book"' by Dr Cyril Smith, an electrical engineer and biophysicist at Salford University, and myself, which has been reviewed." A further updated assessment of ...
between depression and electromotive force by Dowson and colleagues in Southampton. Wertheimer and Leeper have also reported a connection between electric blanket use and ceiling cable heating and fetal death.8' A large number of other references to both domestic and occupational exposure studies are given in a recent book"' by Dr Cyril Smith, an electrical engineer and biophysicist at Salford University, and myself, which has been reviewed. " A further updated assessment of much of the evidence on this topic, which discusses in greater detail most of the references mentioned by Dr Lowry, has also just been published. 12 On the question of mechanism, Dr Lowry's statement, "Any biological effects of electromagnetic fields are likely to be due to the eddy currents that the fields induce in tissues" is not true and shows an ignorance of the work of biophysicists and quantum biologists, who have now provided considerable evidence that highly coherent electromagnetic fields (having similar qualities to those of lasers) can disturb cellular functioning at very low intensities by acting on coherent internal cellular fields." A major contribution to this understanding has been made by Professor Herbert Frohlich, emeritus professor of theoretical physics at the University of Liverpool, who originated the concept of coherent oscillations in biological systems. Indeed, even the National Radiological Protection Board in their recent recommendations (which should have been referred to) acknowledges the reality of nonthermal effects: "There does appear to be evidence for athermal biological effects, particularly of magnetic fields, at all levels of biological organisa-
tion."'s Regarding Dr Lowry's references to the results of Savitz and colleagues and their comments" it is worth noting that the final report of the New York State Power Lines Project stated that if a causal relation is accepted to underlie their findings then the percentage of all cases of childhood cancer attributable to such magnetic fields would be between 10 and 15%.' Had Dr Lowry also sampled views other than those of members of the Central Electricity Generating Board she might have recorded more accurately the range of opinion among researchers on this subject. She might also have contrasted the difference in attitude and consensus between people in the United Kingdom and the United States by mentioning, for example, that eight states in the United States currently have maximum electric field levels along powerline rights of way (Florida also has the first magnetic field guideline), and in Canada British Columbia Hydro are currently buying up houses along a new powerline from homeowners who fear health effects. For those interested to keep abreast of biological research on this topic, as well as at the higher radio frequency and microwave frequencies, a new twice monthly news report has just been launched, details of which can be obtained from me.
8 Wertheimer N, Ieeper E. Possible ef'ccts of electric blankets and heated waterbeds on fetal development. Btoelectromagnetlcs 1988;7:13-22. 9 Wertheimer N, Leeper E. Fctal loss associated with two seasonal sources of electromagnetic field exposure. Am I
Epidemiol 1989;129:220-4. 10 Smith CW, Best ST. Electromagnet'c man: health and hazard in the electrical environment. London: Dent, 1989. 11 Fox B. Review otf'Electromagnetic man: health and hazard in the electrical environment.' N ew Scientist 1989;123:60. 12 Best S. Killing fields; epidemiological esidence. Electronics World and Wireless World February 1990:98-1111. 13 Marino AA, ed. Modern btoelectrtcttv. New York: Marcel Dekker, 1988. 14 Frohlich H. Biological coherence and response to external stimuli. Heidelberg: Springer, 1988. 15 National Radiological Protection Board. fGuidance as to restrictions on exposures to time zvaning electromagnetic fields and the 1988 recommendations of the International Non-Ioniztng Radiation Committee. Didcot: NRPB, 1989. 16 Savitz DA, Wachtel H, Barnes FA, John EMI, Tvrolik JG. Case-control studs of childhood cancer and exposure to 60 Hz magnetic fields. Am] Epidemiol 1988;128:21-38. 17 Ahlbom A, Albert EN, Fraser-Smith AC, et al. Biological effects of p(ner line fields. Nezv York State Power Lines Project, Scientific Advisory Panel final report. New York: NYS Department of Health, 1987.
Hospital formularies SIR,-The study of the effects of a hospital formulary and other interventions by Professor John Feely and colleagues' requires elaboration in several respects. When stating "there is little information on the effect of a formulary" the authors fail to cite the major studies by Rucker and Visconti-` and Daniels and Wertheimer' in the United States, and our group in Australia,"' all of whom have rigorously investigated the impact of formularies and other interventions on drug use by using various approaches and have laid a firm foundation on which formularies may be efficiently implemented in hospitals. Furthermore, Professor Feely and colleagues did not provide specific details of the interventions used. Was feedback' effected by computer generated reports,' written reports, or telephone contact or was it personalised' (and, if so, by whom?)? How was the peer review conducted, by whom, and how often? Was the drug information note used only once? How was it distributed? (Was it posted, personally circulated, or supported by educational meetings?) Was the "note" a note appended to a medication chart or a drug bulletin? This information would help to specify the intervention strategies and their respective effects. With respect to the use of cefotaxime, were changes in antibiotics other than cephalosporins monitored? The authors did not specifically address changes (if any) in the use of antibiotics in hospitals or in antibiotics other than cephalosporins that could be substituted for cefotaxime. Evidence exists that a change (a decrease) in one drug's use may cause changes (increases) in the use of other drugs in the same therapeutic group. "'" RICHARD J PLUMRIDGE CON G BERBATIS Fremantle Hospital,
SIMON BEST
Fremantle, Western Australia 6160, Australia
Electromagnetics News, PO Box 25, Liphook, Hampshire GU30 7SE
I I Lowrv S. Electromagnetic radiation in homes. Br Mfed 7 1989;299:1517-8. (16 December. j 2 Wertheimer N, Leeper E. Adult cancer related to electrical wires near the home. Iniy Epidemiol 1982;11:3445-55. 3 Tomenius L. 50 Hz electromagnetic environment and the incidence of childhood tumours in Stockholm county.
1981;41:267-77. 5 Perry FS, Pearl L. Health effects of ELF fields and illness in multistorey blocks. Public Health 1988;102:11-8. 6 Perry FS, Pearl L, Binns R. Power frequency magnetic field; depressive illness and myocardial infarction. Public Health 1989;103: 177-80. 7 Dowson D, Lewith Gr, Campbell M, Mullee MA, Brewster LA. Overhead high voltage cables and recurrent headache and depressions. Practitioner 22 April 1988:435-6.
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Hospital formularies: need for continuous intervention. BrMedJ7 1990;300:28-30. (6 January.) 2 Rucker 'FD, Visconti JA. Howv effctizve are drug fornularies? .4 descripti've and normnati.e study. Washington, DC': American Societs of Hospital l'harmacists Research and Education Foundation, 1979. 3 Rucker TD. Superior hospital formularies. Hospital l'harmnacv
1982;17:465-524.
Bioelectromagnetics 1986;7:191-207. 4 Perry FS, Reichmanis M, Marino A, Becker RO. Environmental power-frequency magnetic fields and suicide. Health Physics
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4 Daniels CE, Wertheimer AI. Analvsis of- hospital formularv effects of cost control. Topics in Hospital Pharmacyv Management 1982;2:32-49. 5 Plumridge RJ, Stoelwinder JU, Berbatis C(i. Improsing patient care and pharmacy management: the effect of hospital
formularies. Drug Intell Clin Pharm 1984;18:652-6. 6 Plumridge RJ, Berbatis CG. Drug bulletins: effectivevess in modifying prescribing and methods otf itnprotving impact. Drug Intell Clin Pharm, Annals of Pharmacotherapy 1989;23: 330-4. 7 Eisenberg JAI. Do education and feedback changc doctors'
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decisions? In: Doctors' decisions and the cost of medical core. Atsn Arbor, Michigan: Health Administration Press PlerspectiXes, 1986. Hershey CO, Goldberg HI, Cohen DI. The effect oJf computerized feedback coupled with a newsletter upon outpatient prescribing charges. Med Care 1988;26:88-94. Asvorn J, Soumerai SB. Improving drug-therapy decisions through educational outreach: a randomized trial of academically based "detailing." A' EnglJ7Med 1983;308:1457-63. RcillyITA, Abitabilo N, Metsh JM, Lerman L. A drug use index approach to the evaluation of antibiotic utilisation. Mt Sinai3J Med (NI') 1978;45:489-94. Shenfield GM, Jones AN, Paterson JW. Effect of restrictions on prescribing patterns for dextropropoxvphene. Br Med 7 1980;281:651-3.
AUTHORS' REPLY, -Perhaps Drs Richard J Plumridge and Con G Berbatis did not focus on the remainder of our sentence "the effect of a formulary on the quality of prescribing...." We are aware of their and other contributions. Indeed recently they concluded that "little research has been conducted into the impact of drug bulletins in modifying prescribing and containing costs."' Furthermore, putting such experience into practice has proved difficult. In a survey of all major Australian acute care public hospitals they remarked that "methods of improving organizational features and implementation procedures associated with formulary compilation and use are neither widely applied or widely known."2 In our study feedback reports were personalised and written by the chairman of the drugs and therapeutic committee, who with another physician and a pharmacist (with reference to the relevant specialist if appropriate) conducted peer comparison initially on a monthly basis. The drug bulletin was circulated (by post) once but was also incorporated into the formulary and discussed at educational meetings. We agree with Drs Plumridge and Berbatis that decreasing the use of one antibiotic may increase that of another -in our study overall use of antibiotics did not fall. With regard to zefotaxime, however, we (temporarily) achieved our aim-the drug was used more appropriately. For several patients alternative treatment based on sound microbiological information and in accordance with the overall hospital antibiotic policy comprised either clavulanic acid and amoxycillin or gentamicin. Though it is considerably less expensive than the other drugs, the use of gentamicin requires therapeutic drug monitoring.
Assessment of formularies requires information on quality as well as quantity of prescribing (including outcome when possible), feedback to prescribers ("closing the loop"), and a measure of the impact of such therapeutic audit. JOHN FEELY ROBERT CHAN LELIA COCOMAN KENNETH MULPETER PATRICIA O CONNOR Department of Pharmacologp and Therapeutics, Trinitv College Medical School, St James's Hospital, Dublin 8 1 Plumridge RJ, Berbatis CG. Drug bulletins: effectiveness in modifying prescribing and methods of improving impact. Drug
Intell Clin Pharn, Annals of Pharmacotherapy 1989;23:330-4. 2 Plumridge RJ, Stoelwinder JU, Berbatis CG. Improving patient care and pharmacy management: the effect of hospital formularies. Drug Intell Clin Pharn 1984;18:652-6.
Death after flumazenil? SIR,-We feel obliged to comment on the letter from Dr A G Lim.' This letter tells us that an unwell, elderly, obese woman was admitted with profound anaemia. No reference is made to the patient's medical history or medication. Transfusion was later followed by gastroscopy. Sedation was attempted with 4 mg of midazolam given intravenously. The time
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