Jul 26, 1986 - sumption, and Reye's syndrome. He speaks of the relative safety of long term salicylate in juvenile chronic arthritis and the absence of reported.
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cautery of skin lesions in my office, to the great benefit of my patients in saving their time by avoiding the need for referral. The American Academy of Family Practice encourages comprehensive medical care, including such procedures. As these procedures are time consuming, it is only feasible to perform them on a fee for service basis. However, under the NHS capitation system the premium is to do only enough to keep the patient on the doctor's list, so that he may have time to see more patients. This is shown by the low standards of general practice: no routine blood pressure or breast checks at each visit and a general tendency to treat symptoms and diseases, rather than whole patients. In spite of the lauding of health maintenance organisations, they suffer considerable problems. In their efforts to cut costs they discourage laboratory examinations and consultations. The fact that this leads to poorer care is shown by the higher malpractice insurance rates in some states for doctors working in health maintenance organisations. If, as stated, "The whole thrust of thinking in modem general practice is towards economy of medical intervention: the health of the patient is best enhanced by an economy of investigation and medication" then the rational conclusion would be that the health of the nation could best be preserved by having no medical care at all. I and my fellow physicians in primary care think that fee for service payments, allowing the patient to move from doctor to doctor, lead to healthy competition between us as to who can provide the best care.
M G JACOBY Patchogue, NY 11772, USA
What price academic general practice?
SIR,-Academic general practice will welcome Sir Raymond Hoffenberg's endorsement (14 June, p 1545) of much of the Mackenzie report (p 1567). However, it is a pity that one of our most powerful opinion setters seeks to confine general practice to a narrow vocational role, rather than promote a greater element of systematic clinical learning in the setting of general practice. As Sir Raymond emphasises, all students should be given some experience of how general practice works and what a general practitioner does,- although I would argue that this experience is important because many graduates do not enter general practice, rather than the reverse. At any rate this exposure to general practice as a system of care is well achieved by opportunistic learning in a working practice. But apart from this more vocational exposure, there is good reason to suppose that all students would benefit from some redress of the imbalance whereby it is assumed that the structured elements of ctinical learning should be confined largely or solely to the hospital sector. Sir Raymond righdy implies that students must acquire, and tutors must -demonstrate, clinical skills in a way that is different from the more rapid problem solving approach that all experienced clinicians come to adopt. So long as this distinction is appreciated, there is no good reason to suppose that many general practitioners could not revert, in clinical teaching, to the "physicianly approach" that Sir Raymond advocates. This cannot be done satisfactorily in the context of "real life" clinical service (any more than it can in hospital). As Sir Raymond oboserves, the student (and the tutor) need extended time with patients and time to discuss, reflect on, and read about their findings. Given the resources, such a protected learning environment could be created in general
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practice so that there was a community based equivalent to the teaching hospital model.' The traditional basic clinical skills could probably be acquired as well in general practice as in the wards (given equivalent resources) with the added advantage that, because skill in communication and alertness to psychological and social factors in illness are more obviously essential in general practice, the student is more likely to integrate these skills into his clinical methods, rather than regard them as separate modes to be used in particular "psychosocial" situations. Ross J TAYLOR University Department of General Practice, Aberdeen AB9 2AY I Taylor RJ. General practice in the medical school-the way ahead. Update 1985;30:615-9.
SIR,-Sir Raymond Hoffenberg (14 June, p 1545) states the importance of clinical and operational research and comments on the need for establishing the crucial role of general practitioners in preventive medicine. I have recently completed a period of study at Bordeaux University, France, where I was attached to the organisation UNAFORMEC. The Union Nationale des Associations de Formation Medicale Continue was created in 1978 to improve postgraduate education for general practitioners. It also promotes epidemiological research in general practice and increases the impact of preventive medicine. At present French medical training is undergoing a major revision as the result of a governmental decree which came into force in 1985. Academic general practice gains in importance, with established general practitioners now taking part-in the training of interns who wish to pursue a career in family medicine. The general practitioners are being linked with university faculties during the third cycle of medical training. The third cycle for general practitioner interns, "internat de medecine," is roughly equivalent to our preregistration year and vocational training period and lasts two years. In addition there will now be training periods lasting at least four years, the "internat de specialite," in medical specialties including medicine, surgery, biology, and psychiatry but also public health and medical research. Access to these streams is through a highly competitive examination. The streams for public health and medical research are new. Training in public health will enable cooperation to take place not only between hospital and family practitioners but also with sociologists and economists. However, the importance of public health matters will also be emphasised in the other training programmes, particularly those for general practice. The plan for the training course in medical research involves clinical medicine being linked to research of a high standard in association with non-medical research workers. This should lead to a cadre of research doctors who will develop expanding opportunities in biomedical research. Our French colleagues appear to recognise the continued importance of both epidemiological research and public health and are planning for the future.
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a colonic neoplasm in addition to a benign upper gastrointestinal abnormality in 16% of patients with unexplained iron deficiency anaemia. Iron deficiency anaemia is a well' recognised manifestation of gastrointestinal malignancy, especially of the right colon. As the authors emphasise, it is essential to investigate the colon fully in patients with occult gastrointestinal bleeding or iron deficiency anaemia. Many patients continue to be treated with iron without investigation of their anaemia. One hundred and fourteen consecutive patients presenting to this hospital with c'arcinoma of the colon during an 18 month period were studied. Fifty eight of these were found to be anaemic on admission. Three quarters of those with carcinoma of the right colon and one third of all anaemic patients had received iron without investigation for a mean of nine months (range 2-36) before referral. Although Dr Cook and colleagues advocate complete investigation of the gastrointestinal tract to identify the cause of iron deficiency, many patients still receive no investigation at all. The late presentation of gastrointestinal malignancy in an anaemic patient is avoidable, and this is a Lesson of the Week that has still to be learnt. C J CAHILL J A PAIN M E BAILEY Royal Surrey County Hospital,
Guildford, Surrey
Severity scoring in intensive care
SIR,-Drs C J Morgan and M A Branthwaite (14 June, p 1546) advocate the use of APACHE II acute physiology and chronic health evaluation as a unified tool for auditing the outcome of intensive care. We would like to expand further on two points. Firstly, the value of APACHE as an aid to monitoring in the broadest sense and its potential as an educational tool must not be overlooked. Secondly, the problems of acquisition, storage, and useful processing of APACHE information must be addressed if the potential of a unified prognostic scoring system is to be widely used. In intensive care clinical decisions are made on the basis more of trends than of absolute values. Indeed, monitoring is of greatest importance in physiologically unstable patients when instantaneous values alone are inadequate to plan for other than short term support and the development of a trend may provide important insight into a patient's state.' Trend prediction of monitored variables is usually performed by eye, though some automation is available. ' 2 The availability of APACHE, particularly in its original expanded form, makes possible the construction of a 'comprehensive "library" of the patient record, which not only could be the basis of the database mentioned by Drs Morgan and Branthwaite but could also provide the information from which immediate decision support could be generated. APACHE then becomes a unified physiologically based monitor of patient progress, which, with the help of trend analysis, may en'able clinicians to make objective decisions on whether intensive care should be continued or withdrawn as well as providing admission criteria. APACHE data handling and use need not pose ROGER J WOLSTENHOLME difficulties because information processing and Wigan and Leigh Medical Institute, data storage are easily achieved with available Wigan WNl 2NN database software and the ever increasing power of microcomputers. The problem, however, is the entry of data into the computer system in a busy Gastrointestinal investigation of iron intensive care unit. This task will probably devolve deficiency anaemia on to the nurses already overburdened by the large amount of information to be charted. In our own SIR,-We were interested to read the article by Dr unit this currently averages 120 data items per Ian J Cook and others (24 May, p 1380), who found patient per day, and this problem of information
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overload is common to all such units (Price DJ, IEE Colloquium 1984). The most sophisticated system will fail in the absence of data entry. Most clinical and nursing staff dislike the usual QWERTY keyboard, the means of data entry favoured by computer systems. The APACHE scoring described by Knaus et al3 shows the APACHE II system as a 9 x 12 box table. We have used this table as an overlay for a pressure sensitive graphics pad. Data entry is by box ticking, allowing direct data acquisition by a microcomputer. This approach does not need a keyboard, uses existing technology, allows data entry by a familiar method, and provides a record of the data actually entered. Nurses (and doctors) did not train to become typists. P 0 COLLINSON D G CRAMP G BORAN D R G BROWNE Department of Chemical Pathology and Human Metabolism, and Department of Intensive Care, Royal Free Hospital and School of Medicine, London NW3 2QG
R JONES A GRANT Department of Chemical Pathology, University of Leeds, Leeds LS2 9JT I Siegel JH, Farrell EJ, Fichthorn J, et al. The use of multivariable trajectories in defining normal and abnormal time causes of recovery after coronary bypass surgery. J Surg Res 1975;18: 341-56. 2 Bland R, Shoemaker WC, Shabot M. Physiologic monitoring goals for the critically ill patient. Surg Gyn Obstet 1978;147: 833-41. 3 Knaus WA, Draper EA, Draper A, Zimmerman JE. APACHE II: A severity of disease classification system. Cnrt Care Med
1985;13:818-29.
Reye's syndrome, aspirin, and juvenile chronic arthritis SIR,-Dr Michael Tarlow (14 June, p 1543) warns of the danger of the use of aspirin in the febrile child and of the line between a febrile illnessnotably, influenza or chickenpox-aspirin consumption, and Reye's syndrome. He speaks of the relative safety of long term salicylate in juvenile chronic arthritis and the absence of reported Reye's syndrome in this condition in Britain. Hepatomegaly, sometimes massive, with raised transaminase activities is a well documented feature of the systemic pattern of juvenile chronic arthritis per se' and we would like to draw your attention to the particular vulnerability of the liver in this systemic subgroup, especially in younger children. We have seen a syndrome clinically and biochemically indistinguishable from Reye's syndrome in children with systemic juvenile chronic arthritis taking aspirin, and histologically proved Reye's syndrome in juvenile chronic arthritis has been reported from North America.2 Aspirin hepatitis with encephalopathy histologically distinct from Reye's syndrome has also been reported.3 We agree with Dr Tarlow that salicylate therapy need be interrupted only when a local epidemic of chickenpox or influenza develops, but we would also recommend monitoring therapy, with regular measurements of salicylate concentrations and prompt estimation of liver function values, if nausea or vomiting or other gastrointestinal symptoms develop, particularly in the child with systemic disease. ANN HALL
I Schaller J, Beckwith B, Wedgwood RJ. Hepatic involvement in juvenile rheumatoid arthritis. J Pediatr 1970;77:203-10. 2 Remmington PL, Shabino CL, McGee H, Preston G, Saniak AP, Hall WN. Reye's syndrome and juvenile rheumatoid arthritis in Michigan. Am3 Dis Child 1985;139:870-2. 3 Ulshen MH, Grand RJ, Crain JD, Gelfant EW. Hepatotoxicity with encephalopathy associated with aspirin therapy in rheumatoid arthritis. J7 Pedatr 1978;93:1034-7.
Efficacy of a new nystatin formulation in oral candidiasis
SIR,-The report by Dr P J Thompson and colleagues of their study on the efficacy of the
pastille preparation of nystatin in the treatment of oral candidiasis (28 June, p 1699) concluded that it was no better than nystatin suspension, which has been available for many years. The authors accept, however, that nystatin is not perhaps the treatment of choice for oropharyngeal candidiasis since they describe it as only a "reasonably effective" treatment of this condition. In my experience nystatin is a reasonable treatment but less effective than amphotericin in lozenge form. In this unit amphotericin lozenges have been the treatment of first choice for oropharyngeal candidiasis for many years. I also believe that topical amphotericin treatment is preferred to nystatin in most other hospital units, but perhaps not in the Brompton Hospital. A comparisdJ of a "reasonably effective" treatment of oropharyngeal candidiasis with the same "reasonably effective" drug in a different formulation is perhaps of some interest, but much more meaningful information would have been generated from a study designed to compare nystatin pastilles with amphotericin lozenges. The report, however, did contain interesting speculative information about the role of denture cleaning in the treatment of patients with oral candidiasis, and also the possibility that Sjogren's syndrome as well as treatment with atropine analogues may predispose tb the development of oropharyngeal thrush. I assume, therefore, that this report was published because of these interesting extras. G K CROMPTON Respiratory Unit, Northern General Hospital, Edinburgh EH5 2DQ
SIR,-We would like to comment on the methods used by Dr P J Thompson and his colleagues and other aspects of their paper. They used a swab technique to isolate candidal species from the oral cavity on predetermined (but unspecified) sites. This swab technique is notoriously imprecise and in the past 10 years has been superseded by other more sensitive techniques, including impression cultures,' imprint cultures,2 and oral rise cultures.34 It seems inappropriate to assess the results of such a study statistically when the original technique used is inaccurate. Many of the patients were reported as having clinical signs such as glossitis, yet there is no mention of whether such patients underwent routine blood investigations. Nutritional deficiencies are a well recognised cause of glossitis.' Reduced salivary flow can also produce an atrophic glossitis6 but there is no mention in the paper of objective or subjective assessment of xerostomia. Other clinical patient data such as whether or not the patients were smokers are lacking. The carriage rate of Candida albicans is reported as 70% in smokers but only 30% in non-smokers.7 Since BARBARA M ANSELL the patients under study had respiratory disease then inclusion of their smoking habits seems Department of Paediatric Rheumatology, essential. Wexham Park Hospital, One additional point relates to the statement Slough SL2 4HL
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that "Dentures cause tissue trauma, provide sites for colonisation, and diminish salivary flow" attributed to Odds.8 To our knowledge there is no scientific evidence that wearing dentures reduces salivary flow, and this statement is also not substantiated in the reference given. P-J LAMEY L P SAMARANAYAKE Department of Oral Medicine and Pathology, Glasgow Dental Hospital and School, Glasgow G2 3JZ I Budtz-Jorgensen E. The significance of Candida albicans in denture-stomatitis. ScandJ Dent Res 1974;82:151-90. 2 Arendorf TM, Walker DM. The prevalence and intra-oral distribution of Candida albicans in man. Arch Oral Biol 1980: 25:1-10. 3 Samaranayake LP, MacFarlane TW, Lamey P-J, Ferguson MM. A comparison of oral rinse and imprint sampling techniques for investigating the oral carriage of Candida species. J7 Dent Res 1986;65:523. 4 Samaranayake LP, MacFarlane TW, Lamey P-J, Ferguson MM. A comparison of oral rinse and imprint sampling techniques for the detection of yeast, coliform and Staphylococcus aureus carriage in the oral cavity. J Oral Pathol (in press). 5 Challacombe SJ. Haematological abnormalities in oral lichen planus, candidiasis, leukoplakia and non-specific stomatitis.
Int7 Oral Maxillofac Surg 1986;15:72-80. 6 Chisholm DM, Mason DK. Salivary gland function in Sjogren's syndrome-a review. BrDent7 1975;135:393-9. 7 Oliver DE, Shillitoe EJ. Effect of smoking on the prevalence and intra-oral distribution of Candida albicans._7 Oral Pathol 1984; 1:265-70. 8 Odds FC. Candida and candidosts. Leicester: Leicester University Press, 1979:75-100.
A comprehensive bibliography database using a microcomputer SIR,-The paper by Dr David Sellu (21 June, p 1643) describes a bibliographic database capable of holding 30 000 to 65 000 references including reference details and a 150 word abstract. Given that the disk can take 50 000 records in five megabytes this would seem to imply about 5000000 bytes/50 000 records-that is, 100 bytes/record. Most database programs use a relative access file system or something similar and data stored in an uncompressed form, such as ASCII coded text, requiring 1 byte/character. The reference example given of a paper by Skirrow would require about 400 bytes and one with a 150 word technical abstract getting on for 1000 bytes. This would give the system a capacity of around 5000 references rather than the stated 50 000. I am puzzled by this major discrepancy and wonder whether the stated capacity and figures for record searching and transfer are in error by an order of magnitude. D W BULLIMORE St James's Hospital, Leeds LS9 7TF
AUTHORS' REPLY-Dr Bullimore is right in stating that for practical purposes most database management programs storing uncompressed data use 1 byte for each character. He is also correct in his calculation that each of the references would require 1000 bytes of storage space. However, he has misunderstood the contexts in which I used the figures 30 000 and 65 000 and hence the apparent discrepancy in the rest of his calculation. What I stated in my paper was that if the storage capacity of a disk was large enough the program would enable it to hold up to 65 000 references. There is, of course, no linmt to the number of references that the user can computerise, for when a disk is full the file can be continued on other disks. The 30 000 references that I have are held on 60 floppy disks and not on the 5 megabyte hard disk. Each floppy disk has a storage capacity of about 800 kilobytes and can therefore hold 800 references. However, I store no more than 500
