- Email: [email protected]
Bringing global issues to medical teaching
CORRESPONDENCE
Suture of second-degree perineal tears after childbirth Sir—Over the past two decades, an unexplained trend has arisen in the midwifery profession towards leaving second-degree perineal tears unsutured. In a study at Luton and Dunstable Hospital, Luton, UK, 75% of seconddegree tears were sutured in 1996, but only 52% in 1998.1 This change is not supported by research and is thought to be due to several factors. The increased autonomy of midwives in perineal management and a general move towards non-intervention in midwifery could be a factor. In one report, researchers suggest that parturients themselves may be affecting decisions, or that staff shortages might be a factor. The concern is that there are several potential negative sequelae to nonsuturing. There is debate as to whether healing is prolonged, although midwives report that healing is satisfactory when tears are left unsutured.2 However, risk of infection of an open wound seems greater than for a sutured wound and, therefore, the potential for increased pain exists; although counter arguments suggest the increased risk of infection and pain from placement of foreign material, such as suture, in the tissues. A major concern also exists for the persistence of a weakened pelvic floor, since second-degree tears, by definition, involve the superficial muscles of the pelvic floor and could involve the deep pelvic floor muscles. The evidence for the practice of non-suturing is extremely limited. Workers in a small study compared suturing with non-suturing,3 but the study had several limitations, making findings unsuitable to cause a change in practice. The conclusion of a retrospective study that most women were satisfied with how their perinea had healed when left unsutured was also deemed limited.4 Researchers, in a large randomised controlled study, showed that there were no apparent disadvantages to leaving perineal wounds unsutured,5 but tears involved only the skin layer and not second-degree tears. Until randomised controlled studies of adequate quality can support nonsuture, all second-degree tears should be sutured. Stephen M Wild Bishop Auckland General Hospital, Co Durham, UK 1 2
Sandland D. Perineal tears: audit and proposed RCT. Pract Midwife 1999; 2: 32. Steen M. The abused perineum. Br J Midwifery 1998; 6: 428–29.
3 4
5
Head M. Dropping stitches. Nurs Times 1993; 89: 64–65. Clement S, Reed B. To stitch or not to stitch: a long term follow up study of women with unsutured perineal tears. Pract Midwife 1999; 2: 20–28. Gordon B, Mackrodt C, Fern E, Truesdale A, Ayers S, Grant A. The Ipswich Childbirth Study, 1: a randomised evaluation of two stage postpartum perineal repair leaving the skin unsutured. Br J Obstet Gynaecol 105: 435–40.
disease, making it very likely that he had hypertension, and putting him at a high risk of early stroke. David Bateman Royal United Hospital, Combe Park, Bath BA1 3NG, UK (e-mail: [email protected]) 1
McManus IC. Charles Dickens: a neglected diagnosis. Lancet 2001; 358: 2158–61.
Dickens: an alternative diagnosis
Bringing global issues to medical teaching
Sir—I McManus (Dec 22, p 2158)1 proposes that the novelist Charles Dickens had a right parietal or temporoparietal disorder. I think the symptoms described by McManus suggest an alternative neurological diagnosis. The nature of Dickens’ initial visual symptoms in 1868 are unclear, but his description of the same disorder that recurred in March 1870 leaves little doubt that Dickens was describing a recurrent temporary left homonymous hemianopia, not spatial neglect. Patients with spatial neglect are unaware of their deficit. A homonymous hemianopia localises the disorder to the right occipital cortex, not the temporoparietal area. These episodes were due to transient ischaemic attacks in the right posterior circulation. In 1868 Dickens also had temporary left-sided motor symptoms and giddiness, which suggest another vascular episode in the right posterior circulation. Unfortunately, 2 years later, Dickens had a fatal stroke, possibly in the same area. Dickens’ left-sided sensory symptoms began in 1865, without a preceding stroke. If the cause was neurological, it is more likely that the symptoms were due to central post-stroke pain arising from a thalamic infarct, the classic site for stroke that produces post-stroke pain of this kind. The lateral thalamus is also supplied by branches of the posterior circulation. Dickens’ denial of his physical complaints has no neurological explanation. Dickens’ friend Yates is scathing of Dickens, who ignored his symptoms and continued working; however, it is difficult to see what else he could have done. The clinical picture is, therefore, more simply and concisely explained by premature atherothromboembolic disease in the posterior circulation, causing recurrent transient ischaemic attacks and, finally, a fatal stroke, perhaps due to hypertension. McManus reports that Dickens had signs of heart disease, possibly precipitated by renal
Sir—Catherine Bateman and colleagues (Nov 3, p 1539)1 address the necessity for educating medical students about global health issues. However, they neglect a more important perspective— students and physicians must also acquire cross-cultural attitudes, skills, and knowledge that affect directly their clinical decision making. We agree that violence is an international health issue, that African countries need expensive AIDS drugs, that genome mapping must not be used to produce biological weapons for use against specific ethnic groups, and that physicians in training will benefit from global health knowledge. However, our perspective is that of collaborators at an Israeli-US medical school, in which a compulsory course in intemational health and medicine is added to the normal US curriculum.2 The course combines international health issues with practical training in cross-cultural communications and clinical clerkships in Africa, Asia, the Middle East, and in under-served communities in the USA. The focus is mainly on the global physician in her traditional role as clinical decisionmaker and only secondarily as a contributor to health policy. This view emphasises both what medicine in developed countries can do for developing countries, and what developing countries can teach developed ones. Attitudes appropriate for working across national boundaries are just as useful for working across cross-cultural boundaries within a particular European or US city. Working in developing areas that lack advanced technology requires honing of clinical skills that will improve clinical decision making anywhere. Learning about the health effects of army violence will affect a physicians’ ability to better cope with the developed world’s murder epidemic. Learning to use available drugs effectively is a critical skill in the US’s wasteful health economy. From this perspective, a physician trained in global health and medicine who never leaves his or her
THE LANCET • Vol 359 • April 6, 2002 • www.thelancet.com
1253
For personal use. Only reproduce with permission from The Lancet Publishing Group.
CORRESPONDENCE
US or European office will benefit from global medicine training. There is another way of understanding the message of Gro Harlem Brundtland, WHO’s director general, that the process of globalisation has made the disregarding of desperate conditions on another continent impossible. We must realise that all of us, in London, Tel Aviv, and New York, as well as in Lilongwe, Addis Ababa, and Lahore, live on another continent. The great lesson of globalisation is for countries from all continents to collaborate to improve health everywhere. *Carmi Z Margolis, Richard J Deckelbaum, Yaakov Henkin, Michael Alkan *MD Program in International Health and Medicine, Ben-Gurion University of the Negev, PO Box 653, Beer-Sheva 84105, Israel; and Columbia University Health Sciences, Columbia University, NY, USA 1
2
Bateman C, Baker T, Hoornenborg E, Ericsson U. Bringing global issues to medical teaching. Lancet 2001; 358: 1539–42. Urkin J, Alkan M, Henkin Y, Baram S. Integrating global health and medicine into the medical curriculum. Educ Health 2001; 14: 427–31.
Avoiding the point Sir—In an attempt to reduce the frequency of inoculation accidents and the recognised sequelae of seroconversion with blood-borne viruses, several devices have been developed to protect health-care workers from sharps injury. In November, 2000, the US Congress passed the Needlestick Safety and Prevention Act,1 calling on health-care providers to assess needlesafe devices and to supply them for their employees. The UK National Health Service in Scotland has also produced clear recommendations to improve the awareness of needlestick injuries and how to assess needle-safe and needleless systems.2 In the UK, health-care providers should implement measures perceived as necessary under existing health and safety laws3,4 to reduce risk of exposure to blood-borne diseases and to put preventive measures in place. However, no formal assessment of needle-safe devices has been made, nor is there guidance on which areas should be prioritised. Do we need to follow the lead of the US, in passing specific legislation to ensure protection for all health-care workers from needlestick injuries? The UK has well developed procedures for the reporting of inoculation accidents and on the
1254
subsequent management of injuries sustained. The need for legislation should reflect overall risk, however the incidence of these accidents on a national basis is currently unclear. In the University Hospital Birmingham NHS Trust, during 2000, 195 inoculation incidents were reported. This number occurred despite rigorous education and increased awareness campaigns aimed at prevention of these accidents. Does this number indicate the true size of the problem? We also looked at the actual rate of under-reporting of needlestick injuries, by interviewing 84 staff, including junior doctors, nurses, and phlebotomists. The reasons for nonreporting of injuries were also noted. 35 of the 84 staff had received 78 needlestick injuries during the year. Of these, 21 (60%) staff did not report some or all of the instances, giving an under-reporting rate of 65%. The overall number of incidents associated with venesection was 25 (32%); 18 (23%) were associated with intravascular catheters; and 35 (45%) were from other sources. The most common reason for not reporting the incident was that it was judged low risk. A similar study in the US reported a 75% annual underreporting rate.5 The frequency of inoculation incidents may, therefore, be much higher than the standard reported numbers suggest. Since more than half the injuries occurred when taking blood or inserting intravascular catheters, protection of health-care workers must focus initially on these procedures. Appropriate assessment of the available needle-safe devices is needed2 so that national guidance, perhaps involving specific legislation, can be investigated. *D K Dobie, T Worthington, M Faroqui, T S J Elliott Departments of *Clinical Microbiology and Anaesthetics, University Hospital Birmingham NHS Trust, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, UK 1 2
3
4
5
Safety and Prevention Act, HR 5178, 106th Congress, 2nd Session, 2000. Short Life Working Group on Needlestick Injuries in NHSScotland. Needlestick injuries: sharpen your awareness—towards a safer healthier workplace needlestick injuries in the NHSScotland. Edinburgh: Scottish Executive, 2001. The control of substances hazardous to health regulations 1999 (S1 1999/437). London: Stationery Office, 1999. The management of health and safety at work regulations 1999 (S1 1999/3242). London: Stationery Office, 1999. Hamory BH. Under-reporting of needlestick injuries in a university hospital. Am J Infect Control 1983; 11: 174–77.
Avoiding unnecessary risks to our children Sir—Infantile accidental acute intoxication is always the final consequence of a chain of events that includes, among others, child-related factors (oral phase of psychological development, imitation of adults behaviours, infinite curiosity), parent-related factors (nonadequate storage place for potentially toxic products, distraction when watching over children), and toxic-related factors (organoleptic properties, attractive packaging). During 1999, the US Association of Poison Control Centers reported 1 148 693 accidental poisonings in children younger than age 6 years, 42% of which were due to the ingestion of pharmaceutical drugs.1 Certainly, thousands of additional near-miss events occur daily. Therefore, every effort addressed to break the aforementioned chain of events will be welcomed. In the past few months we have noted that some pharmaceutical companies give sweets to doctors as little gifts, which are put into boxes that are almost identical to the packaging of their advertised drugs. Only small warnings, which take up less than 5% of the boxes’ surface, indicate the real content. Inside, the packaging is sometimes a copy of the drug blister packs. Several of us bring these presents home, where our children can see us eating these sweets. One of the most important issues of pharmaceutical industry is to make their products as safe as possible. They spend a large amount of funds to prevent unwanted adverse events and accidental poisonings. This kind of promotional gift goes against such security standards. We believe that this marketing policy must be strongly discouraged to avoid additional unnecessary risks to our children. *Òscar Miró, Santiago Nogué, Guillermo Burillo *Emergency Department, and Toxicology Unit, Hospital Clinic, 08036 Barcelona, Spain (e-mail: [email protected]) 1
Litovitz TL, Klein-Schwartz W, White S, et al. Annual report of the American Association of Poison Control Centers: toxic exposure surveillance system. Am J Emerg Med 2000; 18: 517–74.
DEPARTMENT OF ERROR A pharmaceutical elegy—In this dissecting room review by Colin Martin (Dec 15, p 2089) the title of the picture should have been Secret Remedies #2 (2001). Near-death experience in survivors of cardiac arrest: a prospective study in the Netherlands—In this article by P van Lommel and colleagues (Dec 15, p 2044), the third sentence of the third paragraph should have ended “LSD,28 psilocybine, and mescaline.21
THE LANCET • Vol 359 • April 6, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Suture of second-degree perineal tears after childbirth Sir—Over the past two decades, an unexplained trend has arisen in the midwifery profession towards leaving second-degree perineal tears unsutured. In a study at Luton and Dunstable Hospital, Luton, UK, 75% of seconddegree tears were sutured in 1996, but only 52% in 1998.1 This change is not supported by research and is thought to be due to several factors. The increased autonomy of midwives in perineal management and a general move towards non-intervention in midwifery could be a factor. In one report, researchers suggest that parturients themselves may be affecting decisions, or that staff shortages might be a factor. The concern is that there are several potential negative sequelae to nonsuturing. There is debate as to whether healing is prolonged, although midwives report that healing is satisfactory when tears are left unsutured.2 However, risk of infection of an open wound seems greater than for a sutured wound and, therefore, the potential for increased pain exists; although counter arguments suggest the increased risk of infection and pain from placement of foreign material, such as suture, in the tissues. A major concern also exists for the persistence of a weakened pelvic floor, since second-degree tears, by definition, involve the superficial muscles of the pelvic floor and could involve the deep pelvic floor muscles. The evidence for the practice of non-suturing is extremely limited. Workers in a small study compared suturing with non-suturing,3 but the study had several limitations, making findings unsuitable to cause a change in practice. The conclusion of a retrospective study that most women were satisfied with how their perinea had healed when left unsutured was also deemed limited.4 Researchers, in a large randomised controlled study, showed that there were no apparent disadvantages to leaving perineal wounds unsutured,5 but tears involved only the skin layer and not second-degree tears. Until randomised controlled studies of adequate quality can support nonsuture, all second-degree tears should be sutured. Stephen M Wild Bishop Auckland General Hospital, Co Durham, UK 1 2
Sandland D. Perineal tears: audit and proposed RCT. Pract Midwife 1999; 2: 32. Steen M. The abused perineum. Br J Midwifery 1998; 6: 428–29.
3 4
5
Head M. Dropping stitches. Nurs Times 1993; 89: 64–65. Clement S, Reed B. To stitch or not to stitch: a long term follow up study of women with unsutured perineal tears. Pract Midwife 1999; 2: 20–28. Gordon B, Mackrodt C, Fern E, Truesdale A, Ayers S, Grant A. The Ipswich Childbirth Study, 1: a randomised evaluation of two stage postpartum perineal repair leaving the skin unsutured. Br J Obstet Gynaecol 105: 435–40.
disease, making it very likely that he had hypertension, and putting him at a high risk of early stroke. David Bateman Royal United Hospital, Combe Park, Bath BA1 3NG, UK (e-mail: [email protected]) 1
McManus IC. Charles Dickens: a neglected diagnosis. Lancet 2001; 358: 2158–61.
Dickens: an alternative diagnosis
Bringing global issues to medical teaching
Sir—I McManus (Dec 22, p 2158)1 proposes that the novelist Charles Dickens had a right parietal or temporoparietal disorder. I think the symptoms described by McManus suggest an alternative neurological diagnosis. The nature of Dickens’ initial visual symptoms in 1868 are unclear, but his description of the same disorder that recurred in March 1870 leaves little doubt that Dickens was describing a recurrent temporary left homonymous hemianopia, not spatial neglect. Patients with spatial neglect are unaware of their deficit. A homonymous hemianopia localises the disorder to the right occipital cortex, not the temporoparietal area. These episodes were due to transient ischaemic attacks in the right posterior circulation. In 1868 Dickens also had temporary left-sided motor symptoms and giddiness, which suggest another vascular episode in the right posterior circulation. Unfortunately, 2 years later, Dickens had a fatal stroke, possibly in the same area. Dickens’ left-sided sensory symptoms began in 1865, without a preceding stroke. If the cause was neurological, it is more likely that the symptoms were due to central post-stroke pain arising from a thalamic infarct, the classic site for stroke that produces post-stroke pain of this kind. The lateral thalamus is also supplied by branches of the posterior circulation. Dickens’ denial of his physical complaints has no neurological explanation. Dickens’ friend Yates is scathing of Dickens, who ignored his symptoms and continued working; however, it is difficult to see what else he could have done. The clinical picture is, therefore, more simply and concisely explained by premature atherothromboembolic disease in the posterior circulation, causing recurrent transient ischaemic attacks and, finally, a fatal stroke, perhaps due to hypertension. McManus reports that Dickens had signs of heart disease, possibly precipitated by renal
Sir—Catherine Bateman and colleagues (Nov 3, p 1539)1 address the necessity for educating medical students about global health issues. However, they neglect a more important perspective— students and physicians must also acquire cross-cultural attitudes, skills, and knowledge that affect directly their clinical decision making. We agree that violence is an international health issue, that African countries need expensive AIDS drugs, that genome mapping must not be used to produce biological weapons for use against specific ethnic groups, and that physicians in training will benefit from global health knowledge. However, our perspective is that of collaborators at an Israeli-US medical school, in which a compulsory course in intemational health and medicine is added to the normal US curriculum.2 The course combines international health issues with practical training in cross-cultural communications and clinical clerkships in Africa, Asia, the Middle East, and in under-served communities in the USA. The focus is mainly on the global physician in her traditional role as clinical decisionmaker and only secondarily as a contributor to health policy. This view emphasises both what medicine in developed countries can do for developing countries, and what developing countries can teach developed ones. Attitudes appropriate for working across national boundaries are just as useful for working across cross-cultural boundaries within a particular European or US city. Working in developing areas that lack advanced technology requires honing of clinical skills that will improve clinical decision making anywhere. Learning about the health effects of army violence will affect a physicians’ ability to better cope with the developed world’s murder epidemic. Learning to use available drugs effectively is a critical skill in the US’s wasteful health economy. From this perspective, a physician trained in global health and medicine who never leaves his or her
THE LANCET • Vol 359 • April 6, 2002 • www.thelancet.com
1253
For personal use. Only reproduce with permission from The Lancet Publishing Group.
CORRESPONDENCE
US or European office will benefit from global medicine training. There is another way of understanding the message of Gro Harlem Brundtland, WHO’s director general, that the process of globalisation has made the disregarding of desperate conditions on another continent impossible. We must realise that all of us, in London, Tel Aviv, and New York, as well as in Lilongwe, Addis Ababa, and Lahore, live on another continent. The great lesson of globalisation is for countries from all continents to collaborate to improve health everywhere. *Carmi Z Margolis, Richard J Deckelbaum, Yaakov Henkin, Michael Alkan *MD Program in International Health and Medicine, Ben-Gurion University of the Negev, PO Box 653, Beer-Sheva 84105, Israel; and Columbia University Health Sciences, Columbia University, NY, USA 1
2
Bateman C, Baker T, Hoornenborg E, Ericsson U. Bringing global issues to medical teaching. Lancet 2001; 358: 1539–42. Urkin J, Alkan M, Henkin Y, Baram S. Integrating global health and medicine into the medical curriculum. Educ Health 2001; 14: 427–31.
Avoiding the point Sir—In an attempt to reduce the frequency of inoculation accidents and the recognised sequelae of seroconversion with blood-borne viruses, several devices have been developed to protect health-care workers from sharps injury. In November, 2000, the US Congress passed the Needlestick Safety and Prevention Act,1 calling on health-care providers to assess needlesafe devices and to supply them for their employees. The UK National Health Service in Scotland has also produced clear recommendations to improve the awareness of needlestick injuries and how to assess needle-safe and needleless systems.2 In the UK, health-care providers should implement measures perceived as necessary under existing health and safety laws3,4 to reduce risk of exposure to blood-borne diseases and to put preventive measures in place. However, no formal assessment of needle-safe devices has been made, nor is there guidance on which areas should be prioritised. Do we need to follow the lead of the US, in passing specific legislation to ensure protection for all health-care workers from needlestick injuries? The UK has well developed procedures for the reporting of inoculation accidents and on the
1254
subsequent management of injuries sustained. The need for legislation should reflect overall risk, however the incidence of these accidents on a national basis is currently unclear. In the University Hospital Birmingham NHS Trust, during 2000, 195 inoculation incidents were reported. This number occurred despite rigorous education and increased awareness campaigns aimed at prevention of these accidents. Does this number indicate the true size of the problem? We also looked at the actual rate of under-reporting of needlestick injuries, by interviewing 84 staff, including junior doctors, nurses, and phlebotomists. The reasons for nonreporting of injuries were also noted. 35 of the 84 staff had received 78 needlestick injuries during the year. Of these, 21 (60%) staff did not report some or all of the instances, giving an under-reporting rate of 65%. The overall number of incidents associated with venesection was 25 (32%); 18 (23%) were associated with intravascular catheters; and 35 (45%) were from other sources. The most common reason for not reporting the incident was that it was judged low risk. A similar study in the US reported a 75% annual underreporting rate.5 The frequency of inoculation incidents may, therefore, be much higher than the standard reported numbers suggest. Since more than half the injuries occurred when taking blood or inserting intravascular catheters, protection of health-care workers must focus initially on these procedures. Appropriate assessment of the available needle-safe devices is needed2 so that national guidance, perhaps involving specific legislation, can be investigated. *D K Dobie, T Worthington, M Faroqui, T S J Elliott Departments of *Clinical Microbiology and Anaesthetics, University Hospital Birmingham NHS Trust, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, UK 1 2
3
4
5
Safety and Prevention Act, HR 5178, 106th Congress, 2nd Session, 2000. Short Life Working Group on Needlestick Injuries in NHSScotland. Needlestick injuries: sharpen your awareness—towards a safer healthier workplace needlestick injuries in the NHSScotland. Edinburgh: Scottish Executive, 2001. The control of substances hazardous to health regulations 1999 (S1 1999/437). London: Stationery Office, 1999. The management of health and safety at work regulations 1999 (S1 1999/3242). London: Stationery Office, 1999. Hamory BH. Under-reporting of needlestick injuries in a university hospital. Am J Infect Control 1983; 11: 174–77.
Avoiding unnecessary risks to our children Sir—Infantile accidental acute intoxication is always the final consequence of a chain of events that includes, among others, child-related factors (oral phase of psychological development, imitation of adults behaviours, infinite curiosity), parent-related factors (nonadequate storage place for potentially toxic products, distraction when watching over children), and toxic-related factors (organoleptic properties, attractive packaging). During 1999, the US Association of Poison Control Centers reported 1 148 693 accidental poisonings in children younger than age 6 years, 42% of which were due to the ingestion of pharmaceutical drugs.1 Certainly, thousands of additional near-miss events occur daily. Therefore, every effort addressed to break the aforementioned chain of events will be welcomed. In the past few months we have noted that some pharmaceutical companies give sweets to doctors as little gifts, which are put into boxes that are almost identical to the packaging of their advertised drugs. Only small warnings, which take up less than 5% of the boxes’ surface, indicate the real content. Inside, the packaging is sometimes a copy of the drug blister packs. Several of us bring these presents home, where our children can see us eating these sweets. One of the most important issues of pharmaceutical industry is to make their products as safe as possible. They spend a large amount of funds to prevent unwanted adverse events and accidental poisonings. This kind of promotional gift goes against such security standards. We believe that this marketing policy must be strongly discouraged to avoid additional unnecessary risks to our children. *Òscar Miró, Santiago Nogué, Guillermo Burillo *Emergency Department, and Toxicology Unit, Hospital Clinic, 08036 Barcelona, Spain (e-mail: [email protected]) 1
Litovitz TL, Klein-Schwartz W, White S, et al. Annual report of the American Association of Poison Control Centers: toxic exposure surveillance system. Am J Emerg Med 2000; 18: 517–74.
DEPARTMENT OF ERROR A pharmaceutical elegy—In this dissecting room review by Colin Martin (Dec 15, p 2089) the title of the picture should have been Secret Remedies #2 (2001). Near-death experience in survivors of cardiac arrest: a prospective study in the Netherlands—In this article by P van Lommel and colleagues (Dec 15, p 2044), the third sentence of the third paragraph should have ended “LSD,28 psilocybine, and mescaline.21
THE LANCET • Vol 359 • April 6, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.