Indirect drug-related costs

because we are so easily influenced by the plight of such women that we need to stand back from the situation and assess what is for the best. Is it conceivable that the best that can be offered to those of the "world of Norma McCorvey and Ceauescu’s Romania" is not further suffering and death to a fetus, but new life?

precisely

*R W McCallum, F Alderton, T D Millar *Department of Obstetrics and Gynaecology, Southern General Hospital, Glasgow G51 4TF, UK; and Institute of Biomedical and Life Sciences, Department of Pharmacology, University of Glasgow the medical

1

Murphy JF, O’Driscoll K. Therapeutic abortion: argument. Irish Med J 1982; 75: 304.

2

Sims PF. Life issues 1: abortion in medicine in crisis. In: Brown IL, Cameron NM de S, eds. Edinburgh: Rutherford House, 1988. Myerscough PR. That the Abortion Act of 1967 was a disastrous mistake. Scot Med J 1968; 13: 396.

3

SIR-In your editorial on abortion you seem to suggest that many of the world’s social depravities can be blamed on the outlawing of abortion. You defend this viewpoint by describing the case of Norma McCorvey, an underprivileged "socially compelling case", brought to the US Supreme Court in 1965. However, unless you were to argue that McCorvey’s mother should have had the right to legally abort her daughter, I fail to understand how the lack of availability of such a law at that time could be held responsible for the appalling atrocities experienced by Norma from the time of her birth, including physical abuse, family breakdown, sexual abuse, and rape. Neither do I see how such a law would have prevented Norma, in her poverty, taking to a life of crime and marriage before 16 years of age to a violent man-all this before ever becoming pregnant herself. You then cite a second situation, describing Romania under Ceauescu’s dictatorship as "a nation of Norma brutalising society and outlawing abortion". McCorveys I agree wholeheartedly that both are examples of horrendous brutality, but it is neither fair nor correct to link these perversions of humanity with the altruistic wish to maintain an ultimate respect for all human life. Contrary to your concluding remark, the irreparable damage to the lives of Norma and many Romanian women did not occur as a consequence of safe abortion being unavailable to them. ...

Philippa G de Takats CRC Institute for Cancer Studies, Birmingham B15 2TH, UK

Is it

Queen Elizabeth Hospital,

possible to have thought? SiR-I fail

an

unconscious

how

calling an unconscious thought an unperceived thought (Chapman and Chapman-Santana, Dec 24/31, p 1752) changes anything. The difficulty in assessing the validity of concluding that a person’s thought went from non-perceived to perceived is the same as concluding that a conscious thought came from an unconscious one. Chapman and Chapman-Santana cite an example of an irritable surgeon who did not perceive that he to see

felt angry because of his annoyance with himself for a mistaken diagnosis. How can we prove such a causal connection? In this example, a colleague tells the surgeon of this alleged non-perceived connection, which causes the surgeon to relax and perform better-a paradigm of a successful psychotherapeutic interpretation. I do not see how this example proves anything. What if the surgeon did not relax after the comment? Would that disprove the existence of the non-perceived thought and 588

feeling? What if the surgeon relaxed for a different reason? His colleague’s calm kindness might have relaxed him regardless of the veracity of his perception of the surgeon’s non-perception. Forgotten thoughts and feelings can be remembered, so we have to have a name, perhaps, for where these forgotten thoughts and feelings were before we remembered them. But, we still have the unresolved difficulties of: (1) proving causal connections between current thoughts and feelings and past ones, whether conscious or not; (2) proving the accuracy of remembered thoughts and feelings; and (3) proving the effect of telling someone about his nonperceived thoughts and their relations to current thoughts, acts, and feelings. Arthur Rifkin Department of Psychiatry, Hillside Hospital, Glen Oaks, NY 11004, USA

Indirect

drug-related

costs

SIR-The cost of drugs is not limited to their buying price. Determination of the exact cost of drugs is complex, and involves the cost of both untreated and treated diseases, and the cost of treating .illness resulting from treatment. To evaluate the cost of treatment of side-effects, all patients admitted because of known drug-related illness were identified from the records of a general hospital over a 16-day period in July, 1992. Four groups of patients were identified, with: adverse reactions from normal drug use, overdosage (exclusive of suicide attempts), underdosage, and attempted suicide. Cost was evaluated by multiplying the duration of hospital stay by the recorded cost of a day in hospital. Of the 1760 admissions to hospital (60% for surgery, 40% for medical treatment), 87 (5%) were drug related, with a total stay of 413 days and a total cost of FF874 000 over this 2-week period (table). All but 1 patient with adverse reactions came for allergic skin reactions, and these patients were treated as outpatients. The patients with drug overdosage were significantly older than those in other The groups. drugs involved were digoxin, oral anticoagulants, insulin, benzodiazepines, and theophylline. Patients in the underdosage group consisted of 4 with asthma and 19 with epilepsy, who had stopped their treatment. 9 of the 42 patients (mean age 41 years) who had attempted suicide accounted for 56% of hospital days (mean stay 15), whereas the other 33 (mean age 29) had a mean stay of less than 3 days. Most had attempted suicide

previously. Non-suicide drug-related hospital admissions represented 2-5% of all admissions, and 6-4% of medical admissions, which are close to the usual figures of 3-8%.’ This percentage is certainly an underestimate: only patients for whom the drug causing the disease was known at admission were included. Patients admitted with an uncertain diagnosis

(mostly laboratory test abnormalities) and in whom the illness could only be related to a drug cause after admission were not included. Unavoidable side-effects (ie, allergy) were inexpensive to treat. Drug overdosage was very

*p<0’5 vs all other groups ADR=adverse drug reaction; KF=1000 French Francs (about fl25). Table: Costs of treatment according to patient groups

per patient because of long hospital stays. Most if all cases might have been avoided if drug dosage had been better adjusted and monitored. Drug underdosage was usually caused by patients inappropriately stopping their treatment, suggesting insufficient patient education. Some suicide attempts may have been avoidable, especially in repeat offenders, with appropriate support. Suicide attempts represented 2-4% of all admissions and over half the overall

expensive

not

costs.

yearly costs in this study would be 9 million Francs (excluding suicide), of which less than 2% seems truly unavoidable, plus 10 million Francs for suicide attempts, just for this one hospital covering a population of less than 300 000 inhabitants. The cost-estimates were not adjusted for seasonal changes in disease or drug use. Clearly, druginduced diseases are a major cause of medical costs. Most could or should be avoided. At a time when much emphasis The

is put where

easily,

the limitation of health expenses, here is a domain expense-cutting could probably be done reasonably while increasing quality of care.

on

*Nicholas Moore, Christine Briffaut, Catherine Noblet, Claude Augustin Normand, Christian Thuillez

You also ignore the recent advances in our understanding of the role of the brain in adaptation to stress. The development of techniques that allow changes in neural activity (including gene expression) to be measured have shown that there is a distributed pattern of neural response to acute stress in laboratory animals.3 This response changes in predictable and interesting ways as the stress continues and in concert with alterations in endocrine and behavioural responses. The neurochemical bases for these events are also being studied, and it seems clear that at least three distinct systems (peptides, aminergic pathways, and steroid hormones) contribute to the neural mechanisms responsible for adaptation.5 This new knowledge may well be applied to man before too long. Perhaps there are grounds not only for optimism but even for excitement in view of the advances made in the study of stress in recent years. This optimism results from not only technical innovation, but also the increasing ability of workers in both experimental and clinical spheres to cross boundaries. This collaboration has always been needed; and now it seems to be happening. It is a pity that it has gone unrecognised by your editorial. J Herbert

*Department of Pharmacology, CHU de Rouen, 76031 Rouen, France; and Hôpital Jacques Monod, Le Havre

Department of Anatomy and MRC Cambridge Centre for Brain Repair, University of Cambridge, Cambridge CB2 3DY, UK

1 Einarson TR.

1

Drug-related hospital admissions. Ann Pharmacother

1993; 27: 832-40. 2

Essence of stress 3

SiR-Your pessimistic editorial (Dec 24/31) on the present state of knowledge of stress and the prospects for improving understanding and handling of stress ignores many recent advances. The brave attempts to find a common ground will continue, despite your stricture, simply because they are beginning to be fruitful. There is increasing recognition that stress plays a major aetiological part in many somatic and mental illnesses. By contrast with your conclusion, the absence of cross-disciplinary studies could well have delayed greater understanding of what stress is, and what implications it has for medicine. The definition of stress has moved from a single concept to a generic term for a range of processes. Various findings now suggest that it is persistent, chronic, or repeated stress that is most likely to result in

pathological consequences. Past approaches emphasised the response to stress; but current thinking takes account of the differences in the category of stress, and the process by which it is handledie, the adaptive response. Sources of demand or stress come not only from the physical but also from the social environment since there will always be a limit to the availability of resources, and therefore competition for them. So stress is differentiated according to its source and nature. In human terms, the demands of a job may be distinct (and have different consequences) from, say, those of an unsatisfactory relationship. They may also be different from persistent exposure to danger (eg, war) or deprivation (eg, chronic food shortage). The coping process has received much attention, although this seems to have escaped your editorial. For example, Brown’s’ work shows that

with low self-esteem, or a history of persistent difficulties (ie, stress) are highly likely to become depressed after some catastrophic life event. Marmot’s2 classic study on civil servants confirms in man what has been known for animals: that lack of control increases the pathological consequences of stress (and your editorial supplies more

poor

relationships,

recent

women

and who have

confirmation).

4

5

Brown GW, Bifulco A, Andrews P. Self-esteem and depression IV: effect on course and recovery. Soc Psychiatry Psychiatr Epidemiol 1990; 25: 244-49. Marmot MG, Rose G, Shipley M, Hamilton PJS. Employment grade and coronary heart disease in British civil servants. J Epidemiol Commun Health 1978; 32: 244-49. Arnold FJL, de Lucas Bueno M, Shiers H, Hancock DC, Evan GI, Herbert J. Expression of c-fos in regions of the basal limbic forebrain following intra-cerebroventricular corticotropin-releasing factor (CRF) in unstressed or stressed male rats. Neuroscience 1992; 51: 377-90. Chen X, Herbert J. Regional changes in c-fos expression in the basal forebrain and brainstem during adaptation to repeated stress: correlations with cardiovascular, hypothermic and endocrine responses. Neuroscience 1995; 64: 675-85. Herbert J. Peptides in the limbic system; neurochemical codes for coordinated adaptive responses to behavioural and physiological demand. Progr Neurobiol 1993; 41: 723-91.

opportunity cost of surrogate post-transfusion hepatitis Lost

markers in

SiR-Blajchman and colleagues (Jan 7, p 21) in their report of a prospective study of post-transfusion hepatitis in Canada show that surrogate markers for non-A, non-B hepatitis are now of little value in reducing the frequency of post-transfusion hepatitis-but not so before 1992. Their data enable us to quantify the lost opportunity cost of not implementing the use of surrogate markers for more than three decades. In 1959, John LaDue and associates’ showed that donor blood with raised aspartate aminotransferase (AST) activity was 3-5 times more likely to transmit hepatitis than blood with normal AST concentrations. In 1960, on the basis of LaDue’s work, I tried to convince the medical director of the Milwaukee Blood Center to introduce AST/alanine aminotransferase (ALT) screening of donors. The suggestion was rejected because it would have meant additional costs, would have increased the number of rejected donors, and because liver function tests (specifically thymol turbidity and cephalin flocculation) were known at the time to be ineffective in decreasing the frequency of post-transfusion hepatitis.2 The blood bank community did not appreciate that ALT was a sensitive test for hepatocellular necrosis and not at all comparable to thymol turbidity.3 Moreover, I and my laboratory associates gave up 589