- Email: [email protected]
DISABLED CHILD AS INCOME
907 resources out
of their present niche into
general practice-over his
dead body I would guess. So it would appear that this editorial on undergraduate general was written by someone with next to no experience in clinical teaching, no knowledge of undergraduates, and neither skills in nor even sympathy for general practice-and it was published on April 1. So the new Editor does have a sense of humour.
practice
Dib Lane Surgery, Leeds LS8 3AY
transplant? Only
a comprehensive health service can adequately train doctors in the science of medicine, and in the art of communicating with patients and their families. This threat to the provision of medical education comes on the heels of the green-paper on student loans. This concerted attack on medical education will dissuade some of the most talented school leavers from entering the profession. We cannot overemphasise the damage we feel these political directives will have, and we urge all those working in the NHS to defend the service vigorously.
ARNOLD G. ZERMANSKY
DISABLED CHILD AS INCOME
wheeled into my consulting room by her She looked to be about 18 months old, but she in a pram. parents, was 6 and had been born in the London area with a large occipital encephalocele. The mother had had several miscarriages, an anencephalic baby, and a child with spina bifida who had also died; she had two normal children. An attempt to operate on the encephalocele at age 4 months had been abandoned in theatre when the child’s condition deteriorated. Subsequently, the father had given up work to help look after the child, and the family had moved to the north of Scotland to start a new life. The lesion was large, and it was difficult to handle and undress the child. She could scarcely move and her responses were limited to smiling to her mother’s voice. I offered to carry out a scan with a view to a further attempt at reducing the size of the lesion, to make nursing easier. However, the parents were adamant that nothing should be done that might jeopardise the child’s life. They relied on her for the family’s income of L196 per week in attendance, invalid care, and mobility allowances, income support, and child benefit (for all three children). They were exploring the possibility of registering the child as a charity. The notion of a severely malformed, handicapped 6-year-old earning a living for a family raises questions. Isit ethical for a child to be used in this way? Is this the intention of our welfare arrangements-or does it smack of the days when children were sent out to work or of Roman times when children might be deliberately maimed so that they would become more effective beggars? One must respect the parents for their willingness to keep such a child at home, and at the same time save public money by avoiding the need for institutional care. This child seemed comfortable and was certainly well cared for. It is unlikely that active interference or treatment would make much difference to her wellbeing. But may there not be circumstances where there is a temptation for a child to be inappropriately kept going or deprived of potentially helpful treatment to maintain the family income? The financial allowances for the underprivileged and handicapped have lately come in for some criticism. However, this child is bringing in almost L200 a week, enabling the family to maintain their own house, run a car, and feed and clothe themselves.
SIR,-A girl
was
Raigmore Hospital, Inverness IV2 3UJ
C. A. S. GALLOWAY
NHS WHITE-PAPER AND MEDICAL EDUCATION
SIR,-It was encouraging to see so many letters questioning the Government’s white-paper Working for Patients (March 11, p 558). As final year medical students we are very concerned by the proposals. We have grown up with the National Health Service and want to practise medicine within it. However, it is the clear intention of this Government to reduce spending on the NHS while coercing patients to use private health care. On the first page of the document, signed by the Prime Minister, is the statement "The NHS will continue to be available to all, regardless of income, and to be financed mainly out of general taxation". The rest of the text details how the Government intends to reduce their responsibility for planning the health provision for the whole nation. Medical education in Britain has a high reputation but we see no provision for maintaining such high standards in the white-paper. The review takes no account of the requirements to train the doctors of tomorrow. When allocated to an orthopaedic firm will we have to travel, say, to Sheffield to watch the hip replacements that have been contracted out and go to Wales the next week to watch a renal
London Hospital Medical London El 2AD
College,
ALEX ALLINSON NICK FRANK ALEXA MORCOM LISE HERTEL
DILTIAZEM AND HEART BLOCK
SIR,-Dr Waller and Professor Inman (March 18, p 617) and Hassell and Creamerl report examples of heart block and bradycardia after treatment with diltiazem either alone or in combination with a beta-blocker. We report another case in a patient during acute myocardial ischaemia. A 55-year-old man with ischaemic heart disease was admitted with prolonged chest pain. He was taking atenolol 100 mg once daily. Electrocardiogram showed new anterior T wave inversion that later reverted to normal. Cardiac enzymes were raised, but not diagnostic ofinfarcdon. Diltiazem was added and after three 60 mg doses sinus rhythm changed to junctional bradycardia, 50/min, which resolved spontaneously after 30 min. This example further highlights the potential hazards of diltiazem, especially in combination with a beta-blocker, this time in the setting of acute myocardial ischaemia. R. E. NAGLE T. LOW-BEER Oak Selly Hospital, R. HORTON Birmingham B29 6JD 1. Hassell
AB, Creamer JE. Profound bradycardia after the addition of diltiazem betablocker. Br Med J 1989; 298: 675.
to a
ONCOGENIC VIRUSES AND CERVICAL CANCER
SIR,-Dr Tidy and colleagues (Feb 25, p 434) describe the prevalence of human papillomavirus (HPV) type 16 in cytological material from normal cervices. This confirms our observation of a surprisingly high prevalence of this viral DNA in both abnormal and normal cervices. We have re-examined this material (36 cervical smears from women with histologically confirmed cervical epithelial abnormality), using the polymerase chain reaction (PCR) to determine the prevalence of type 2 herpes simplex virus (HSV) and Epstein-Barr virus (EBV) DNA. The method of collecting and processing this material has previously been described. Oligonucleotide primers were used to amplify a segment within the E6 region of HPV 2 and 16 DNA, a region of BgIIIN fragment of HSV type 2, and the BamHIW repeat region of EBV. Positive and negative controls were used to exclude, in so far as is possible, cross-contamination. PCR amplification products were analysed by gel electrophoresis and Southern blotting with oligonucleotide probes representing the central portion of the amplified viral sequences. Thus the specificity of the analysis relies not only on the amplification of a fragment of predicted size but also on the ability of the amplified product to
hybridise to a specific oligonucleotide probe. HPV DNA was found in smears from all 36 patients; HSV DNA in smears from 11 and EBV from 12; HPV and either HSV or EBV DNA was found in 19 smears, and 4 patients had all three types of viral DNA. The frequency with which we have found DNA from more than one oncogenic virus in abnormal cervical tissue should compel revision of previously held opinions. HSV type 2 was discarded as a potential oncogenic agent largely because viral DNA could not be consistently demonstrated in premalignant and cancerous tissue. Our findings suggest either that there has been a substantial change in the prevalence of genital HSV infection or that previous failure to demonstrate HSV DNA reflected the poor sensitivity of the techniques then available. Conversely, the high prevalence of HPV infection found in cytologically normal individuals by PCR must be was
of their present niche into
general practice-over his
dead body I would guess. So it would appear that this editorial on undergraduate general was written by someone with next to no experience in clinical teaching, no knowledge of undergraduates, and neither skills in nor even sympathy for general practice-and it was published on April 1. So the new Editor does have a sense of humour.
practice
Dib Lane Surgery, Leeds LS8 3AY
transplant? Only
a comprehensive health service can adequately train doctors in the science of medicine, and in the art of communicating with patients and their families. This threat to the provision of medical education comes on the heels of the green-paper on student loans. This concerted attack on medical education will dissuade some of the most talented school leavers from entering the profession. We cannot overemphasise the damage we feel these political directives will have, and we urge all those working in the NHS to defend the service vigorously.
ARNOLD G. ZERMANSKY
DISABLED CHILD AS INCOME
wheeled into my consulting room by her She looked to be about 18 months old, but she in a pram. parents, was 6 and had been born in the London area with a large occipital encephalocele. The mother had had several miscarriages, an anencephalic baby, and a child with spina bifida who had also died; she had two normal children. An attempt to operate on the encephalocele at age 4 months had been abandoned in theatre when the child’s condition deteriorated. Subsequently, the father had given up work to help look after the child, and the family had moved to the north of Scotland to start a new life. The lesion was large, and it was difficult to handle and undress the child. She could scarcely move and her responses were limited to smiling to her mother’s voice. I offered to carry out a scan with a view to a further attempt at reducing the size of the lesion, to make nursing easier. However, the parents were adamant that nothing should be done that might jeopardise the child’s life. They relied on her for the family’s income of L196 per week in attendance, invalid care, and mobility allowances, income support, and child benefit (for all three children). They were exploring the possibility of registering the child as a charity. The notion of a severely malformed, handicapped 6-year-old earning a living for a family raises questions. Isit ethical for a child to be used in this way? Is this the intention of our welfare arrangements-or does it smack of the days when children were sent out to work or of Roman times when children might be deliberately maimed so that they would become more effective beggars? One must respect the parents for their willingness to keep such a child at home, and at the same time save public money by avoiding the need for institutional care. This child seemed comfortable and was certainly well cared for. It is unlikely that active interference or treatment would make much difference to her wellbeing. But may there not be circumstances where there is a temptation for a child to be inappropriately kept going or deprived of potentially helpful treatment to maintain the family income? The financial allowances for the underprivileged and handicapped have lately come in for some criticism. However, this child is bringing in almost L200 a week, enabling the family to maintain their own house, run a car, and feed and clothe themselves.
SIR,-A girl
was
Raigmore Hospital, Inverness IV2 3UJ
C. A. S. GALLOWAY
NHS WHITE-PAPER AND MEDICAL EDUCATION
SIR,-It was encouraging to see so many letters questioning the Government’s white-paper Working for Patients (March 11, p 558). As final year medical students we are very concerned by the proposals. We have grown up with the National Health Service and want to practise medicine within it. However, it is the clear intention of this Government to reduce spending on the NHS while coercing patients to use private health care. On the first page of the document, signed by the Prime Minister, is the statement "The NHS will continue to be available to all, regardless of income, and to be financed mainly out of general taxation". The rest of the text details how the Government intends to reduce their responsibility for planning the health provision for the whole nation. Medical education in Britain has a high reputation but we see no provision for maintaining such high standards in the white-paper. The review takes no account of the requirements to train the doctors of tomorrow. When allocated to an orthopaedic firm will we have to travel, say, to Sheffield to watch the hip replacements that have been contracted out and go to Wales the next week to watch a renal
London Hospital Medical London El 2AD
College,
ALEX ALLINSON NICK FRANK ALEXA MORCOM LISE HERTEL
DILTIAZEM AND HEART BLOCK
SIR,-Dr Waller and Professor Inman (March 18, p 617) and Hassell and Creamerl report examples of heart block and bradycardia after treatment with diltiazem either alone or in combination with a beta-blocker. We report another case in a patient during acute myocardial ischaemia. A 55-year-old man with ischaemic heart disease was admitted with prolonged chest pain. He was taking atenolol 100 mg once daily. Electrocardiogram showed new anterior T wave inversion that later reverted to normal. Cardiac enzymes were raised, but not diagnostic ofinfarcdon. Diltiazem was added and after three 60 mg doses sinus rhythm changed to junctional bradycardia, 50/min, which resolved spontaneously after 30 min. This example further highlights the potential hazards of diltiazem, especially in combination with a beta-blocker, this time in the setting of acute myocardial ischaemia. R. E. NAGLE T. LOW-BEER Oak Selly Hospital, R. HORTON Birmingham B29 6JD 1. Hassell
AB, Creamer JE. Profound bradycardia after the addition of diltiazem betablocker. Br Med J 1989; 298: 675.
to a
ONCOGENIC VIRUSES AND CERVICAL CANCER
SIR,-Dr Tidy and colleagues (Feb 25, p 434) describe the prevalence of human papillomavirus (HPV) type 16 in cytological material from normal cervices. This confirms our observation of a surprisingly high prevalence of this viral DNA in both abnormal and normal cervices. We have re-examined this material (36 cervical smears from women with histologically confirmed cervical epithelial abnormality), using the polymerase chain reaction (PCR) to determine the prevalence of type 2 herpes simplex virus (HSV) and Epstein-Barr virus (EBV) DNA. The method of collecting and processing this material has previously been described. Oligonucleotide primers were used to amplify a segment within the E6 region of HPV 2 and 16 DNA, a region of BgIIIN fragment of HSV type 2, and the BamHIW repeat region of EBV. Positive and negative controls were used to exclude, in so far as is possible, cross-contamination. PCR amplification products were analysed by gel electrophoresis and Southern blotting with oligonucleotide probes representing the central portion of the amplified viral sequences. Thus the specificity of the analysis relies not only on the amplification of a fragment of predicted size but also on the ability of the amplified product to
hybridise to a specific oligonucleotide probe. HPV DNA was found in smears from all 36 patients; HSV DNA in smears from 11 and EBV from 12; HPV and either HSV or EBV DNA was found in 19 smears, and 4 patients had all three types of viral DNA. The frequency with which we have found DNA from more than one oncogenic virus in abnormal cervical tissue should compel revision of previously held opinions. HSV type 2 was discarded as a potential oncogenic agent largely because viral DNA could not be consistently demonstrated in premalignant and cancerous tissue. Our findings suggest either that there has been a substantial change in the prevalence of genital HSV infection or that previous failure to demonstrate HSV DNA reflected the poor sensitivity of the techniques then available. Conversely, the high prevalence of HPV infection found in cytologically normal individuals by PCR must be was