- Email: [email protected]
Encephalitis in New York
1
Ko AI, Galvaõ Reis M, Ribeiro Dourado CM, Johnson WD Jr, Riley LW, and the Salvador Leptospirosis study group. Urban epidemic of severe leptospirosis in Brazil. Lancet 1999; 354: 820–25. 2 Lee HW, Van der Groen G. Hemorrhagic fever and renal syndrome (HFRS). Prog Med Virol 1989; 36: 62–102. 3 Van Loock F, Thomas I, Clement J, Ghoos S, Colson P. A case-control study after a hantavirus outbreak in the South of Belgium: who is at risk? Clin Infect Dis 1999; 28: 834–39. 4 LeDuc J, Smith G, Pinheiro F, Vasconcelos P, Rosa E, Maiztegui J. Isolation of a Hantaan-related virus from Brazilian rats and serologic evidence of its widespread distribution in SouthAmerica. Am J Trop Med Hyg 1985; 34: 810–15. 5 Hinrichsen SL, Medeiros de Andrade A, Clement J, et al. Hantavirus infection in Brazilian patients from Recife with suspected leptospirosis. Lancet 1993; 341: 50.
diagnostic and therapeutic shortcomings and identify conditions unsuspected antemortem, where is the evidence that such information reliably alters subsequent clinical behaviour? We need such evidence before we accept the dogma that low rates are bad and high rates always good. There is a practical issue to consider. The UK and other countries has a shortage of pathologists. Biopsy diagnosis and reporting on specimens have become more complex and place increasing demands on pathologists’ time, whereas necropsies are time-consuming and expensive. Given the manpower crisis facing the specialty of pathology, the relative benefits of necropsy as against other activities that pathologists perform need to be considered. Peter A Hall Department of Pathology, Gloucestershire Royal Hospital, Gloucester GL1 3NN, UK (e-mail: [email protected])
Do we really need a higher necropsy rate? Sir—A Lugli and colleagues (Oct 16, p 1391)1 add to the evidence for a continuing fall in necropsy rates. In many countries there has been a sharp fall in necropsy rates over many years, and several studies attest to the inaccuracy of clinical diagnosis of cause of death. Certainly necropsy has an important place in clinical practice: it has a key role in medical student teaching, it is important in postgraduate training, it has essential medicolegal roles, and it is often an endpoint in research studies. However, there is a ritualistic mantra, exemplified by Lugli et al, that “low autopsy rates are bad and that everything possible should be done to increase autopsy rates”. But what is the minimum acceptable rate? Put another way, is there any evidence for a strong correlation between a high necropsy rate and better clinical practice? I know of none. Many east European countries have very high rates but do their health services provide demonstrably better care as a consequence? There are many good reasons for post-mortem examinations. However, what is more important, a modest number of targeted, well-conducted necropsies at which clinicians are present (at least for a demonstration of key findings) and where there is the opportunity for clinicopathological correlation or large numbers of examinations without the crucial step of good clinical contact? Let us move away from the ritual arguing for high necropsy rates towards a more balanced perspective. Although it is well established that necropsy can highlight
2004
1
Lugli A, Anabitarte M, Beer JH. Effect of simple interventions on necropsy rate when active informed consent is required. Lancet 1999; 354: 1391.
Encephalitis in New York Sir—I take issue with your Oct 9 editorial1 about the management of the encephalitis crisis in New York City. Our leadership, for once unchallenged by the media, failed to address issues of the greatest urgency. These issues include years of neglect in the area of larvae control in coastal and lake and pond regions. Intervention at this stage is a much less toxic process and yields long-term results. It might have allowed us to avoid the use of massive amounts of the more hazardous organophosphates during the encephalitis crisis. Our city’s leadership also failed to involve local leaders and concerned citizens, who objected to the shortsighted and non-specific intervention plan instituted here. This plan exempted many experienced members of the scientific community from contributing information relevant to the selection of pesticides, developing protocols to determine the specific areas in need of application, selecting those areas in need of repeat applications, and the implementation of a method for informing and protecting millions of people from excessive and random exposures to the toxins used. You remarked upon the “willingness” of the population to be “exposed” to pesticides. Whereas most New Yorkers and I would agree that spraying was a necessary step, I doubt that any of us would give permission for our persons to be
sprayed, no matter how dilute the solution used. There were times when no notice was given about changes in schedules/locations for application. Socalled advance notice often consisted of only 2–3 h, and information only available to those able to reach the mayor’s office of emergency management by phone or who happened to be watching a particular cable television channel. I am unaware of any safe level of exposure recorded for children. Yet many opportunities for exposure via dermal, respiratory, and gastrointestinal routes existed daily for the entire population. There were no plans implemented to clean playground equipment, close park areas, protect city workers out on the street during and after applications, and so on. Pesticide application should be termed a necessary risk and not just one of the many toxins present in the everyday life of a city dweller. The mayor’s oft repeated litany of false assurances about the benign nature of the concentrations used of malathion, resmethrin, and sumethrin were not contradicted by the media. Although I applaud the absence of tabloid journalism during this crisis, the public trust in the media to keep us informed was violated. Barbara R Rubin 266-11 Hillside Avenue, Floral Park, New York 11004, USA 1
Editorial. Exotic diseases close to home. Lancet 1999; 354: 1221.
Dangers of bed rest Sir—Chris Allen and colleagues have made a worthy contribution (Oct 9, p 1229),1 but older readers will regret that they failed to mention Richard Asher’s masterly essay. 2,3 Asher’s word-picture of the patient on bed rest is unforgettable: “The blood clotting in his veins, the lime draining from his bones, the scybala stacking up in his colon, the flesh rotting from his seat, the urine leaking from his distended bladder, and the spirit evaporating from his soul”. Need more be said? Kenneth W Heaton Claverham House, Stream Cross, Claverham, Somerset BS49 4QD, UK 1
2 3
Allen C, Glazsiou P, Del Mar C. Bed rest: a potentially harmful treatment needing more careful evaluation. Lancet 1999; 354: 1229–32. Asher RAJ. The dangers of going to bed. BMJ 1947; ii: 967–68. Jones FAJ, ed. Richard Asher talking sense. Bath: Pitman, 1972.
THE LANCET • Vol 354 • December 4, 1999
Ko AI, Galvaõ Reis M, Ribeiro Dourado CM, Johnson WD Jr, Riley LW, and the Salvador Leptospirosis study group. Urban epidemic of severe leptospirosis in Brazil. Lancet 1999; 354: 820–25. 2 Lee HW, Van der Groen G. Hemorrhagic fever and renal syndrome (HFRS). Prog Med Virol 1989; 36: 62–102. 3 Van Loock F, Thomas I, Clement J, Ghoos S, Colson P. A case-control study after a hantavirus outbreak in the South of Belgium: who is at risk? Clin Infect Dis 1999; 28: 834–39. 4 LeDuc J, Smith G, Pinheiro F, Vasconcelos P, Rosa E, Maiztegui J. Isolation of a Hantaan-related virus from Brazilian rats and serologic evidence of its widespread distribution in SouthAmerica. Am J Trop Med Hyg 1985; 34: 810–15. 5 Hinrichsen SL, Medeiros de Andrade A, Clement J, et al. Hantavirus infection in Brazilian patients from Recife with suspected leptospirosis. Lancet 1993; 341: 50.
diagnostic and therapeutic shortcomings and identify conditions unsuspected antemortem, where is the evidence that such information reliably alters subsequent clinical behaviour? We need such evidence before we accept the dogma that low rates are bad and high rates always good. There is a practical issue to consider. The UK and other countries has a shortage of pathologists. Biopsy diagnosis and reporting on specimens have become more complex and place increasing demands on pathologists’ time, whereas necropsies are time-consuming and expensive. Given the manpower crisis facing the specialty of pathology, the relative benefits of necropsy as against other activities that pathologists perform need to be considered. Peter A Hall Department of Pathology, Gloucestershire Royal Hospital, Gloucester GL1 3NN, UK (e-mail: [email protected])
Do we really need a higher necropsy rate? Sir—A Lugli and colleagues (Oct 16, p 1391)1 add to the evidence for a continuing fall in necropsy rates. In many countries there has been a sharp fall in necropsy rates over many years, and several studies attest to the inaccuracy of clinical diagnosis of cause of death. Certainly necropsy has an important place in clinical practice: it has a key role in medical student teaching, it is important in postgraduate training, it has essential medicolegal roles, and it is often an endpoint in research studies. However, there is a ritualistic mantra, exemplified by Lugli et al, that “low autopsy rates are bad and that everything possible should be done to increase autopsy rates”. But what is the minimum acceptable rate? Put another way, is there any evidence for a strong correlation between a high necropsy rate and better clinical practice? I know of none. Many east European countries have very high rates but do their health services provide demonstrably better care as a consequence? There are many good reasons for post-mortem examinations. However, what is more important, a modest number of targeted, well-conducted necropsies at which clinicians are present (at least for a demonstration of key findings) and where there is the opportunity for clinicopathological correlation or large numbers of examinations without the crucial step of good clinical contact? Let us move away from the ritual arguing for high necropsy rates towards a more balanced perspective. Although it is well established that necropsy can highlight
2004
1
Lugli A, Anabitarte M, Beer JH. Effect of simple interventions on necropsy rate when active informed consent is required. Lancet 1999; 354: 1391.
Encephalitis in New York Sir—I take issue with your Oct 9 editorial1 about the management of the encephalitis crisis in New York City. Our leadership, for once unchallenged by the media, failed to address issues of the greatest urgency. These issues include years of neglect in the area of larvae control in coastal and lake and pond regions. Intervention at this stage is a much less toxic process and yields long-term results. It might have allowed us to avoid the use of massive amounts of the more hazardous organophosphates during the encephalitis crisis. Our city’s leadership also failed to involve local leaders and concerned citizens, who objected to the shortsighted and non-specific intervention plan instituted here. This plan exempted many experienced members of the scientific community from contributing information relevant to the selection of pesticides, developing protocols to determine the specific areas in need of application, selecting those areas in need of repeat applications, and the implementation of a method for informing and protecting millions of people from excessive and random exposures to the toxins used. You remarked upon the “willingness” of the population to be “exposed” to pesticides. Whereas most New Yorkers and I would agree that spraying was a necessary step, I doubt that any of us would give permission for our persons to be
sprayed, no matter how dilute the solution used. There were times when no notice was given about changes in schedules/locations for application. Socalled advance notice often consisted of only 2–3 h, and information only available to those able to reach the mayor’s office of emergency management by phone or who happened to be watching a particular cable television channel. I am unaware of any safe level of exposure recorded for children. Yet many opportunities for exposure via dermal, respiratory, and gastrointestinal routes existed daily for the entire population. There were no plans implemented to clean playground equipment, close park areas, protect city workers out on the street during and after applications, and so on. Pesticide application should be termed a necessary risk and not just one of the many toxins present in the everyday life of a city dweller. The mayor’s oft repeated litany of false assurances about the benign nature of the concentrations used of malathion, resmethrin, and sumethrin were not contradicted by the media. Although I applaud the absence of tabloid journalism during this crisis, the public trust in the media to keep us informed was violated. Barbara R Rubin 266-11 Hillside Avenue, Floral Park, New York 11004, USA 1
Editorial. Exotic diseases close to home. Lancet 1999; 354: 1221.
Dangers of bed rest Sir—Chris Allen and colleagues have made a worthy contribution (Oct 9, p 1229),1 but older readers will regret that they failed to mention Richard Asher’s masterly essay. 2,3 Asher’s word-picture of the patient on bed rest is unforgettable: “The blood clotting in his veins, the lime draining from his bones, the scybala stacking up in his colon, the flesh rotting from his seat, the urine leaking from his distended bladder, and the spirit evaporating from his soul”. Need more be said? Kenneth W Heaton Claverham House, Stream Cross, Claverham, Somerset BS49 4QD, UK 1
2 3
Allen C, Glazsiou P, Del Mar C. Bed rest: a potentially harmful treatment needing more careful evaluation. Lancet 1999; 354: 1229–32. Asher RAJ. The dangers of going to bed. BMJ 1947; ii: 967–68. Jones FAJ, ed. Richard Asher talking sense. Bath: Pitman, 1972.
THE LANCET • Vol 354 • December 4, 1999