DNA and the law

608

Audit and

pathology

SiR,—Your Feb 10 editorial discusses the introduction of audit procedures for pathology laboratories in the UK. One can indeed come perilously close to dying from a "surfeit of audit". This department is accredited, and audited, by four external agenciessoon to be five-for its various functions. These agencies concern themselves severally with the training of medical students, junior doctors, and laboratory technicians, and with the overall operation of the hospital (the Canadian Council of Hospital Accreditation, CCHA). Shortly we shall add a provincial licensing body. All these organisations demand the same mountain of data, but of course on different sets of forms. I make no mention of our multiplicity of internal audit committees. Each accrediting agency marches to its own drum, but in 1988, by a malignant coincidence of biorhythms, each of them decided to conduct an on-site survey and inspection. I estimated that the pile of paperwork occupied one full-time equivalent employee for a year, but of course this body was not supplied; time required was drawn from productive time, patient-care time, or unpaid overtime by dedicated staff. When provincial licensing begins, we shall not only open another drain on our resources, but also we shall be expected to detach staff to do unto others as we have been done to, or accept that we shall be audited by civil servants. No-one can be against quality and its assurance, they go along with motherhood, apple-pie, and the flag. What our system lacks are two things. One, the recognition by our funding powers that audit, as presently practised, subtracts from patient care by transfer of resources; and two that no-one audits the auditors, to see whether all this compulsive activity does have any objectively proveable effect on quality. A colleague of mine, chairing an internal audit committee, questioned the CCHA about this; he got a three-page reply saying, in effect, we can’t prove it, but we’re sure it must be good for you. I think it is all displacement activity; prevented from doing what we should be doing by lack of resources, we turn to something else. As our old Siamese cat used to do, when in doubt, wash. We may provide less and less patient-care, but we shall be very clean.

of

Department Pathology, University Hospital, Saskatoon, SK, Canada S7N OXO

Department of Haematology, Sheffield Children’s Hospital, Sheffield S10 2TH, UK

J. S. LILLEYMAN

1. The College Accreditation Steering Committee. Royal College of Pathologists’ United Kingdom pilot study of laboratory accreditation. J Clin Pathol 1990; 43: 89-91

Incompetent adults and SiR,—There

are

consent

three situations-abortion, sterilisation, and

surgery to permit organ donation-in which for incompetent adults

H. E. EMSON

SiR,—Your editorial spotlights for

some members of the Royal of the College Pathologists strength and weaknesses of the pilot study which is now being extended. The hope that separate visits to cover training can be avoided should be accepted with great caution because accreditation procedures, although detailed, are

organisational. I think the training programmes, most of which are based on form of rotational arrangements within a region need constant and certainly more frequent than five-yearly analyses, and a much deeper assessment of the training programmes available. The resources allocated to training, the amount of one-to-one teaching, and the "trainee tailored" education towards which we should be aiming all need an approach other than accreditation. The integration of counselling and the monitoring of career progress should be distinct from the accreditation system. In this region we have produced for the Royal College of Pathologists proposals for registrar rotation under the new examination regulations which do not ignore the "accredibility" of the laboratories but look much more closely at what is offered in respect of training programmes and comprehensive coverage of the specialty. Some laboratories may not seek the commercial reassurance of accreditation yet offer a module of training which is valuable as a part of the whole; increasingly training programmes cross the conventional laboratory boundaries so that they offer the trainee both what he wants and what he needs to pass the College some

examinations. St Richard’s Hospital, Chichester, West Sussex PO19 4SE, UK

SiR,—Your somewhat wry leader concludes "one cannot run a clinical laboratory with one eye on the hospital car-park awaiting the next inspector’s limousine and one ear cocked for the district manager’s knock". Having been closely involved in the Royal College of Pathologists’ pilot study of accreditation which prompted that observation,l I would respectfully offer two comments. First, any head of department who displays such paranoia is obviously in need of the sort of help the scheme aims to provide, and secondly, to avoid raising anybody’s hopes, it should be made clear that no accreditation inspectors have been (or will be) provided with limousines. The latter assertion, at least, should be borne out in a phase-2 study which is due to be done in four further regions during 1990. This second attempt at pathology department accreditation aims to apply the lessons learned in the first. It will try to define more objectively the standard to be achieved, will take particular account of the views of local clinicians and managers, and will examine participation by pathologists in local audit schemes. The Department of Health is supporting the programme which is being conducted by the audit steering committee of the College of Pathologists with representatives from other professions and interested groups. The hope is that a formula for a national scheme will emerge-a scheme that will offer a simple and effective way of ensuring that pathology departments in both the public and private sectors provide an adequate service. Whether that ambition will be realised remains to be seen, but pathologists who regard the prospect as some sort of threat should look to their own departments to find out why.

MICHAEL NICHOLLS

permission must first be sought from the High Court.1 There is a fourth situation which is similar-namely, where HIV antibody testing is indicated in a mentally impaired person who cannot give or refuses consent after counselling. The occasion will arise when HIV antibody status must be established to protect mentally handicapped fellow residents who take part in, but cannot comprehend the concept of, high-risk activities. The North West Hertfordshire mental handicap unit’s working party on HIV disease has decided that a declaration from the Courts must be secured before serological testing in these circumstances, and that recommendation has been supported by the Mental Health Act Commission. Leavesden

Hospital,

PETER L. HALL

Watford, Herts WD5 ONU 1. Brahams D

Incompetent adults and consent to treatment. Lancet 1989; i:

340.

DNA and the law SiR,—Your Feb

17 editorial described accurately some of the encountered in the United States with DNA fingerprinting in forensic casework. Your comments about the use of the technique in cases of disputed paternity, however, need some correction. You state that the long established serological methods can exclude paternity virtually without doubt, but the fact is that this happens only in about 20% of cases of disputed paternity. Further, although you state that if the putative father is not excluded, the probability that he is the father is often several thousand to one. Before DNA fingerprinting introduced greater levels of certainty, there were many cases each year in the UK where conventional methods produced results that were inconclusive. We know this to

difficulties

609

because many of these cases were and still are subsequently for testing by DNA fingerprinting so that an unequivocal answer can be given. You go on to say that magistrates can understand simple blood groups and similar serological systems. Our experience, having made presentations to well over half the magistrates in England, is that this is certainly not the case, and the message constantly given to us is that the reports produced after testing with conventional blood grouping methods can be confusing and frequently inconclusive. With DNA fingerprinting magistrates receive clear unequivocal be

so

sent to us

case

reports.

Our experience of solving over three thousand paternity disputes by means of DNA fingerprinting backs our opinions and is further supported by the fact that almost all such cases are now thankfully solved with this new and powerful technique. Cellmark

Diagnostics,

Abingdon Business Park, Abingdon, Oxfordshire OX14 1 DY, UK

Illegal acts of Scottish Health

PHILIP WEBB

Minister

SIR,-Mr Hunter (Feb 17, p 414), who has had a wealth of Scottish Health Service experience, asserts that Mr Michael Forsyth has broken the law in abolishing the National Medical Consultative Committee together with the other NCCs which were set up by statute. He may well be right but the NCCs were, I was informed, not abolished but suspended, which is apparently at least within the letter of the law. He is certainly right that the NCCs were not consulted in the process leading up to the White Paper. But who were? A characteristic of this Government is the certainty with which it holds its own convictions and that any expert dissent is always

self-seeking. His advice to us, however, may not be right. The NMCC and the other NCCs all made their apprehensions known before their suspension. In this new and unheeding environment what good would come from us reconvening and publishing what would be repetitive advice? As chairman of the NMCC and chairman of the new nonstatutory National Medical Advisory Committee I believe it and the other NACs, although curtailed in their powers, must continue to advise the Minister on what we believe are often unworkable proposals which seem not to be based on knowledge of how the National Health Service works, of how patients think, and of what doctors do. As the difficulties multiply, as they must, the Government may then be prepared to listen, and the effects on our patients could at least be ameliorated. If, however, it becomes apparent that our advice is consistently ignored then the calibre of the membership of the NACs will drop and their function wither. Ninewells Hospital and Medical School, Dundee DD1 9SY, UK

J. W. CRAWFORD

Paroxysmal precordial purring sign in epiglottitis SiR,—The diagnosis of acute epiglottitis (supraglottitis) in an adult with a sore throat is difficult to prove on the basis of clinical history and physical examination.1 Lateral neck X-rays and/or laryngoscopy are often required. The number of patients seen with acute pharyngitis is large, and further diagnostic evaluation is time-consuming and expensive. However, diagnosis of epiglottitis is critically important since the disease can run a fulminating, even fatal, course even in the absence of alarming presenting symptoms and signs. One of us (H. C. L.), a 66-year-old physician, was admitted to hospital with a sore throat. His symptoms were those of a severe pharyngitis with hoarseness, fever, throat pain, difficulty swallowing, oropharyngeal secretions, and dyspnoea. He also noted a purring or fluttering sensation in the precordium. At first, the patient thought that this sensation was cardiac in origin but it was not reminiscent of palpitations, it occurred only during exhalation, and he had a normal cardiovascular examination. Respiratory

examination revealed only inspiratory stridor. Soft tissue filins of the neck revealed a swollen epiglottis angled over swollen supraglottic structures. He was kept under observation in the intensive care unit, and given antibiotics, oxygen, and dexamethasone. The purring or fluttering sensation resolved as his dyspnoea and stridor abated. Clinical resolution of all symptoms was rapid and the patient was discharged after 3 days. Following convalescence, the patient mimicked the fluttering sensation for others by placing the tip of his tongue against the anterior portion of the hard palate; forcing air between the two caused vibration of the tongue in a trill-like manner. We suspect that air rushing from the glottis and around the swollen epiglottis perched over it set up eddy currents or turbulence which caused the epiglottis to waver or flutter much like a sail luffing in the breeze. This probably resulted in the purring sensation during exhalation. Have other patients with epiglottitis noted precordial purring? Is exhalational epiglottal flutter the cause? Can a physical sign of such fluttering be appreciated and used to help establish the diagnosis of acute epiglottitis and follow the course of the illness? Department of Medicine, Miriam Hospital, Brown University, Providence, Rhode Island 02906, USA

FRED J. SCHIFFMAN HERBERT C. LICHTMAN

1.

Shapiro J, Eavey RD, Baker AS. Adult supraglottitis: a prospective analysis. JAMA

2.

1988; 259: 563-67. Mayo Smith MF, Hirsch PJ, Wodzinski SF, Schiffman FJ. Acute epiglottitis in adults: an eight year experience in the State of Rhode Island. N Engl J Med 1986;

314: 1133-39. 3. Baker AS, Eavey RD. Adult 1185-86.

supraglottitis (epiglottitis). N Engl J Med 1986; 314:

Differentiation between specific and non-specific hepatitis C antibodies in chronic liver disease SiR,—We have used the Ortho Diagnostics System enzyme immunoassay for detecting antibodies to hepatitis C virus (HCV)l to assess the incidence of HCV infection in patients with chronic liver disease. Sera were collected from 100 potential liver transplant patients and we found 6 anti-HCV positive patients with liver diseases not normally associated with virus infection (table i). This could indicate infection with HCV during transfusions of blood and blood products, but it could also be interpreted as false-positive reactions with non-specific antibodies cross-reacting with the recombinant HCV antigen. Table 11 shows the optical density (OD) values for the positive samples. Samples from patients with cryptogenic cirrhosis all had OD values greater than 11(mean 2-38) while 6 samples from patients with liver disease associated with obstruction or metabolic or immunological changes had OD values of 09 or less (mean 0-69). To find out if the low OD values seen with some samples were non-specific, all anti-HCV-positive samples were retested twiceas previously and again with an 8 mol/1 urea wash during the first ELISA washing procedure. This urea wash should dissociate weak-binding or low-avidity antibodies from the antigen.2,3 The avidity of immunoglobulin G during the acute phase of viral TABLE I-HCV ANTIBODY STATUS OF PATIENTS WITH CHRONIC LIVER DISEASE