebo in the treatment of patients suffering from anxiety neurosis,24 though many studies may be criticised on methodological grounds.2" Even when dealing with psychiatric patients, however, the beneficial effect of benzodiazepines has sometimes been found to be restricted to patients with high levels of anxiety; when given to patients with low anxiety levels benzodiazepines have been found to be no better than placebo.2627 The evidence for the efficacy of benzodiazepines in general practice is unconvincing: mariy reports are methodologically inadequate, and the more rigorous studies have failed to show any advantage over placebo.28 It might be argued that benzodiazepines are likely to be superior to placebo only in patients suffering from severe anxiety symptoms and that these patients are uncommon in general practice. Benzodiazepines are often used as hypnotics and they do seem more effective than placebo in
