Feb 12, 1983 - Perivale Maternity Hospital,. Greenford,. Middlesex UB6 8EL. Intensive attention improves glycaemic control in insulin dependent diabetes.
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the benefit of vitamin supplementation. Meanwhile, supplementation should be offered only to those women whose high risk justifies it, and these pregnancies, even when not included in the MRC trial, should be carefully monitored for evidence of benefit and potential harm. A P READ R HARRIS Department of Medical Genetics, St Mary's Hospital, Manchester M13 OJH
Czeizel A. Schisis-association. Am J Med Genet 1981; 10:25-35. Fraser FC, Czeizel A, Hanson C. Increased frequency of neural tube defects in sibs of children with other malformations. Lancet 1982;ii:144-5. Tolarova M. Periconceptional supplementation with vitamins and folic acid to prevent the recurrence of cleft lip. Lancet 1982;ii:217. ' Smithells RW, Sheppard S, Schorah CJ, et al. Vitamin supplementation and neural tube defect. Lancet 1981;ii:1425. ' Laurence KM, James N, Miller M, Tennant GB, Campbell H. Double-blind randomised controlled trial of folate treatment before conception to prevent recurrence of neural tube defects. Br MedJ 1981 ;282:1509-11. Seller MJ, Perkins KJ. Prevention of neural tube defects in curly-tail mice by maternal administration
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discuss alternative sites for vaccination if there is any tendency for keloid or hypertrophic scar formation in the individual. We believe that it is for the profession to impress on the public that every attempt is made to control the disease and that an "unavoidable" scar is a small price to pay for this. S J JACHUCK C L BouND Occupational Health Department, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE
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of vitamin A. Prenatal Diagnosis (in press).
BCG vaccination scars SIR,-Mr Roy Sanders and Mr M G Dickson (11 December, p 1679) have clearly described the management of the BCG scar and have suggested an alternative site as a solution to the problem. They have not, however, described the need for some uniformity in the policy and the management of medicolegal implications. We wish to describe our experiences and thus convey the occupational health problems associated with the BCG scar. Hospital employees are at a higher risk of contracting tuberculosis and are screened for evidence of tuberculosis or vaccination in the past before their employment. It is easy to rescreen the population seeking employment for evidence of previous BCG vaccination when a conventional site is used. There is no better evidence of BCG vaccination than the presence of a scar. We tried ascertaining the vaccination state by retrieving this information from general practice records. Only 220' of these records contained the information. In view of this observation we screened all prospective employees and found that 23 0 had escaped BCG vaccination in school. Vaccination can be given in any of the alternative sites mentioned in the leading article provided the request is made at the time of vaccination. Unfortunately, dissatisfaction is usually expressed long after the event. Between 1975 and 1981 we administered 500 BCG vaccinations. Only two claims for compensation were made-two and three years after the vaccination. Both complainants (female) stressed their dissatisfaction with the site rather than the nature of the scar; the scars were conventional in both women. The inability to wear garments that do not cover the scar was the reason given for their dissatisfaction. BCG is usually given by the school health service in this country before the age of 13. Fashion changes with time and imposes on the profession the need to modify periodically the site of vaccination to prevent
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in appropriate cases in order to identify the occasional case where there is a need for subsequent follow up or even biopsy. We must remember that cervical cancer can rarely present in pregnancy. Patients having shared care should return to the specialist antenatal clinic around 32 weeks' gestation, mainly so that the specialist can check the presentation and measure blood pressure, fetal growth, etc. Around 36 weeks she should again attend the specialist clinic mainly so that he can make an assessment of pelvic adequacy and consider the prospects for labour in addition to the other customary observations. When maturity is reached patients should attend the specialist clinic weekly to ensure that postmaturity will not endanger the fetus. The sentiments expressed by Dr Bull regarding good communications should be applauded. The national cooperation card should enable most useful information to be exchanged. Otherwise, what is needed is a feeling of teamwork, with professional groups cooperating and complementing each other. Each should to some extent cross check the observations made on the patient and be prepared to alert the team if the case is deviating from normal. I have no doubt that good cooperation of this type is in the best interests of patient care. R M BURTON
SIR,-Dr W A M Cutting replied to your leading article (11 December, p 1679) that a small pitted scar over the deltoid was not sufficient for a BCG immunisation programme to consider changing its site of innoculation or discontinuing vaccination (8 January, p 148). Dr Cutting seems to have completely misunderstood the argument. No one is bothered about a small pitted scar. The deltoid area, however, happens to be, after the presternal area, the area of the body most susceptible to keltoid scarring. This is a disabling condition for which there is no satisfactory treatment. Movement of the site of inocculation by only a few centimetres would make BCG innoculation scarring a rarity. Far from jeopardising the inoculation programme its acceptibility could only be increased. BRYAN J MAYOU Perivale Maternity Hospital, St Thomas's Hospital, London SE1 7EH
Greenford, Middlesex UB6 8EL
***This correspondence is now closed.-ED, BM7. The GP and the specialist: obstetrics
SIR,-Over many years I have become convinced that shared care in obstetrics, discussed by Dr M J V Bull (8 January, p 141), is in the best interests of patients, even for those who may be considered normal. Clinical assessment should have a somewhat critical approach, resisting the assumption that a case is necessarily normal and will remain normal in every particular. For shared care to function satisfactorily both the general practitioner obstetrician and the specialist must be able to carry out their proper functions. Patients should certainly be referred early for specialist assessment. By early I mean about 10 weeks' gestation and I hope not as late as 16 weeks. The dating of a pregnancy is often called into question, in many cases at an advanced stage of gestation. In this event most reliance should be placed on a careful bimanual examination by a specialist obstetrician of some experience carried out at this early stage. The specialist should assess the size of the uterus relative to the dates, exclude any abnormality of the genital tract, and in most cases make an assessment of the mechanical adequacy of the pelvis. Most patients appreciate the need for such examination, and the minority who over-react can be counselled and encouraged to attend for future litigation. Fortunately, most recipients parentcraft lessons to gain confidence and of the vaccination are grateful for the service understanding. Rhesus grouping and rubella immunity and accept the scar. It is for a small minority that we have to offer an alternative site to avoid state should certainly be checked as soon as legal complications. For some there is no part possible, but in most cases I encounter this is of the body which is free from incrimination. best achieved on referral to the specialist We acccpt, however, that the vaccinator should clinic. Cervical cytology should be obtained
Intensive attention improves glycaemic control in insulin dependent diabetes
SIR,-We were interested to read the results reported in the letter from Dr R H Harrad and others (1 January, p 59). The problem of motivation (of both patient and doctor) is fundamental to achieving improved control of blood glucose concentrations with present methods. The excellent control that can be achieved in nearly all cases of diabetic pregnancy is a good example of the strong motivation that patients can have, which often wanes following delivery. It is much more difficult in our experience to generate and maintain the necessary enthusiasm in diabetics who are otherwise perfectly well and free of complications, We infer from their letter that Dr Harrad and others selected their patients on the basis of their retinopathy. We wonder, if this is true, whether the patients were told that they had retinopathy since this could provide a very powerful incentive to the patient to intensify efforts to improve control. Any improvement in control as a result of home blood glucose monitoring alone does seem to depend on the procedure being performed several times daily on a regular basis. As we indicated in our original paper, we were not able to maintain this intensity in our group of uncomplicated diabetics. The problem of motivation seems to remain, therefore, the major difficulty. Whatever the reason, however, the sustained improvement in control obtained in the patients at St Thomas's Hospital is encouraging. We would agree that a specialist diabetic nursing sister may well be thought by a diabetic to be more approachable than a doctor, hence prompting more frequent contact between patient and counsellor. We
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cannot agree, however, with the statement: quine resistance has not been noted in the feels oneself, even if disagreeing with the "Patients prefer to use reagent strips with a area. Maloprim was an inappropriate anti- method of expressing it." malarial drug for that particular region. meter." JEAN WILSON R WORTH Glasgow G41 3SE G H REE Department of Medicine, Royal Hallamshire Hospital, Sheffield S10 2JF
Hospital for Tropical Diseases, London NW1 OPE
P D HOME D G JOHNSTON J ANDERSON Moon-boot foot syndrome K G M M ALBERTI Royal Victoria Infirmary, SIR,-Warm water immersion foot (18 DeNewcastle upon Tyne NEI 4LP cember, p 1774) is also found among wearers of other types of thermally insulated boots and can occur with shorter, but repeated, Audits of antibiotic prescribing periods of exposure. I have seen two persons, a professional ski SIR,-In deciding to prescribe a drug the patroller and a National Park Board ranger, benefits, risks, and costs of giving the drug who complained of swelling, tenderness, and are balanced against those of not giving it. softness of the skin from wearing plastic ski The audits from Bristol (8 January, p 118) boots. They wear such boots for about eight detail patients whose treatment was later hours each day during a six day working week considered unnecessary, but not those for of the three month skiing season in New whom antibiotics were delayed, or -withheld, Zealand. At the end of the day the removable in retrospect unwisely. The two populations plastic foam linings of their boots are often are related, and an audit which does not saturated with sweat. Despite cleaning and measure both may be dangerous. drying these linings and the resolution of Antibiotics are most effective when given symptoms overnight warm water immersion early, often before investigations are complete. foot is liable to recur in these otherwise Doctors increasingly feel guilty about giving healthy individuals. antibiotics without a cast iron indication, but Plastic boots are often injection moulded the price of delay is occasionally much higher at the time of purchase to fit the individual than that of many courses of antibiotic which, foot, and because of the excellent thermal when the patient has recovered, were arguably insulating properties wearers prefer to use not needed. thin synthetic socks that allow a snug fitting T H HUGHES-DAVIES of the boot to the foot. Unfortunately, a snug London WC1 fitting encourages the closed miniature environment around the foot. This cause of warm water immersion foot is therefore Chemoprophylaxis of malaria in Africa difficult to prevent while the present fashions in skiing footwear persist. Other people who SIR,-Dr D B A Hutchinson and Mr J A could also be at risk of developing warm Farquhar (1 January, p 62) state that Maloprim water immersion foot, and associated fungal (pyrimethamine and dapsone), at a dosage of infections of the foot, include bathing pool one tablet weekly, has not been reported to attendants, operators of paper making cause agranulocytosis. machinery, and women who wear winter In January 1981 a 53 year old man came to fashion boots throughout the day. the highlands of New Guinea from the West, R PHILIPP where his doctor had recommended Maloprim Department of Community Health., one tablet weekly as an antimalarial. He took University of Bristol, the tablets regularly- and properly. At the end Bristol BS8 2PR of March 1981 he developed a feverish illness, was given thtee injections of penicillin, and, shortly before admission to hospital, four Doctors' dilemmas tablets of amodiaquine. On examination he was acutely ill, febrile, and confused; the SIR,-I am sure that the two discussants (15 only localising sign was a spreading cellulitis January, p 219) who commented on Professor with no pus formation in the perianal region. Dudley's procedure would admit that although His total white cell count was less than 106/1, they have their painful problems they seldom and no granulocytes were seen. Septicaemia have to deal with a case which in surgery secondaiy to agranulocytosis was diagnosed; often arises suddenly, even unexpectedly, the patient died two days after admission. A leaving little time to consider the ideal way bone marrow specimen was examined by Dr to deal with it. Usually by the time a patient J C White, consultant haematologist at Port requires hospice treatment (wonderful and Moresby, whose opinion was: "There is rewarding work) those firstline problems have overall interference with marrow function, been dealt with. As the surgeon said: "Hospital practice is with particularly severe granulopoeitic suppression and agranulocytosis, which must be never tidy; no two patients and no two considered in relation to the effects of drugs families are the same." The caring surgeon and/or infection." (or family doctor) is constantly filled with While I cannot be certain that this patient's discontent about the way he has dealt with illness was caused by Maloprim it seems more any particular case and is never sure he has likely to be responsible than penicillin or got it right. So it seemed strange that the amodiaquine, given after the onset of his last two discussants, who seldom have to take the illness. I questioned the patient's wife most first agonising steps depicted in the film, were carefully about any other drugs taken, but so sure that there was a right way and that it was not Professor Dudley's. As he said: these three were the only ones admitted to. A sad footnote to the story is that there is "Medicine is never simple; there is never one little transmission of malaria in the area right way; and one should give a colleague where the patient was resident, and chloro- credit for at least as much compassion as one
Hours of work of junior hospital doctors SIR,-While supporting the efforts of the Hospital Junior Staff Committee to reduce the unacceptable burden of work represented by a one in two rota for resident house staff we do not accept that similar changes in the on call rotas for registrars and senior registrars are desirable or feasible if standards of patient care and surgical training are to be maintained. Such a reduction in on call rotas would be possible only with a system of cross cover, whereby patients would be cared for by doctors unacquainted with their cases; we do not consider this acceptable in surgery. As surgeons in training we have a responsibility to all our patients and particularly those on whom we have operated, and we would expect to be called should postoperative problems occur. Thus our out of hours work pattern is dictated by the vicissitudes of surgery, and a reduction in rotas to one in three would not change our commitments but merely provide an excuse for regional health authorities to cut units of medical time against the wishes of both consultants and senior registrars on the grounds that the BMA recommends the move. We urge all surgical staff (and those of other acute specialties) seriously to consider the effects of the current BMA recommendation on patient care and registrar training. We suggest that a one in three rota is against the interests of most, if not all, senior surgical registrars and that current practice at regional level and above should not be changed without the agreement of all the individuals concerned; we also suggest that the BMA's recommendations should be restricted to resident hospital doctors. PAUL HURST St Thomas's Hospital, London SEI 7EH
Representing senior surgical registrars at St Thomas's Hospital
Budgeting for pharmaceuticals SIR,-Mr Mahesh Patel (15 January, p 241) claims that drugs account for over 15%, of total health expenditure and that drug sales are rising at about 15%/ annually. It may help to clarify this point if it is noted that, in manufacturers' price terms, total sales to the NHS (family practitioner services and hospital sector combined) actually accounted for about 9-2% of total UK health service spending in 1981. Non-economists might also note that Mr Patel was not adjusting for inflation when he claimed that expenditure on medicines is climbing at 15% a year. Another way of presenting the available data is to say that, although there were some fluctuations, NHS pharmaceutical spending (again in manufacturers' prices) rose only slightly as a percentage of total NHS outlays throughout the 1970s. In 1970 it approximated to 8 4% of all NHS expenditure. D G TAYLOR Deputy Director Office of Health Economics, London SWIA 2DY
