- Email: [email protected]
Beta-blockade withdrawal
THE LANC ET, OCT O BE R
25, 1975
819
BETA-BLOCKADE WITHDRAWAL SIR,-Your editorial (Sept. 27, p. 592) commenting on the work of Miller and his colleagues I emphasises the serious dangers of sudden withdrawal of beta-blockers in patients with ischremic heart-disease and concludes that these drugs should not be withdrawn abruptly. Although there are a number of possible explanation s, the most likely occurrence is sympathetic overactivity following release of beta-blockade with a resultant increase in heart -rate, cardiac contracility, and myocardial oxygen consumption; furthermore, the increase in sympathetic activity may lead to [ifethreatening ectopic arrhythmias. In support of thi s I would like to draw attention to the occurrence of a withdrawal syndrome in three patients following the sudden cessation of propranolol which was being admini stered in high doses (2000 mg, 1440 mg, and 960 mg daily) for the treatment of hypertension. 2 The syndrome, which was in man y respect s indistinguishable from florid thyrotoxicosis, was characterised by distress of such severity as to make the patient seek hospital attention-tenseness, anxiety, palpitations, and excessive perspiration. On examination the patients were anxious, restle ss, and worried, and there was a tachycardia and tremor of the outstretched hands which were warm and moist. These symptoms occurred within a week of stopping propranolol and were relieved within 24 hours by as little as a quarter of the original dose. These manifestations can only have been caused by sympathetic overactivity, and if this were to occur-even in a less dramatic form because of lower dosage--in patient s with ischremic heart-disease the effects on a diseased myocardium might well be catastrophic. I strongly endorse your plea for gradual withdrawal of all beta-adrenergic blocking drugs, and I am tempted to suggest that gradual withdrawal of drugs should be a general pharmacological principle. 18 Ely Place, Dublin 2, Eire.
EOIN
T.
O'BRIEN
PATHOLOGICAL SPECIMENS IN THE POST SJR,-The Post Office welcomes the concern expre ssed by Dr Simpson and Professor Zuckerman (Oct. 11, p. 70 1) about poor packaging of pathological specimens sent through the post. They echo misgivings which have been voiced to the Department of Health and Social Security and other bodies about the casual way some medical, veterinary, and other scientific workers despatch potentially dangerous sub stances. To avoid risk to the people who handle the se packages, the British Post Office has stringent requirements-and there are equally strict international regulations--for the posting and packaging of such materials. Perhaps I may remind your readers of what they are. First, pathological specimens may not normally be sent by post, unless they are sent for examination or analysis to a recognised medical authority or laboratory, or to a med ical or dental practitioner or veterinary surgeon. T hey ma y only be sent by first-class letter post and the y have to be packaged and labelled in a prescribed manner. Any packet found in the parcel post, or found in the letter post not properly packed and labelled, will be destroyed with all wrappings and enclosures. Persons who send dangerous liquids or substances by post without complying with the requirements for packaging and labelling are liable to prosecution. Requirements for packaging pathological specimens are : The liquid or substance must be enclosed in a container which is hermetically sealed or otherwise securely closed. The container must be placedin a strong wooden or metal case (any I. Miller. R. R., Olsen, H. G., Amsterdam. E. A., Ma son, D. T. Ne ws En g l. ] .Med. 1975,293, 4t6. . 2. O'Brien, E. T ., MacK inn on, J. Br. H eart]. 1972,34,1042.
other case must be approved by the Post Office before use) in such a way that it cannot shift about. The container must be surrounded by enough absorbent materialsawdust or Callan wool-Io prevent any leakage from the package if the container became damaged. The outside of the package must be marked "Fra gile With Care" and "Pathological Specimen" . Any organisation in the United Kingdom intending to send pathological specimens through the post should first send samples of the containers they propose to use to Postal Headquarters (PMkl ), St Martin's Ie Grand, London ECIA IHQ, to confirm that they are acceptable. Organisations in other countries should consult their own postal authority. Finally, if laboratories do receive packages of this kind which have been damaged in transit, we ask them to try to preserve them as far as they are able in as near as possible the condition in which the y arrive, and inform their local Head Postmaster. This will help the Post Office in its efforts to stop dangerous materials being sent by post in a way which could harm others. Postal Head qu art er s, St j\1a rtin's Ie G rand, London EC IA IHQ.
J. C. JEFFR EY Principal Medical Officer (Posts)
FAMILY-PLANNING SERVICES SJR,-With reference to your editorial of Oct. 11 (p.694 ), we should like to point out that the Government had no need "to win, by a touch of gold .. . the cooperation of . . . tho se hospital consultants who are concerned with contraception and sterilisation" . Contraception and sterilisation are alread y widely available in the Health Service . In the Grampian Health Board Area in 1974, 1500 sterilisations were performed mostly on social grounds, and it will cost the Board at least £40 000 to remunerate doctors for performing a similar number next year. There is no question of extra work being involved, and for the profession's negotiators to pretend that there is, is dishonest . We believe the situation 10 be similar in many other parts of Britain. This scheme is, therefore, a catastrophic waste of money which the Health Ser vice can ill afford. In addition, this scheme will have man y damaging effects: firstly, women ma y not receive the objective counselling the y have the right to expect in matters of family planning if some of the alternatives which a doctor may suggest involve a large personal fee for him; secondly, item-of-service payments of this magnitude will certainly prove divisive within the medical profession with ill-feeling and dissension about the administration of the scheme between units and within units; also, man y more arduous, time-consuming, or highly skilled aspects of our work will remain unrewarded and may suffer as a result; there will be a trend towards performance of sterilisation (and reversal), operations in clinical situations where inadequate facilities or expertise are available; the teaching of medical students and nurses that fertility control is an integral part of medical care will be made difficult , if contraception and sterilisation are adm inistratively considered matters for which special payments must be made. It seems especially inappropriate that this ridiculous scheme has been negotiated at the very time when the Health Service has been reorganised to tr y to pro vide integrated med ical care for the public . We are absolutel y opposed to any item-of-service payment for family-plann ing services, and hope that the scheme will be reconsidered. Aberdeen Maternity Hospital . Corn hill Road. Aberdeen. AB9 2ZA.
MARI ON H. HAL L ALLANTEMPLETON
SIR,-Your annotation gives a fa ir summary of the new item-of-service extras negotiated for hospital doctors. In common with several of my colleagues in this department I
25, 1975
819
BETA-BLOCKADE WITHDRAWAL SIR,-Your editorial (Sept. 27, p. 592) commenting on the work of Miller and his colleagues I emphasises the serious dangers of sudden withdrawal of beta-blockers in patients with ischremic heart-disease and concludes that these drugs should not be withdrawn abruptly. Although there are a number of possible explanation s, the most likely occurrence is sympathetic overactivity following release of beta-blockade with a resultant increase in heart -rate, cardiac contracility, and myocardial oxygen consumption; furthermore, the increase in sympathetic activity may lead to [ifethreatening ectopic arrhythmias. In support of thi s I would like to draw attention to the occurrence of a withdrawal syndrome in three patients following the sudden cessation of propranolol which was being admini stered in high doses (2000 mg, 1440 mg, and 960 mg daily) for the treatment of hypertension. 2 The syndrome, which was in man y respect s indistinguishable from florid thyrotoxicosis, was characterised by distress of such severity as to make the patient seek hospital attention-tenseness, anxiety, palpitations, and excessive perspiration. On examination the patients were anxious, restle ss, and worried, and there was a tachycardia and tremor of the outstretched hands which were warm and moist. These symptoms occurred within a week of stopping propranolol and were relieved within 24 hours by as little as a quarter of the original dose. These manifestations can only have been caused by sympathetic overactivity, and if this were to occur-even in a less dramatic form because of lower dosage--in patient s with ischremic heart-disease the effects on a diseased myocardium might well be catastrophic. I strongly endorse your plea for gradual withdrawal of all beta-adrenergic blocking drugs, and I am tempted to suggest that gradual withdrawal of drugs should be a general pharmacological principle. 18 Ely Place, Dublin 2, Eire.
EOIN
T.
O'BRIEN
PATHOLOGICAL SPECIMENS IN THE POST SJR,-The Post Office welcomes the concern expre ssed by Dr Simpson and Professor Zuckerman (Oct. 11, p. 70 1) about poor packaging of pathological specimens sent through the post. They echo misgivings which have been voiced to the Department of Health and Social Security and other bodies about the casual way some medical, veterinary, and other scientific workers despatch potentially dangerous sub stances. To avoid risk to the people who handle the se packages, the British Post Office has stringent requirements-and there are equally strict international regulations--for the posting and packaging of such materials. Perhaps I may remind your readers of what they are. First, pathological specimens may not normally be sent by post, unless they are sent for examination or analysis to a recognised medical authority or laboratory, or to a med ical or dental practitioner or veterinary surgeon. T hey ma y only be sent by first-class letter post and the y have to be packaged and labelled in a prescribed manner. Any packet found in the parcel post, or found in the letter post not properly packed and labelled, will be destroyed with all wrappings and enclosures. Persons who send dangerous liquids or substances by post without complying with the requirements for packaging and labelling are liable to prosecution. Requirements for packaging pathological specimens are : The liquid or substance must be enclosed in a container which is hermetically sealed or otherwise securely closed. The container must be placedin a strong wooden or metal case (any I. Miller. R. R., Olsen, H. G., Amsterdam. E. A., Ma son, D. T. Ne ws En g l. ] .Med. 1975,293, 4t6. . 2. O'Brien, E. T ., MacK inn on, J. Br. H eart]. 1972,34,1042.
other case must be approved by the Post Office before use) in such a way that it cannot shift about. The container must be surrounded by enough absorbent materialsawdust or Callan wool-Io prevent any leakage from the package if the container became damaged. The outside of the package must be marked "Fra gile With Care" and "Pathological Specimen" . Any organisation in the United Kingdom intending to send pathological specimens through the post should first send samples of the containers they propose to use to Postal Headquarters (PMkl ), St Martin's Ie Grand, London ECIA IHQ, to confirm that they are acceptable. Organisations in other countries should consult their own postal authority. Finally, if laboratories do receive packages of this kind which have been damaged in transit, we ask them to try to preserve them as far as they are able in as near as possible the condition in which the y arrive, and inform their local Head Postmaster. This will help the Post Office in its efforts to stop dangerous materials being sent by post in a way which could harm others. Postal Head qu art er s, St j\1a rtin's Ie G rand, London EC IA IHQ.
J. C. JEFFR EY Principal Medical Officer (Posts)
FAMILY-PLANNING SERVICES SJR,-With reference to your editorial of Oct. 11 (p.694 ), we should like to point out that the Government had no need "to win, by a touch of gold .. . the cooperation of . . . tho se hospital consultants who are concerned with contraception and sterilisation" . Contraception and sterilisation are alread y widely available in the Health Service . In the Grampian Health Board Area in 1974, 1500 sterilisations were performed mostly on social grounds, and it will cost the Board at least £40 000 to remunerate doctors for performing a similar number next year. There is no question of extra work being involved, and for the profession's negotiators to pretend that there is, is dishonest . We believe the situation 10 be similar in many other parts of Britain. This scheme is, therefore, a catastrophic waste of money which the Health Ser vice can ill afford. In addition, this scheme will have man y damaging effects: firstly, women ma y not receive the objective counselling the y have the right to expect in matters of family planning if some of the alternatives which a doctor may suggest involve a large personal fee for him; secondly, item-of-service payments of this magnitude will certainly prove divisive within the medical profession with ill-feeling and dissension about the administration of the scheme between units and within units; also, man y more arduous, time-consuming, or highly skilled aspects of our work will remain unrewarded and may suffer as a result; there will be a trend towards performance of sterilisation (and reversal), operations in clinical situations where inadequate facilities or expertise are available; the teaching of medical students and nurses that fertility control is an integral part of medical care will be made difficult , if contraception and sterilisation are adm inistratively considered matters for which special payments must be made. It seems especially inappropriate that this ridiculous scheme has been negotiated at the very time when the Health Service has been reorganised to tr y to pro vide integrated med ical care for the public . We are absolutel y opposed to any item-of-service payment for family-plann ing services, and hope that the scheme will be reconsidered. Aberdeen Maternity Hospital . Corn hill Road. Aberdeen. AB9 2ZA.
MARI ON H. HAL L ALLANTEMPLETON
SIR,-Your annotation gives a fa ir summary of the new item-of-service extras negotiated for hospital doctors. In common with several of my colleagues in this department I