Exeter and North Devon Health Authority,. Exeter EXl 1PQ. WILLIE HAMILTON. Exeter. 1 Spencer K,Carpenter P. Prospective study of prenatal screening.
Responses of 88 dental and 71 medical general practitioners when asked if they considered antibiotic prophylaxis to be necessaryfor various groups ofpatients having surgical dental treatment. Figures are numbers (percentages) Prophylaxis necessary Practitioner
Yes 20 (23) 15 (21)
No 67 (76) 54 (76)
Don't know 1 (1) 2 (3)
17 (17) (19) 12 8 (9) 22 (31) 17 (19) 13 (18) 2 (2) 4 (6)
(5) 24 (3) 34 (39) 5 (7) 4 (4) 4 (6) 0 0
Cardiacpacemaker
{Dental iMedical
Small ventricular septal defect
{Dental IMedical
Spitzholtervalve
{Dental IMedical {Dental AMedical {Dental PMedical
67 (76) 57 (80) 46 (52) 44 (62) 68 (77) 54 (76) 86 (98) 67 (94)
Hip replacement
{Dental iMedical
37 (42) 6 (8)
48 (55) 61(86)
43 (3) (6)
Previous rheumatic fever
Dental IMedical
86 (98) 54 (76)
2 (2) 13 (18)
40 (6)
Corrected congenital heart malformation
{Dental iMedical
64 (73) 38 (53)
22 (25) 29 (41)
2 4 (2) (6)
Medical
256 (37)
62 (687)
4 (6)
{Medical
69 (97)
2 (3)
Atrial septal defect Prosthetic heart valve
Coronary artery bypass graft Previous infective endocarditis
and the priority of the alternative antibiotics for "special risk" patients who are allergic to penicillin is not clear (clindamycin seems to be the most convenient for both clinicians and patients and is also the cheapest of the three alternatives given). Fifthly, some standardisation regarding dental prophylaxis for patients who have received a cardiac transplant is required as two of the main centres for cardiac transplantation (Papworth and Harefield Hospitals) differ in the advice they give. The current guidelines could be improved in other ways too. Action is now required to rationalise and publicise the existing guidelines. ROGERDAVIES Maxillofacial Department, Queen Alexandra Hospital, Cosham, Portsmouth P06 3LY
Labelling drug ampoules EDITOR,-R Hugh James and Peter G Rabey are right to draw attention to the shortcomings of the labelling of drug ampoules. In fact, an NHS specification was written last year by the National Pharmaceutical Supply Group. This seems to me (an anaesthetist) to be a great improvement on much of the current practice but is little known or observed. A few manufacturers have followed the guidance, and the clear black print on a yellow background that they use is an obvious improvement. Users of drugs must take responsibility for what they do. But the purchasers of drugs should be responsible for not digging holes for the careless to fall into. B P GURATSKY
Wirral Hospital, Wirral, Merseyside L49 5PE 1 James RH, Rabey PG. Illegibility drug ampoule labels. BMJ 1993;307:658-9. (11 September.)
Author's reply EDrroR,-It is a pity that when Peter G Rabey and I performed a literature search for our report on the illegibility of labelling on drug ampoules' we did not discover the specification written by the National Pharmaceutical Supply Group mentioned by B P Guratsky. Its suggestions go beyond the issues raised in our paper but seem sensible. I would like to make a few points. Firstly, why is the specification almost universally ignored?
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Secondly, the specification is vague on the precise size of type, stating that "the typeface and size of type chosen shall be such that the optimum use is made of the space available and maximum legibility is achieved." This seems to allow wide interpretation, and I would prefer to see a stated minimum size of type. Thirdly, the specification requires that the names should be written with an initial capital letter and then lower case letters. This style was used in less than half the ampoules we examined. Fourthly, the failure of the pharmaceutical industry in general to use this specification reinforces our suggestion that a British standard should be introduced. Finally, why does the Medicines Control Agency permit the sale of drugs that do not conform to this specification? I support the final paragraph of Guratsky's letter and hope that the letter may advertise the existence of this specification and help lead to an improvement in labelling. R HUGH JAMES
Leicester Royal Infirmary, Leicester LEl 5WW 1 James RH, Rabey PG. Illegibility of drug ampoule labels. BMJ 1993;307:658-9. (11 September.)
Major incident planning EDrTOR,-We agree with Jane Pateman that, to function effectively in an emergency, staff need to be familiar with the principles of their role.' We recently conducted a survey of medical staff's awareness of and training in major incident planning and disaster medicine throughout South East Thames region.2 This followed on from a similar survey that we conducted at district level.3 We found that only 39% of trainees had been circulated with any literature related to major incident plans. Less than a third of all staff (consultants or trainees) had attended a session at which the major incident plan was explained. Training exercises had been held in 88% of hospitals surveyed but in most cases had tested only communications. Pateman's point that any district general hospital in Britain may be called on to deal with a major incident is true. Eight of the 17 hospitals that we surveyed had implemented their major incident plan within the past 10 years. As a result of this survey we have recommended that all new front line medical staff should attend an induction course at which an overview of the local major incident plan is presented. We also suggest that the handbook for trainee staff should
contain a summary of the major incident plan. Finally, full advantage should be taken of all opportunities to participate in full scale exercises with all the emergency services. L BRENNAN F SAGE D SIMPSON
Department of Anaesthesia, Medway Hospital, Gillingham, Kent ME7 5NY 1 Pateman J. Lessons from a major incident. BMJ 1993;307:808. (25 September.) 2 Brennan L, Sage F, Simpson D. Major incident planning in South East Thames region. Journal of Accident and Emergency Medicine (in press). 3 Brennan L, Simpson D. Major incident plans. Anaesthesia 1992;47:74-5.
Prenatal screening for Down's syndrome ED1TOR,-Kevin Spencer and Paul Carpenter's paper on prenatal screening for Down's syndrome with free 13 human chorionic gonadotrophin raises several interesting points.' Firstly, a screening policy seems to have been introduced in two district health authorities before evaluation (hence the prospective study). If this is so I assume that the approval of the ethics committee was obtained, although it is not mentioned. This is particularly important when an opt out policy is used. The uptake of 89% is extremely high and raises the question of whether adequate information and counselling were available before the test was done (again, there is no mention of this). Secondly, the main non-financial costs of the screening programme are psychological, arising from notification of a high risk that the fetus has Down's syndrome.2 The false positive rate should include all mothers so notified and be quoted as 6-9% (not the adjusted rate of 5-2% given in the abstract). Thirdly, can the identification of seven unexplained deaths be regarded as a benefit of a screening programme? Were these deaths related to the screening, possibly being associated with increased maternal anxiety or even due to amniocentesis? It is essential to know how many similar deaths occurred at the same stage in pregnancy in mothers not at high risk of their fetus having Down's syndrome. The ethical problems of such screening have been aired many times. Nevertheless, some acknowledgment of these problems might have been appropriate-not simply assessment of technical ability but also evidence of a more holistic approach, which, sadly, is often lacking in modern medicine. ALISON ROUND Exeter and North Devon Health Authority,
Exeter EXl 1PQ
WILLIE HAMILTON Exeter 1 Spencer K, Carpenter P. Prospective study of prenatal screening for Down's syndrome with free P3 human chorionic gonado-
trophin. BMY 1993;309:764-9. (25 September.)
2 Marteau TM. Psychological consequences of screening for Down's syndrome. BMJ 1993;307:146-7. (17 July.)
Authors' reply EDITOR,-In our paper we identified several retrospective studies that we, in collaboration with others, had carried out to ascertain the effectiveness of screening with a fetoprotein and free [ human chorionic gonadotrophin. In these studies we had shown the feasibility of such a screening programme based on our protocol. The decision to extend our screening programme for neural tube defects to include routine screening for Down's
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