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HERPES ZOSTER
466 SERIAL
N.B.T.
REDUCTION TESTS IN 5 PATIENTS WHELMING BACTERIAL INFECTION
WITH
HERPES ZOSTER
OVER-
SiR,—Your leader,l Smallpox Target Zero, prompts me ask when we are to have Herpes Zoster Target Zero ? The difficulties are immense but the rewards would be enormous if this torture of the aged could be eliminated. I am sure many consultants will support me in asking for urgent research into this elusive problem.
to
4 Waterden
Road,
J. S. PHILLPOTTS.
Guildford.
GENERAL PRACTITIONERS’ OPINIONS OF A NEW HOSPITAL-DISCHARGE LETTER
SIR,-In
an
attempt
to
improve communications
hospital doctors and general practitioners we designed a problem-oriented discharge letter.2We believed that the new letter would reach the general practitioner more quickly, that the problem-list component of the
between
experienced false-positive tests in thalassaemia8 and malaria,7 but our most striking results were in 5 children with overwhelming bacterial infection (3 with staphylococcal septicaemia, 1 with multiple abscesses, and 1 with severe cellulitis and bronchopneumonia) in whom both resting and stimulated tests were extremely low (see table). Esposito and Delalla9 reported 12 cases of purulent meningitis with false-negative N.B.T. reduction tests on Rubinstein and Pelet 10 peripheral-blood specimens. discussed the possible xtiology of false-negative N.B.T. reduction tests due to transient malfunction of the neutrophils ; and Cocchi et al.ll reported a longitudinal study in premature infants in which he noted a decrease in N.B.T. reduction associated with worsening of the infants’ condition. Of our 5 patients, 3 (nos. 1-3) had received medication from a private clinic prior to admission but all 5 were given intravenous penicillin and kanamycin on admission. The false-negative N.B.T. test was probably unrelated to antimicrobial inhibition as in 3 patients in whom we repeated the N.B.T. test the test became elevated while they were on the same antibiotic regimen (see table). Patient 3 died twelve hours after admission, so we were unable to repeat the test. In the other 4 patients subjective and objective clinical improvement coincided with an elevation of the N.B.T. reduction test. In patient 2 the antibiotic regimen was changed on day three and the child started to recover; unfortunately there was a relapse on day seventeen and the child died four days later. In overwhelming infection bacterial products may possibly damage or even kill the phagocytes after ingestion and prevent them fromreacting in the usual manner to These " altered " phagocytes are later removed N.B.T. from the circulation by tissue macrophages, and new phagocytes take their place which can react to N.B.T. and produce the expected response. We suggest that serial N.B.T. tests should be performed on patients who appear to have overwhelming infection but in whom the first test is unexpectedly low. We conclude that, in general, the N.B.T. reduction test is useful in differentiating bacterial and viral infections.
False-positive and false-negative results do occur, but despite such reactions its usefulness is not invalidated; and in overwhelming infections, serial N.B.T. tests might provide a guide to the patient’s clinical course. Department of Pædiatrics, Siriraj Hospital, Mahidol University, Bangkok 7, Thailand. 8.
WARREN LENNEY VINAI SUVATTE SOODSAKORN TUCHINDA.
Tanphaichitr, P., Medanandha, V., Phuwastien, P. Asian J. Med. 1973, 9, 205. 9. Esposito, R., Delalla, F. Lancet, 1972, i, 747. 10. Rubenstein, A., Pelet, B. ibid. 1973, i, 382. 11. Cocchi, P., Mori, S., Becattini,A. Acta pœdiat. scand. 1971, 60, 475.
letter would be useful in itself to G.P.s, that the letter would prove more useful to the G.P. than the traditional essay letter as a document on which to plan further management, and that a feedback system from the practitioner could be established in which he returned the problem list with any additions or changes. The first year’s experience with the new discharge letter in Glasgow confirms its usefulness and acceptability. During the period April, 1973, to April, 1974, 102 general practitioners received the new discharge letter from a general medical ward of the Western Infirmary, Glasgow, a large teaching hospital. Each letter was accompanied by a short questionary inviting opinions of the new-style system. 86 completed questionaries were returned; 15 G.P.S did not reply, and 1 had died. Over 90% of doctors agreed that the new letter was generally acceptable, that the problem list was helpful, and that the brief notes on the active problems were adequate. 88% received the letter within a few days of the patient’s discharge, and 88% found the new letter more useful than the old for future management. The second part of the questionary invited general comments on the new system. 38% of the doctors volunteered a generally favourable comment, 6% responded unfavourably, and 56% did not complete this section. 16 doctors wrote specifically that they had received the new letter quickly; whereas 4 doctors commented on delay. The only recurring criticism (7 doctors) was that the new letter had had to be folded twice to fit the generalpractice record envelope. On average 1-5 days elapsed between the discharge of the patient and the posting of the letter. With seven letters there were unacceptably long intervals but since these were due to secretarial and mailing problems over Christmas and loss in the post, these letters were excluded from the analysis of speed. The new-style discharge letter seems to be generally acceptable and quick, and it seems to be generally more useful for planning further management than the traditional letter. Few G.P.S took the opportunity to feed back data to the hospital by returning an updated list, and this is an area which merits further investigation. The system has run without problems for more than a year despite rotation through the Unit of doctors not previously familiar with the procedure. The discharge letter is regarded as a secretarial " priority ", and by eliminating dictation and encouraging abstraction of data by a secretary as near discharge as possible we have considerably reduced the delay associated with the old system. A full problemoriented approach is not necessary; the minimum require1. Lancet, 1974, i, 295. 2.
Stevenson, J. G., Boyle, C. M., Alexandra, W. D. Lancet, 1973, 1,928
N.B.T.
REDUCTION TESTS IN 5 PATIENTS WHELMING BACTERIAL INFECTION
WITH
HERPES ZOSTER
OVER-
SiR,—Your leader,l Smallpox Target Zero, prompts me ask when we are to have Herpes Zoster Target Zero ? The difficulties are immense but the rewards would be enormous if this torture of the aged could be eliminated. I am sure many consultants will support me in asking for urgent research into this elusive problem.
to
4 Waterden
Road,
J. S. PHILLPOTTS.
Guildford.
GENERAL PRACTITIONERS’ OPINIONS OF A NEW HOSPITAL-DISCHARGE LETTER
SIR,-In
an
attempt
to
improve communications
hospital doctors and general practitioners we designed a problem-oriented discharge letter.2We believed that the new letter would reach the general practitioner more quickly, that the problem-list component of the
between
experienced false-positive tests in thalassaemia8 and malaria,7 but our most striking results were in 5 children with overwhelming bacterial infection (3 with staphylococcal septicaemia, 1 with multiple abscesses, and 1 with severe cellulitis and bronchopneumonia) in whom both resting and stimulated tests were extremely low (see table). Esposito and Delalla9 reported 12 cases of purulent meningitis with false-negative N.B.T. reduction tests on Rubinstein and Pelet 10 peripheral-blood specimens. discussed the possible xtiology of false-negative N.B.T. reduction tests due to transient malfunction of the neutrophils ; and Cocchi et al.ll reported a longitudinal study in premature infants in which he noted a decrease in N.B.T. reduction associated with worsening of the infants’ condition. Of our 5 patients, 3 (nos. 1-3) had received medication from a private clinic prior to admission but all 5 were given intravenous penicillin and kanamycin on admission. The false-negative N.B.T. test was probably unrelated to antimicrobial inhibition as in 3 patients in whom we repeated the N.B.T. test the test became elevated while they were on the same antibiotic regimen (see table). Patient 3 died twelve hours after admission, so we were unable to repeat the test. In the other 4 patients subjective and objective clinical improvement coincided with an elevation of the N.B.T. reduction test. In patient 2 the antibiotic regimen was changed on day three and the child started to recover; unfortunately there was a relapse on day seventeen and the child died four days later. In overwhelming infection bacterial products may possibly damage or even kill the phagocytes after ingestion and prevent them fromreacting in the usual manner to These " altered " phagocytes are later removed N.B.T. from the circulation by tissue macrophages, and new phagocytes take their place which can react to N.B.T. and produce the expected response. We suggest that serial N.B.T. tests should be performed on patients who appear to have overwhelming infection but in whom the first test is unexpectedly low. We conclude that, in general, the N.B.T. reduction test is useful in differentiating bacterial and viral infections.
False-positive and false-negative results do occur, but despite such reactions its usefulness is not invalidated; and in overwhelming infections, serial N.B.T. tests might provide a guide to the patient’s clinical course. Department of Pædiatrics, Siriraj Hospital, Mahidol University, Bangkok 7, Thailand. 8.
WARREN LENNEY VINAI SUVATTE SOODSAKORN TUCHINDA.
Tanphaichitr, P., Medanandha, V., Phuwastien, P. Asian J. Med. 1973, 9, 205. 9. Esposito, R., Delalla, F. Lancet, 1972, i, 747. 10. Rubenstein, A., Pelet, B. ibid. 1973, i, 382. 11. Cocchi, P., Mori, S., Becattini,A. Acta pœdiat. scand. 1971, 60, 475.
letter would be useful in itself to G.P.s, that the letter would prove more useful to the G.P. than the traditional essay letter as a document on which to plan further management, and that a feedback system from the practitioner could be established in which he returned the problem list with any additions or changes. The first year’s experience with the new discharge letter in Glasgow confirms its usefulness and acceptability. During the period April, 1973, to April, 1974, 102 general practitioners received the new discharge letter from a general medical ward of the Western Infirmary, Glasgow, a large teaching hospital. Each letter was accompanied by a short questionary inviting opinions of the new-style system. 86 completed questionaries were returned; 15 G.P.S did not reply, and 1 had died. Over 90% of doctors agreed that the new letter was generally acceptable, that the problem list was helpful, and that the brief notes on the active problems were adequate. 88% received the letter within a few days of the patient’s discharge, and 88% found the new letter more useful than the old for future management. The second part of the questionary invited general comments on the new system. 38% of the doctors volunteered a generally favourable comment, 6% responded unfavourably, and 56% did not complete this section. 16 doctors wrote specifically that they had received the new letter quickly; whereas 4 doctors commented on delay. The only recurring criticism (7 doctors) was that the new letter had had to be folded twice to fit the generalpractice record envelope. On average 1-5 days elapsed between the discharge of the patient and the posting of the letter. With seven letters there were unacceptably long intervals but since these were due to secretarial and mailing problems over Christmas and loss in the post, these letters were excluded from the analysis of speed. The new-style discharge letter seems to be generally acceptable and quick, and it seems to be generally more useful for planning further management than the traditional letter. Few G.P.S took the opportunity to feed back data to the hospital by returning an updated list, and this is an area which merits further investigation. The system has run without problems for more than a year despite rotation through the Unit of doctors not previously familiar with the procedure. The discharge letter is regarded as a secretarial " priority ", and by eliminating dictation and encouraging abstraction of data by a secretary as near discharge as possible we have considerably reduced the delay associated with the old system. A full problemoriented approach is not necessary; the minimum require1. Lancet, 1974, i, 295. 2.
Stevenson, J. G., Boyle, C. M., Alexandra, W. D. Lancet, 1973, 1,928