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ALMONERS VERSUS MEDICAL SOCIAL WORKERS
108
stipulated. Obviously this may lead to difficulties in considering the effect of treatment in a serious disorder. Even a 10% reduction in mortality, for instance, would be important. A sequential trial would require a large number of patients to detect such an effect with confidence. The size of the reduction in the number of patients required for a sequential trial as opposed to a non-sequential trial depends on the true difference between the treatments. If the difference is considerable, the number of patients may be reduced by 40% or more; but if the true difference is small, the reduction in numbers is only about 15%.
Sequential analysis will be used increasingly in clinical Reports should contain all the specifications of the analyses, and the implications of these specifications should be generally understood. trials.
Department of Medicine, Queen Elizabeth Hospital, Birmingham, 15.
R. F. FLETCHER.
ALMONERS VERSUS MEDICAL SOCIAL WORKERS
attention to the pathogenic potential of the haemolytic strain usually regarded as non-pathogenic, and to emphasise that more notice should be taken of this microorganism, which can cause acute pharyngitis4 and may play a part in chronic bronchitis similar to the untypable H. influenzoe. K. S. RODAN.
JAUNDICE IN A PATIENT TAKING NORETHISTERONE COMPOUND TABLETS
SiR,-Jaundice associated with norethisterone administration has not previously been reported in the U.K.; but Tyler and Olson5 comment briefly on 2 cases in the U.S.A. A young woman, awaiting surgery for mitral stenosis, was prescribed ’Anovlar’ (a compound tablet of norethisterone 4 mg. and ethinyl oestradial 0-05 mg.) for contraceptive purposes. The tablet
was
taken
cyclically in
the usual scheme for ovula-
answer to Dr. Sowry (Dec. 19) is that it is late to protest over the change of name of years almoners to medical social workers (M.S.W.).
SIR, The too
The principal reason is that the professional training undertaken by M.s.w.s demands a wider view of their function in the treatment of the whole patient. It is no longer enough to regard them as donators of alms or, worse still, as a means of clearing a much-wanted bed. A constant complaint in the medical press is that the Health Service does not properly or fully utilise our professional training. The move of the M.s.w.s is prompted by similar reasons, and here the medical profession is in the position of
putting this right.
Admittedly, the term "medical social worker " is too long; but, if its use brings some general insight into their function in the hospital, it will serve its purpose. M. P. WALSH.
Surbiton, Surrey.
PATHOGENICITY OF HÆMOPHILUS INFLUENZÆ
SIR,-In my letter (Nov. 14) I omitted to state in the first paragraph the site to which my comments referred. I should have thought that it was clear from the subsequent text that I was concerned with findings in sputa and throat swabs. I can assure Dr. Darrell (Dec. 12) and Dr. Turk (Dec. 26) that I have seen cases of meningitis and other pyogenic infections caused by H. influenzoe. The
point of my letter has largely been missed by both. I was impressed by the number of throat swabs and sputa which grew the hasmolytic type of the hamiophilus group, not infrequently in pure culture on blood-agar, and surprised that, when discussing it with some of my colleagues, they had seldom met it. I therefore assumed that it might have escaped recognition. I agree with Dr. Turk and Dr. Darrell that most of these bacteria would be classified as H. parainfluenzae and few as H. hamolyticus on their x and v dependencies, but recently Butlerthrew some doubt on these classifications. So far as I can see, no work has been published on the antigenic structure of these hasmolytic strains and its relation to pathogenicity, although, according to Alexander2 some produce capsules. The same worker states, except for its rare occurrence as a cause of sub-acute bacterial endocarditis, no pathogenic role is recognised ". Sensitivity tests were routinely done with discs, the penicillin being 5 units, and the cloxacillin discs 5 flg. As I read it, Barber and Garrod3 did not test H. parainfluenzae and referred to this strain only in connection with endocarditis. Far from suggesting that the hsemophilus group is non-pathogenic, the purpose of my letter was to draw "
1. Butler, L. O. J. gen. Microbiol. 1962, 29, 189. 2. Alexander, H. E. in Bacterial and Mycotic Infection in Man (edited by R. J. Dubos); p. 481. Philadelphia, 1958. 3. Barber, M., Garrod, L. P. Antibiotics and Chemotherapy. Edinburgh, 1963.
tion inhibition, and halfway through the second cycle clinical jaundice became obvious. The accompanying figure shows the onset of symptoms closely related to the ingestion of anovlar and the subsequent course of the illness. During the first course of anovlar the patient experienced nausea and vomiting, which she described as being " like morning sickness of pregnancy ". After completion of this first course the symptoms disappeared, and menstrual " bleeding occurred. In the first few days of the second course the patient noted some itchiness, which was followed by an itchy blotchy urticarial eruption, notably over the upper chest and back. This was immediately followed by the onset of jaundice with dark urine and pale stools. The patient persisted to the end of the second course of anovlar, and thus took a total of 40 "
tablets. There had been no contact with cases of infective hepatitis, and the patient had had no injections in the preceding six months. She was taking digoxin (0-25 mg. b.d.) but had taken On admission she was severely jaundiced, no other drugs. and the liver edge was just palpable and was tender at the right costal margin. Urobilinuria and bilirubinuria were both present. Liver-function tests suggested an obstructive jaundice with slight cellular damage. Normal stool pigmentation returned after two weeks. The depth of jaundice fluctuated to a greater extent than the plasmabilirubin levels indicated. Plain X-ray of abdomen and, later, cholecystography did not reveal any gallstones, and the gallbladder showed good function. The Paul-Bunnell test was negative. Lactate dehydrogenase isoenzymes showed a normal pattern, and, just before the patient’s discharge, bromsulphthalein retention was found to be less than 5%. Mitral valvotomy was successfully performed six months 4. 5.
Pittman, M. J. Bact. 1953, 65, 750. Tyler, E. T., Olson, H. J. J. Amer. med. Ass. 1959, 169, 1843.
stipulated. Obviously this may lead to difficulties in considering the effect of treatment in a serious disorder. Even a 10% reduction in mortality, for instance, would be important. A sequential trial would require a large number of patients to detect such an effect with confidence. The size of the reduction in the number of patients required for a sequential trial as opposed to a non-sequential trial depends on the true difference between the treatments. If the difference is considerable, the number of patients may be reduced by 40% or more; but if the true difference is small, the reduction in numbers is only about 15%.
Sequential analysis will be used increasingly in clinical Reports should contain all the specifications of the analyses, and the implications of these specifications should be generally understood. trials.
Department of Medicine, Queen Elizabeth Hospital, Birmingham, 15.
R. F. FLETCHER.
ALMONERS VERSUS MEDICAL SOCIAL WORKERS
attention to the pathogenic potential of the haemolytic strain usually regarded as non-pathogenic, and to emphasise that more notice should be taken of this microorganism, which can cause acute pharyngitis4 and may play a part in chronic bronchitis similar to the untypable H. influenzoe. K. S. RODAN.
JAUNDICE IN A PATIENT TAKING NORETHISTERONE COMPOUND TABLETS
SiR,-Jaundice associated with norethisterone administration has not previously been reported in the U.K.; but Tyler and Olson5 comment briefly on 2 cases in the U.S.A. A young woman, awaiting surgery for mitral stenosis, was prescribed ’Anovlar’ (a compound tablet of norethisterone 4 mg. and ethinyl oestradial 0-05 mg.) for contraceptive purposes. The tablet
was
taken
cyclically in
the usual scheme for ovula-
answer to Dr. Sowry (Dec. 19) is that it is late to protest over the change of name of years almoners to medical social workers (M.S.W.).
SIR, The too
The principal reason is that the professional training undertaken by M.s.w.s demands a wider view of their function in the treatment of the whole patient. It is no longer enough to regard them as donators of alms or, worse still, as a means of clearing a much-wanted bed. A constant complaint in the medical press is that the Health Service does not properly or fully utilise our professional training. The move of the M.s.w.s is prompted by similar reasons, and here the medical profession is in the position of
putting this right.
Admittedly, the term "medical social worker " is too long; but, if its use brings some general insight into their function in the hospital, it will serve its purpose. M. P. WALSH.
Surbiton, Surrey.
PATHOGENICITY OF HÆMOPHILUS INFLUENZÆ
SIR,-In my letter (Nov. 14) I omitted to state in the first paragraph the site to which my comments referred. I should have thought that it was clear from the subsequent text that I was concerned with findings in sputa and throat swabs. I can assure Dr. Darrell (Dec. 12) and Dr. Turk (Dec. 26) that I have seen cases of meningitis and other pyogenic infections caused by H. influenzoe. The
point of my letter has largely been missed by both. I was impressed by the number of throat swabs and sputa which grew the hasmolytic type of the hamiophilus group, not infrequently in pure culture on blood-agar, and surprised that, when discussing it with some of my colleagues, they had seldom met it. I therefore assumed that it might have escaped recognition. I agree with Dr. Turk and Dr. Darrell that most of these bacteria would be classified as H. parainfluenzae and few as H. hamolyticus on their x and v dependencies, but recently Butlerthrew some doubt on these classifications. So far as I can see, no work has been published on the antigenic structure of these hasmolytic strains and its relation to pathogenicity, although, according to Alexander2 some produce capsules. The same worker states, except for its rare occurrence as a cause of sub-acute bacterial endocarditis, no pathogenic role is recognised ". Sensitivity tests were routinely done with discs, the penicillin being 5 units, and the cloxacillin discs 5 flg. As I read it, Barber and Garrod3 did not test H. parainfluenzae and referred to this strain only in connection with endocarditis. Far from suggesting that the hsemophilus group is non-pathogenic, the purpose of my letter was to draw "
1. Butler, L. O. J. gen. Microbiol. 1962, 29, 189. 2. Alexander, H. E. in Bacterial and Mycotic Infection in Man (edited by R. J. Dubos); p. 481. Philadelphia, 1958. 3. Barber, M., Garrod, L. P. Antibiotics and Chemotherapy. Edinburgh, 1963.
tion inhibition, and halfway through the second cycle clinical jaundice became obvious. The accompanying figure shows the onset of symptoms closely related to the ingestion of anovlar and the subsequent course of the illness. During the first course of anovlar the patient experienced nausea and vomiting, which she described as being " like morning sickness of pregnancy ". After completion of this first course the symptoms disappeared, and menstrual " bleeding occurred. In the first few days of the second course the patient noted some itchiness, which was followed by an itchy blotchy urticarial eruption, notably over the upper chest and back. This was immediately followed by the onset of jaundice with dark urine and pale stools. The patient persisted to the end of the second course of anovlar, and thus took a total of 40 "
tablets. There had been no contact with cases of infective hepatitis, and the patient had had no injections in the preceding six months. She was taking digoxin (0-25 mg. b.d.) but had taken On admission she was severely jaundiced, no other drugs. and the liver edge was just palpable and was tender at the right costal margin. Urobilinuria and bilirubinuria were both present. Liver-function tests suggested an obstructive jaundice with slight cellular damage. Normal stool pigmentation returned after two weeks. The depth of jaundice fluctuated to a greater extent than the plasmabilirubin levels indicated. Plain X-ray of abdomen and, later, cholecystography did not reveal any gallstones, and the gallbladder showed good function. The Paul-Bunnell test was negative. Lactate dehydrogenase isoenzymes showed a normal pattern, and, just before the patient’s discharge, bromsulphthalein retention was found to be less than 5%. Mitral valvotomy was successfully performed six months 4. 5.
Pittman, M. J. Bact. 1953, 65, 750. Tyler, E. T., Olson, H. J. J. Amer. med. Ass. 1959, 169, 1843.