- Email: [email protected]
A medical maxim reinstated
Correspondence
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who had been involved in the care of the index patient, and a cleaner responsible for the cubicle of the same patient. Both had a rapid and fatal course. All of these patients were negative for Lassa, Crimean Congo, Marburg, and Ebola viruses; however, PCR identified a new arenavirus in all of the affected patients.1 On Oct 5, another nursing sister who had been involved in the care of patient two became ill with fever, leukopenia, thrombocytopenia, and rash and she also tested positive for the arenavirus. Oral ribavirin was started along with supportive therapy, but the hepatitis and thrombocytopenia worsened and she became confused. Consultations with international colleagues indicated that oral therapy was unlikely to achieve the minimum inhibitory concentrations necessary to eradicate the virus rapidly.2,3 As a consequence, a source of intravenous ribavirin was urgently sought. We managed to find a supply of Virazole 100 g/L from Valeant pharmaceuticals (Aliso Viejo, CA, USA) in the Netherlands who, after substantial delay and at the exorbitant price of US$45 000, agreed to supply a 10-day course to the Morningside Clinic. On initiation of therapy there was a prompt improvement and the patient was subsequently discharged well. We feel that this cost represented pure opportunism by a company exploiting the urgency of the situation. A supply of this drug should be available to WHO to distribute at its discretion and at reasonable cost in times of need. Had this outbreak been in an institution other than a private clinic, access would have been severely limited. Given the devastating effects of this disease, and the potential for significant further spread locally both nosocomially and in the community or even internationally, access should not be restricted by cost or commercial interests. 546
We declare that we have no conflict of interest.
*Guy Antony Richards, Nivesh H Sewlall, Adriano Duse [email protected] Johannesburg Hospital, Johannesburg, Gauteng, South Africa (GAR); Morningside Clinic, Johannesburg, South Africa (NHS); and University of the Witwatersrand School of Pathology, Johannesburg, South Africa (AD) 1
2
3
WHO. New virus from Arenaviridae family in South Africa and Zambia—update. http:// www.who.int/csr/don/2008_10_13/en/index. html (accessed Jan 29, 2009). Bausch DG, Sesay SS, Oshin B. On the front lines of Lassa fever. Emerg Infect Dis 2004; 10: 1889–90. Bausch DG, Demby AH, Coulibaly M, et al. Lassa fever in Guinea—I: epidemiology of human disease and clinical observations. Vector Borne Zoonotic Dis 2001; 1: 269–81.
A medical maxim reinstated Juan Gérvas and colleagues’ laudable Viewpoint (Dec 6, p 1997)1 epitomises an intellectual feature of The Lancet: a succinct and critical analysis of a dominant paradigm in medicine is juxtaposed with an apt reappraisal of a traditional view, endangered in the current Zeitgeist that acclaims the very paradigm. In this case, promotion of clinical prevention, not as sufficiently evidence-based as touted, is counterbalanced by a call for sound clinical judgment against untoward consequences by innumerable preventive activities. Prevention today involves several different vested interests: government policies to restrict healthcare budgets, industry’s eagerness to seize an emerging market, and currently healthy individuals’ beliefs that any disease can be prevented. Meanwhile clinicians are inundated with contradictory guidelines and recommendations to prevent a myriad of diseases. I commend Gérvas and colleagues for their unusual insight in acknowledging individuals’ wishes for immaculate health,2 which are, in my view, exacerbated by widespread consumerism and medicolegal litigiousness.
Under these circumstances, I fear that evidence-based medicine could degenerate into evidence-led defensive medicine, where the value of individual clinical expertise and judgment is dismissed, and, as a result, clinicians are demoralised in their struggle in the real world. Prevention is indeed better than cure for imminent damages to our professional integrity. In this regard, Gérvas and colleagues’ suggested principles for the assessment of various preventive measures, which highlight the importance of ordinary practice and clinical decision-making, are a modern embodiment of the “First do no harm” maxim, and provide an effective prevention of the degradation of our profession. I declare that I have no conflict of interest.
Yuji Sato [email protected] Centre for Clinical Research, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan 1
2
Gervas J, Starfield B, Heath I. Is clinical prevention better than cure? Lancet 2008; 372: 1997–99. Elliot C. Better than well: American medicine meets the American dream. New York: W W Norton, 2003.
Department of Error Gilbert M, Fosse E. Inside Gaza’s Al-Shifa hospital. Lancet 2009; 373: 200–02—In figure A of this Special Report (Jan 17), the number of children killed due to the Israeli assault on Jan 7 should be 172. The figure legend should read: “The numbers of children and women killed (A) or injured (B) by Israeli assault in Jan 4–12, 2009.” Similarly, the heading for figure A should read: “Number of children and women killed due to Israeli assault” and the heading for figure B should read: “Number of children and women injured due to Israeli assault”. The first paragraph of the Casualties section on p 202 should read: “As of Jan 12 at 4 pm, Israeli attacks on Gaza have injured more than 4250 people and killed 910—41% of these deaths are women and children (see figure). 1789 children (younger than 18 years) were casualties in the conflict, 292 of whom have been killed, and 1497 of whom have been wounded, by Israeli military forces.”
www.thelancet.com Vol 373 February 14, 2009
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who had been involved in the care of the index patient, and a cleaner responsible for the cubicle of the same patient. Both had a rapid and fatal course. All of these patients were negative for Lassa, Crimean Congo, Marburg, and Ebola viruses; however, PCR identified a new arenavirus in all of the affected patients.1 On Oct 5, another nursing sister who had been involved in the care of patient two became ill with fever, leukopenia, thrombocytopenia, and rash and she also tested positive for the arenavirus. Oral ribavirin was started along with supportive therapy, but the hepatitis and thrombocytopenia worsened and she became confused. Consultations with international colleagues indicated that oral therapy was unlikely to achieve the minimum inhibitory concentrations necessary to eradicate the virus rapidly.2,3 As a consequence, a source of intravenous ribavirin was urgently sought. We managed to find a supply of Virazole 100 g/L from Valeant pharmaceuticals (Aliso Viejo, CA, USA) in the Netherlands who, after substantial delay and at the exorbitant price of US$45 000, agreed to supply a 10-day course to the Morningside Clinic. On initiation of therapy there was a prompt improvement and the patient was subsequently discharged well. We feel that this cost represented pure opportunism by a company exploiting the urgency of the situation. A supply of this drug should be available to WHO to distribute at its discretion and at reasonable cost in times of need. Had this outbreak been in an institution other than a private clinic, access would have been severely limited. Given the devastating effects of this disease, and the potential for significant further spread locally both nosocomially and in the community or even internationally, access should not be restricted by cost or commercial interests. 546
We declare that we have no conflict of interest.
*Guy Antony Richards, Nivesh H Sewlall, Adriano Duse [email protected] Johannesburg Hospital, Johannesburg, Gauteng, South Africa (GAR); Morningside Clinic, Johannesburg, South Africa (NHS); and University of the Witwatersrand School of Pathology, Johannesburg, South Africa (AD) 1
2
3
WHO. New virus from Arenaviridae family in South Africa and Zambia—update. http:// www.who.int/csr/don/2008_10_13/en/index. html (accessed Jan 29, 2009). Bausch DG, Sesay SS, Oshin B. On the front lines of Lassa fever. Emerg Infect Dis 2004; 10: 1889–90. Bausch DG, Demby AH, Coulibaly M, et al. Lassa fever in Guinea—I: epidemiology of human disease and clinical observations. Vector Borne Zoonotic Dis 2001; 1: 269–81.
A medical maxim reinstated Juan Gérvas and colleagues’ laudable Viewpoint (Dec 6, p 1997)1 epitomises an intellectual feature of The Lancet: a succinct and critical analysis of a dominant paradigm in medicine is juxtaposed with an apt reappraisal of a traditional view, endangered in the current Zeitgeist that acclaims the very paradigm. In this case, promotion of clinical prevention, not as sufficiently evidence-based as touted, is counterbalanced by a call for sound clinical judgment against untoward consequences by innumerable preventive activities. Prevention today involves several different vested interests: government policies to restrict healthcare budgets, industry’s eagerness to seize an emerging market, and currently healthy individuals’ beliefs that any disease can be prevented. Meanwhile clinicians are inundated with contradictory guidelines and recommendations to prevent a myriad of diseases. I commend Gérvas and colleagues for their unusual insight in acknowledging individuals’ wishes for immaculate health,2 which are, in my view, exacerbated by widespread consumerism and medicolegal litigiousness.
Under these circumstances, I fear that evidence-based medicine could degenerate into evidence-led defensive medicine, where the value of individual clinical expertise and judgment is dismissed, and, as a result, clinicians are demoralised in their struggle in the real world. Prevention is indeed better than cure for imminent damages to our professional integrity. In this regard, Gérvas and colleagues’ suggested principles for the assessment of various preventive measures, which highlight the importance of ordinary practice and clinical decision-making, are a modern embodiment of the “First do no harm” maxim, and provide an effective prevention of the degradation of our profession. I declare that I have no conflict of interest.
Yuji Sato [email protected] Centre for Clinical Research, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan 1
2
Gervas J, Starfield B, Heath I. Is clinical prevention better than cure? Lancet 2008; 372: 1997–99. Elliot C. Better than well: American medicine meets the American dream. New York: W W Norton, 2003.
Department of Error Gilbert M, Fosse E. Inside Gaza’s Al-Shifa hospital. Lancet 2009; 373: 200–02—In figure A of this Special Report (Jan 17), the number of children killed due to the Israeli assault on Jan 7 should be 172. The figure legend should read: “The numbers of children and women killed (A) or injured (B) by Israeli assault in Jan 4–12, 2009.” Similarly, the heading for figure A should read: “Number of children and women killed due to Israeli assault” and the heading for figure B should read: “Number of children and women injured due to Israeli assault”. The first paragraph of the Casualties section on p 202 should read: “As of Jan 12 at 4 pm, Israeli attacks on Gaza have injured more than 4250 people and killed 910—41% of these deaths are women and children (see figure). 1789 children (younger than 18 years) were casualties in the conflict, 292 of whom have been killed, and 1497 of whom have been wounded, by Israeli military forces.”
www.thelancet.com Vol 373 February 14, 2009