- Email: [email protected]
Aromagram for antibiotic activity
Fitness to drive in the elderly SiR-O’Neill and colleagues (Nov 12, p 1366) describe a postal questionnaire which was sent to 121 physicians caring for general medical and geriatric patients to assess the doctors’ knowledge about fitness to drive motor vehicles. Eighteen diseases were listed and the physicians were asked what should be done. The options were no action, a ban on driving, or notification to the Driver and Vehicle Licensing Authority. There were important omissions from the list of diseases-namely, those related to sleep, including sleepdisordered breathing, periodic leg movements, and poor sleep habits, all of which are common in the elderly and can result in daytime somnolence sufficient to cause impairment of ability to drive. Obstructive sleep apnoea is present in of the American population with an increased prevalence above the age of 40.’’ It is much more common in those who are overweight. Data from Canada3and the USA show unambiguously that sleep apnoea is associated with impairment in psychomotor function and an increased car crash rate.-I,5 In most provinces of Canada physicians are required to report patients with sleep apnoea, narcolepsy, and other sleep disorders to the local motor-vehicle licensing agencies. Sleep-related problems with subsequent daytime somnolence are strikingly common in the elderly, and not to consider this group of diseases in a survey related to fitness to drive is a serious omission.
2-4%
*M Lertzman, M
Kryger
Section of Respiratory Medicine, and Sleep Disorders Centre, St Boniface General Hospital, Winnipeg, Manitoba, Canada R2H 2A6
1
2
Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disorder breathing among middle-aged adults. N Engl J Med 1993; 328: 1230-35. Sleep apnea, sleepiness and driving risk. Official statement of American Thoracic Society. Am J Respir Cnt Care Med 1994; 150: 1463-73.
3 4 5
George C, Nickerson PW, Hanly PJ, Millar TW, Kryger MH. Sleep apnoea patients have more automobile accidents. Lancet 1987; ii: 447. Findley L, et al. Automobile accidents in patients with obstructive sleep apnea. Am Rev Respir Dis 1988; 138: 337-40. Kryger M, Roth T, Dement W. Pnnciples and practice of sleep medicine, 2nd ed. Philadelphia: WB Saunders, 1994.
Aromagram for antibiotic activity SIR-The use of aromagrams provides a rapid visual method show the individual characteristics of different wines. We have adapted this method to illustrate the spectrum of activity of antibiotics against groups of bacteria that are important in defined clinical situations. For the purpose of this exercise, segment sizes were based on published frequencies of bacterial isolation 1,2 and the shaded areas were constructed with percentage sensitivity of isolates from a reference text,3 although these data do not necessarily accord with our local experience. The figure shows an example for community-acquired to
(amoxycillin) versus hospital-acquired (amoxycillin and gentamicin) pneumonia. The useful activity of amoxycillin in pneumonias of different aetiology is immediately apparent, as is the benefit and possible weakness in combined amoxycillin/gentamicin therapy for hospitalacquired infection. In addition to showing the role of individual antibiotics, the method clarifies the rational choice of second line therapy and is a flexible presentation method for discussing the value of antibiotic combinations when images can be superimposed with the use of projection acetates, although clearly they cannot describe antibiotic interactions such as synergy or antagonism. 64
Figure: An antibiograph to display the efficacy of amoxycillin (amox) in community-acquired pneumonia (CAP) and amoxycillin and gentamicin (gent) in hospital-acquired pneumonia (HAP) Each segment size based on frequency of bacterial isolation; the more active the drug against that group of isolates the greater the shading within that segment. Once the data had been assembled, each antibiograph was drawn in roughly 15-20 min with Harvard Graphics 3.0 on Opus Personal Computer. S pneumoniae= Streptococcus pneumoniae; M catarrhalis=Moraxella catarrhalis; S aureus=Staphylococcus aureus; E co/i=Escherichia coli; P aeruginosa=Pseudomonas aerugmosa.
These charts were used as the basis for a recent discussion on the use of antibiotics in our intensive care unit. We were impressed by their ability to convey patterns of antibiotic susceptibility rapidly and effectively. They are
to produce with computer graphics packages and could be especially useful when adapted to local patterns of bacterial isolation and sensitivity; sets could be produced for rapid reference on the wards to reinforce antibiotic policies. This method of data presentation might be very useful for students or a general medical audience to whom traditional tables of antibiotic minimum inhibitory concentration values remain a barrier to understanding.
simple
*A F Maggs, G
Phillips
Department of Medical Microbiology, University of Dundee, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
only if there are facilities to ensure that a minimum fitinducing charge is used. All ECT should be conducted under licence issued by regional independent panels. A licence would be issued to a consultant to allow a set number of treatments within a set period for a specific patient. The consent issue needs unambiguous resolution. Could the General Medical Council offer ethical practice guidelines? Lastly, a national clinical audit could elicit data about use and benefits of ECT, and provide evidence of short-term and long-term problems that would outweigh the benefits of rapid symptom resolution.
Tony Baker 1
2
3
MacFarlane JT, Colville A, Guion A, MacFarlane RM, Rose DH. Prospective study of aetiology and outcome of adult lower-respiratorytract infections in the community. Lancet 1993; 341: 511-14. Bartlett JG, O’Keefe P, Tally FP, Louie TJ, Gorbach SL. Bacteriology of hospital--acquired pneumonia. Arch Intern Med 1986; 146: 868-71. Wiedemann B, Atkinson BA. Susceptibility to antibiotics: species incidence and trends (Ch 26), In: Lorian V, ed. Antibiotics in laboratory medicine, 3rd ed. Baltimore: Williams & Wilkins, 1991.
ECT and young minds SiR-National Association for Mental Health (MIND) seeks the abolition of electroconvulsive therapy (ECT) for children and young people. I support this campaign as a consultant in child and adolescent psychiatry. No body has the power to abolish ECT and the campaign will only succeed if doctors, under the leadership of the Royal College of Psychiatrists, agree to a moratorium on its use. The main difficulties are: (i) the ethics of uninformed consent and compulsory treatment; (ii) risk of brain damage; (iii) misapplication of treatment; and (iv) inadequate knowledge and equipment. There are no controls for the administration of ECT, provided that the patient (or their parents in the case of
minors) gives consent. Although ECT is a so-called life saving treatment for catatonia, melancholia, and mania, can a person in a psychotic state give informed consent? Can a doctor inform about hazards and the efficacy of other treatments when there is insufficient knowledge? Is it ethical to subject a person to a potentially damaging treatment
against their will? Does only clinical solution.
anyone need ECT? ECT is
never
the
With respect to consent, Joseph Heller might have said, "You’d have to be mad to say ’Yes’." Perhaps people who say "No" are sane, but they are deemed incompetent to refuse. A catch 22 that is resolved by the phrase "doctor knows best". In ECT, high electrical currents (to produce convulsions) are associated with memory problems. Young skulls have a lower electrical resistance and for the same electrical charge will be exposed to a higher current than older skulls. Teenagers in the UK do not receive a minimum fit-inducing charge because the technology has not been imported from the USA. Do psychiatrists use ECT safely and appropriately? Anecdotes of misuse and damage abound. There was nothing to stop a consultant from administering ECT to a 6year-old boy with Gilles de la Tourette’s syndrome. Another used the Mental Health Act to override the objections of parents of a girl who clearly had post-traumatic stress disorder after a gang rape. Research has shown that ECT was used only sixty times in a decade to treat minors. That research did not include teenagers who were admitted to acute adult psychiatric wards by psychiatrists who use ECT
routinely. I hope that rational argument will bring about the following changes. ECT should not be given to patients aged under 16 years. ECT should be given to 16-20-year-olds
Ashwood Centre,
Woking, Surrey GU22 7JR, UK
Placebos in medicine SiR-Your series focusing on placebos marks the renewed interest of the profession in this subject. Although most contributions were excellent I was disappointed by Joyce’s report of placebo and complementary medicine (Nov 5, p 1279). For instance, the German word for complementary medicine is not, as Joyce states, Nicht-Schulmedizin but Auf3enseitermedizin (outsider medicine), chelation therapy is not oral, Kirlian-photography and iridology are not therapies but diagnostic methods, and the Kleijnen paper on homoeopathy is not a meta-analysis (even though it is described as such in its abstract). More importantly Joyce sets highly questionable criteria for research into complementary medicine. He claims that trials should not necessarily be placebo-controlled, randomised, or patient blind because "patients, to a large extent, select treatments and doctors themselves". Imagine a trial of, say, acupuncture to prevent migraine, in which patients are not randomised but self-selected to have no acupuncture, placebo (sham) intervention is incorporated, and no attempt is made to blind patients towards the type of therapy. Because of the complex nature of the placebo effect it is quite foreseeable that with such a design acupuncture would be perceived as effective irrespective of whether or not it is better than a sham treatment. If such a study were used as proof for any treatment it would fall short of being bad science. An issue untouched by Joyce might have been more fruitful to cover: are there elements in (complementary) therapy which enhance the placebo effect? Candidates are (a) time spent with a given patient, (b) empathy, (c) exotic flair, (d) invasiveness, and (e) individualisation of treatment. If it is true that complementary medicine is especially good at inducing a placebo response (this is a speculation that needs to be tested by research) then surely mainstream medicine would be well advised to identify the aspects involved and make the best possible use of them? Therefore (and for other reasons) it is in my view relevant to answer the question, are complementary therapies better than placebo interventions or not? E Ernst Centre for Complementary Health Studies,
University of Exeter,
Exeter EX2 4NT, UK
SiR-Now we have found the solution to the problem: we eliminate all words that might clearly describe medieval relicts of quackery and give them a new namecomplementary medicine. This is a typical kind of manipulation by semantics by which Joyce and several others (especially in my country) try to change unconventional treatments into something valuable to cure patients. Readers of The Lancet should read very carefully what Joyce has listed under the heading "some
merely
65
2-4%
*M Lertzman, M
Kryger
Section of Respiratory Medicine, and Sleep Disorders Centre, St Boniface General Hospital, Winnipeg, Manitoba, Canada R2H 2A6
1
2
Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disorder breathing among middle-aged adults. N Engl J Med 1993; 328: 1230-35. Sleep apnea, sleepiness and driving risk. Official statement of American Thoracic Society. Am J Respir Cnt Care Med 1994; 150: 1463-73.
3 4 5
George C, Nickerson PW, Hanly PJ, Millar TW, Kryger MH. Sleep apnoea patients have more automobile accidents. Lancet 1987; ii: 447. Findley L, et al. Automobile accidents in patients with obstructive sleep apnea. Am Rev Respir Dis 1988; 138: 337-40. Kryger M, Roth T, Dement W. Pnnciples and practice of sleep medicine, 2nd ed. Philadelphia: WB Saunders, 1994.
Aromagram for antibiotic activity SIR-The use of aromagrams provides a rapid visual method show the individual characteristics of different wines. We have adapted this method to illustrate the spectrum of activity of antibiotics against groups of bacteria that are important in defined clinical situations. For the purpose of this exercise, segment sizes were based on published frequencies of bacterial isolation 1,2 and the shaded areas were constructed with percentage sensitivity of isolates from a reference text,3 although these data do not necessarily accord with our local experience. The figure shows an example for community-acquired to
(amoxycillin) versus hospital-acquired (amoxycillin and gentamicin) pneumonia. The useful activity of amoxycillin in pneumonias of different aetiology is immediately apparent, as is the benefit and possible weakness in combined amoxycillin/gentamicin therapy for hospitalacquired infection. In addition to showing the role of individual antibiotics, the method clarifies the rational choice of second line therapy and is a flexible presentation method for discussing the value of antibiotic combinations when images can be superimposed with the use of projection acetates, although clearly they cannot describe antibiotic interactions such as synergy or antagonism. 64
Figure: An antibiograph to display the efficacy of amoxycillin (amox) in community-acquired pneumonia (CAP) and amoxycillin and gentamicin (gent) in hospital-acquired pneumonia (HAP) Each segment size based on frequency of bacterial isolation; the more active the drug against that group of isolates the greater the shading within that segment. Once the data had been assembled, each antibiograph was drawn in roughly 15-20 min with Harvard Graphics 3.0 on Opus Personal Computer. S pneumoniae= Streptococcus pneumoniae; M catarrhalis=Moraxella catarrhalis; S aureus=Staphylococcus aureus; E co/i=Escherichia coli; P aeruginosa=Pseudomonas aerugmosa.
These charts were used as the basis for a recent discussion on the use of antibiotics in our intensive care unit. We were impressed by their ability to convey patterns of antibiotic susceptibility rapidly and effectively. They are
to produce with computer graphics packages and could be especially useful when adapted to local patterns of bacterial isolation and sensitivity; sets could be produced for rapid reference on the wards to reinforce antibiotic policies. This method of data presentation might be very useful for students or a general medical audience to whom traditional tables of antibiotic minimum inhibitory concentration values remain a barrier to understanding.
simple
*A F Maggs, G
Phillips
Department of Medical Microbiology, University of Dundee, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
only if there are facilities to ensure that a minimum fitinducing charge is used. All ECT should be conducted under licence issued by regional independent panels. A licence would be issued to a consultant to allow a set number of treatments within a set period for a specific patient. The consent issue needs unambiguous resolution. Could the General Medical Council offer ethical practice guidelines? Lastly, a national clinical audit could elicit data about use and benefits of ECT, and provide evidence of short-term and long-term problems that would outweigh the benefits of rapid symptom resolution.
Tony Baker 1
2
3
MacFarlane JT, Colville A, Guion A, MacFarlane RM, Rose DH. Prospective study of aetiology and outcome of adult lower-respiratorytract infections in the community. Lancet 1993; 341: 511-14. Bartlett JG, O’Keefe P, Tally FP, Louie TJ, Gorbach SL. Bacteriology of hospital--acquired pneumonia. Arch Intern Med 1986; 146: 868-71. Wiedemann B, Atkinson BA. Susceptibility to antibiotics: species incidence and trends (Ch 26), In: Lorian V, ed. Antibiotics in laboratory medicine, 3rd ed. Baltimore: Williams & Wilkins, 1991.
ECT and young minds SiR-National Association for Mental Health (MIND) seeks the abolition of electroconvulsive therapy (ECT) for children and young people. I support this campaign as a consultant in child and adolescent psychiatry. No body has the power to abolish ECT and the campaign will only succeed if doctors, under the leadership of the Royal College of Psychiatrists, agree to a moratorium on its use. The main difficulties are: (i) the ethics of uninformed consent and compulsory treatment; (ii) risk of brain damage; (iii) misapplication of treatment; and (iv) inadequate knowledge and equipment. There are no controls for the administration of ECT, provided that the patient (or their parents in the case of
minors) gives consent. Although ECT is a so-called life saving treatment for catatonia, melancholia, and mania, can a person in a psychotic state give informed consent? Can a doctor inform about hazards and the efficacy of other treatments when there is insufficient knowledge? Is it ethical to subject a person to a potentially damaging treatment
against their will? Does only clinical solution.
anyone need ECT? ECT is
never
the
With respect to consent, Joseph Heller might have said, "You’d have to be mad to say ’Yes’." Perhaps people who say "No" are sane, but they are deemed incompetent to refuse. A catch 22 that is resolved by the phrase "doctor knows best". In ECT, high electrical currents (to produce convulsions) are associated with memory problems. Young skulls have a lower electrical resistance and for the same electrical charge will be exposed to a higher current than older skulls. Teenagers in the UK do not receive a minimum fit-inducing charge because the technology has not been imported from the USA. Do psychiatrists use ECT safely and appropriately? Anecdotes of misuse and damage abound. There was nothing to stop a consultant from administering ECT to a 6year-old boy with Gilles de la Tourette’s syndrome. Another used the Mental Health Act to override the objections of parents of a girl who clearly had post-traumatic stress disorder after a gang rape. Research has shown that ECT was used only sixty times in a decade to treat minors. That research did not include teenagers who were admitted to acute adult psychiatric wards by psychiatrists who use ECT
routinely. I hope that rational argument will bring about the following changes. ECT should not be given to patients aged under 16 years. ECT should be given to 16-20-year-olds
Ashwood Centre,
Woking, Surrey GU22 7JR, UK
Placebos in medicine SiR-Your series focusing on placebos marks the renewed interest of the profession in this subject. Although most contributions were excellent I was disappointed by Joyce’s report of placebo and complementary medicine (Nov 5, p 1279). For instance, the German word for complementary medicine is not, as Joyce states, Nicht-Schulmedizin but Auf3enseitermedizin (outsider medicine), chelation therapy is not oral, Kirlian-photography and iridology are not therapies but diagnostic methods, and the Kleijnen paper on homoeopathy is not a meta-analysis (even though it is described as such in its abstract). More importantly Joyce sets highly questionable criteria for research into complementary medicine. He claims that trials should not necessarily be placebo-controlled, randomised, or patient blind because "patients, to a large extent, select treatments and doctors themselves". Imagine a trial of, say, acupuncture to prevent migraine, in which patients are not randomised but self-selected to have no acupuncture, placebo (sham) intervention is incorporated, and no attempt is made to blind patients towards the type of therapy. Because of the complex nature of the placebo effect it is quite foreseeable that with such a design acupuncture would be perceived as effective irrespective of whether or not it is better than a sham treatment. If such a study were used as proof for any treatment it would fall short of being bad science. An issue untouched by Joyce might have been more fruitful to cover: are there elements in (complementary) therapy which enhance the placebo effect? Candidates are (a) time spent with a given patient, (b) empathy, (c) exotic flair, (d) invasiveness, and (e) individualisation of treatment. If it is true that complementary medicine is especially good at inducing a placebo response (this is a speculation that needs to be tested by research) then surely mainstream medicine would be well advised to identify the aspects involved and make the best possible use of them? Therefore (and for other reasons) it is in my view relevant to answer the question, are complementary therapies better than placebo interventions or not? E Ernst Centre for Complementary Health Studies,
University of Exeter,
Exeter EX2 4NT, UK
SiR-Now we have found the solution to the problem: we eliminate all words that might clearly describe medieval relicts of quackery and give them a new namecomplementary medicine. This is a typical kind of manipulation by semantics by which Joyce and several others (especially in my country) try to change unconventional treatments into something valuable to cure patients. Readers of The Lancet should read very carefully what Joyce has listed under the heading "some
merely
65