- Email: [email protected]
PSYCHIATRIC PATIENTS AND THEIR NOTES
162 2. Chantler C. Nursing sick children. Arch Dis Child 1981; 56: 241-42. 3. Court SDM (chairman). Fit for the future: Report of the Committee on Child Health
NURSING REQUIREMENTS FOR CHILDREN’S INPATIENT CARE
4.
SiR,-Bed occupancy rates are widely used in decisions on how budgets for acute services should be allocated but this method does take into account the special needs of children in hospital. We have evaluated a simple alternative method of assessing the utilisation of children’s inpatient facilities. This children’s department has 42 medical and surgical beds on two wards, there being 3 cots/beds in a side-ward designated for intensive care, 9 double and 7 single cubicles, and 14 cots/beds in small bays. The nursing establishment of 298 whole-time equivalents (WTE) has often seemed inadequate for the supervision that is necessary. The recognition of this shortfall prompted our own audit of nursing activity on the wards. During 1985 the senior nurse on duty at each shift recorded all admissions, overnight stays, and day cases, categorising them as of high, medium, or low dependency, along the lines recommended by the British Paediatric Association/British Association for Perinatal Paediatrics’ for use in neonatal care. High-dependency beds require a nurse in attendance at all times-ie, at least 4 WTE per bed to allow for 24 hour cover and leave. Medium dependency beds require at least 2 and low-dependency at least I WTE per bed. Hospital admission records show that 3421 children were admitted in 1985 with a bed occupancy rate of 46%. Our audit recorded that 3910 children had used inpatient facilities; the extra children were day cases, previous inpatients seen for review, and children sent by a general practitioner for assessment. The usage of the wards varied month to month, the peak being in December, January, and February. The miniinum nursing level to provide a year-round service was calculated from the mean bed usage over a year (table) and was found to be 21 % higher than the existing establishment or an extra 6 trained children’s nurses. However, this addition would not correct all the understaffing during the peak
Services. London: HMSO, 1976. BPA/BAPS Joint Committee on Nursing. Children’s wards and their nurse staffing in the UK 1980. London: Brinsh Paediatric Association, 1981.
not
months. CATEGORIES OF DEPENDENCY AND NURSES
REQUIRED
Children in hospital need specialised nursing care which not only takes account of their clinical needs but also caters for their emotional vulnerability.2 Ten years ago the Court report3 recommended at least 5 trained staff for every 20 beds. In 1980 41 % of children’s wards in England and Wales had lower nurse/bed ratios than thiS.4 Paediatricians have found it difficult to persuade managers of the need to increase the nursing establishment on their wards because the commonly used methods of audit take no account of the specialised needs of children in hospital. Our audit records bed usage by nursing dependency rather than by simply counting occupied beds. One-third of the children in this survey were in high or medium dependency beds. The categories of dependency and associated nursing establishment were extrapolated from those recommended for care of the newborn. Although these recommendations are not accepted by the Department of Health and Social Security, they are recognised by a House of Commons Select Committee on Social Services. ’
We thank Dr Sarah Stewart-Brown and Prof David Baum for their comments.
A. M. EMOND V. H. JONES T. L. CHAMBERS
Children’s Department, Southmead Hospital, Bristol BS10 5NB 1.
Categories of babies receiving neonatal 1985.
care.
London: British Paediatric
Association,
DEMAND FOR ORGAN TRANSPLANTATION IN CHILDREN
SIR,-Dr Harrison’s estimate (Dec 13, p 1383) of the size of the
supply of organs for transplantation in children if anencephalic fetuses were to be used as donors of "spare parts" seems reasonable enough. But the statements about demand require considerably more documentation before they can be accepted as credible. Do the parents of all children with an organ failure which makes them eligible for organ transplantation demand transplantation? There are enough questions about the quality of life after organ transplant’ to make one wonder. Are surgeons responding to need-or are they creating a need to which they respond? The words of fashion designer Diana Vreeland come to mind here. When asked to explain her phenomenal success, she replied: "Give ’em what they don’t know they want." 90 La Cuesta Drive, Greenbrae, California 94904, USA
1.
WILLIAM A. SILVERMAN
Christopherson LK. Quality of life. Organ transplantation and artificial organs. Int J Technology Assessment Health Care-1986; 2: 553-62.
CONFIDENTIALITY OF PRE-EMPLOYMENT
HEALTH SCREENING
.
SiR,-Aris Mariner and colleagues (Dec 6, pl337) are concerned about the confidentiality of pre-employment health screening. I am a consultant adviser in occupational health for several health authorities in the South-East. Our procedure is that all health questionnaires are filled in privately by the applicant and sent in a sealed envelope to the occupational health department, where the forms are seen by the medical and nursing staff. The applicants are assessed on the basis of their health questionnaire and medical interview/examination. At no time are the forms seen by anyone outside the department. We require a detailed health questionnaire within the health authority to assess any aspect of the applicant’s health which could cause concern at work. Equally we have to match the person to the job and the job to the person. These health questionnaires, together with other notes, are kept confidentially in the occupational health department with no access apart from the department’s staff. The clerical staff are only involved with the filing of these documents and these staff are also subject to the rules of confidentiality that no information must be divulged outside the department. Our system is good and reasonable, and we advocate it to other areas. Occupational Health Department, Eastbourne Health Authority, District General Hospital, Eastbourne, East Sussex BN21 2UD
J. M. DAVIDSON
PSYCHIATRIC PATIENTS AND THEIR NOTES
SIR,-Dr Sergeant (Dec 6, p 1322) supports his argument that psychiatric patients would be harmed by reading their medical records by citing extracts from studies which reached a many
different conclusion. He reports that Stein’ "found that 32% of the 102 psychiatric inpatients felt more pessimistic after reading their case-notes and 51 % were upset by some of the entries". This is accurate, but far from the whole picture. Stein wrote: "The vast majority of the patients (77, or 92 %) were in favor of open medical records. They felt that access to their medical records during hospitalization helped them to better understand their problems (75, or 86%) and take a more active role in their treatment (72, or 85%)". Furthermore, 68 % said that access had afforded an opportunity to correct inaccuracies; 84% felt comfortable about reading their records and 71 % felt more self-confident as a result. Stein then went on to say: "However, a substantial minority felt more pessimistic after reading their records (26, or 32%) and roughly half of the
163
patients 51%)".
said they were upset by some of what they read (43, or Stein concluded that "the benefits seem to outweigh the
costs".
Sergeant states that 26 % of staff knew of at least one patient who had been harmed. But he does not acknowledge that Stein suggests they may all have been referring to the same one or two patients; that 70% of staff believed access "helped the treatment of most patients"; and that none thought that access was generally harmful. He cites McFarlane’s study2 in which psychiatric patients with major psychoses saw their records and says of it only that there were "no differences between those granted access to their current hospital records and those who were not". McFarlane found no difference on matters such as refusal of medication, but reported that those who saw their records were "more likely to have correct information about their condition and treatment" and that viewing the record had sometimes proved helpful by "allaying suspicions, developing trust and even in achieving consent for a specific treatment". McFarlane concluded that access was not detrimental and could be used as a therapeutic tool. Most of those who argue for a right of access accept the need for some limitation in a minority of cases, perhaps to allow access to be deferred until after a period of acute disturbance. But the published evidence suggests that the crucial safeguard is the presence of staff to explain what is seen in the record and that, given this, access is not generally harmful—on the contrary, it may be of great value. ,
Campaign for Freedom of Information, 3 Endsleigh Street, London WC1H ODD
MAURICE FRANKEL
1 Stein EJ, Furedy RL, Simonton MJ, Neuffer CH. Patient access to medical records on a psychiatric inpatient unit. Am J Psychiatry 1979; 136: 327-29. 2 McFarlane WJG, Bowman RG, MacInnes M. Patient access to hospital records. Can J Psychiatry 1980; 25: 497-502
LEGAL INTERFERENCE AND CLINICAL FREEDOM
SIR,-I have the dilemma of sharing the views of both Dr Lunn (Jan 3, p 45) and Dr Tomlin (Dec 6, p 1337) about the safety of patients when anaesthetised. The presence of a vigilant anaesthetist may appear to be a first requirement of minimal monitoring of the anaesthetised patient. This does not solve Tomlin’s logistic difficulty of caring for his anaesthetised patient in the operating room and also his patients in the recovery area. Nor does it address the circumstances where patients are, for practical purposes, anaesthetised for hours or days in the intensive care unit and are receiving intravenous opioids, hypnotics, and muscle relaxants administered intermittently or by infusion (by nurses). It is not my experience that an anaesthetist is physically present at all times at the bedside of patients anaesthetised in this way. There surely must be a middle course somewhere between the views expressed by Tomlin and Lunn. Whether anaesthetists have assistants who are paramedics, nurse anaesthetists, or (as now) nurses trained or training in intensive care, I would hope that the law could recognise that delegation of responsibility in anaesthesia (and other medical specialties is a fact of life. Shackleton Department of Anaesthetics, Southampton General Hospital, Southampton SO9 4XY
FATTY ACID
J. M. MANNERS
&bgr;-OXIDATION DEFECTS AND SUDDEN INFANT DEATH
SIR,-Dr Bennett and colleagues (Dec 20/27, p 1470) state that our population of sudden infant death (SIDS) related cases in which we found inherited disorders of fat oxidation1 was highly selected. There may have been selection in the sense that our interest in fatty acid-p-oxidation defects was known but there has not been a true selection on our part. However, we are not claiming that 60% of SIDS
fat oxidation defect. Within eleven cases, near-miss SIDS cases and their siblings, and infants reacting abnormally to immunisation) 13 had a fat-oxidation defect. These 13 infants had an abnormal odour. The perception of such an odour (sweaty feet odour in the room or an acrid, fatty smell on the breath or skin) is the starting point for our biochemical investigations. These disorders cases are
related
to a
months, among 39 children (siblings of SIDS
are
thought to be rare in the general population but our clinical and
biochemical investigations in infants without
a
SIDS-related
problem allowed us to recognise 37 cases of multiple acyl-CoA dehydrogenase deficiency, ethylmalonic-adipicaciduria, or medium-chain acyl-CoA dehydrogenase deficiency. These potentially severe disorders may not be so infrequent, and it is not surprising that they may be encountered in families with SIDS antecedents. It seems too early to try to determine the exact frequency of such disorders in the general population of infants or in SIDS families. In every pioneering study, the typical cases appear first, those without problems of diagnosis. Later on, with more detailed and more sensitive methods, problems of interpretation arise. For example, in mid-November, we introduced a rapid screening method for medium-chain acyl-CoA dehydrogenase deficiency, measuring octanoic acid in plasma and urine before and after alkaline hydrolysis. Normally, there is no detectable octanoic acid in plasma, and urinary concentrations are 1-3 umol/mmol creatinine. Among 15 siblings of SIDS cases, near-miss SIDS cases, or infants with abnormal reactions after an immunisation, selected on the perception of an acrid, fatty smell on their skin, and studied under normal conditions, we have found 8 infants with plasma octanoic values between 9 and 45 Nmol/I (mean 20). In 7 patients whose urine was studied, the level of free octanoic acid was above 3 /lffiol/mmol before alkaline hydrolysis and increased sharply afterwards. Are these infants homozygous or heterozygous for mediumchain acyl-CoA dehydrogenase deficiency? Should we wait for a metabolic crisis to confirm the diagnosis and begin treatment? Study of octanoate oxidation by leucocytes will help us to confirm the diagnosis in some cases. However, it seems that the octanoate oxidation rate has no predictive value for disease severity. With the same residual octanoate oxidation rate, some patients have expressed the disease clinically. Others have not: are they "time bombs" or will they never express the disease? This is a new challenge-whether to treat or not to treat such infants, who may be at risk for SIDS. Paediatric Clinic, Hôpital de la Salpêtrière, 75651 Pans, France
JEAN-PAUL HARPEY
Biochemistry Laboratory, CHU Necker-Enfants Malades, Paris
CHRISTIANE CHARPENTIER
INSERM U 134, Hôpital de la Salpêtrière
MARION PATURNEAU-JOUAS
1.
2
Harpey J-P, Charpentier C, Coudé M, Divry P, Patumeau-Jouas M. Sudden infant death syndrome (SIDS) and multiple acyl-CoA dehydrogenase deficiency (MADD), ethylmalonic-adipic (EMA-AD) aciduria or systemic carnitine deficiency (SCD). 24th annual symposium of Society for the Study of Inborn Errors of Metabolism (Amersfoort, Netherlands, September, 1986) abstr 56. Duran M, Hofkamp M, Rhead WJ, et al. Sudden child death and "healthy" affected family members with medium-chain acyl-coenzyme A dehydrogenase deficiency. Pediatrics 1986, 78: 1052-57.
STREPTOCOCCUS BOVIS BACTERAEMIA AND ITS ASSOCIATION WITH ALIMENTARY-TRACT NEOPLASM
SiR,—Following Klein and colleagues’1 description in 1977 of two patients with Streptococcus bovis endocarditis and adenocarcinoma of the colon several publications have reported Strep bovis endocarditis coincident with cancer of the However, there is still no proof of a causal gastrointestinal connection between these observations. Most reports have been anecdotal and there have been few series; such series, numbering 29-36 patients with Strep bovis bacteraemia, have revealed a frequency of gastrointestinal neoplasm, polyposis, or other gastrointestinal disorder of between 17 and 55%. Another difficulty is the identification of Strep bovis in clinical laboratories.’ Furthermore, the interval between bacteraemia and recognition of the neoplasm has not been established. Since colonic cancer has an estimate doubling time of 626 days clinical recognition of a bacteraemia
or
tract.
up to 7 years,S Finally, we need to know the natural incidence of the gastrointestinal neoplasm in this
malignant disease could take population.
We have analysed 90 cases of Strep bovis bacteraemia (table). The strains were collected in the period 1951-80 and identified in the
NURSING REQUIREMENTS FOR CHILDREN’S INPATIENT CARE
4.
SiR,-Bed occupancy rates are widely used in decisions on how budgets for acute services should be allocated but this method does take into account the special needs of children in hospital. We have evaluated a simple alternative method of assessing the utilisation of children’s inpatient facilities. This children’s department has 42 medical and surgical beds on two wards, there being 3 cots/beds in a side-ward designated for intensive care, 9 double and 7 single cubicles, and 14 cots/beds in small bays. The nursing establishment of 298 whole-time equivalents (WTE) has often seemed inadequate for the supervision that is necessary. The recognition of this shortfall prompted our own audit of nursing activity on the wards. During 1985 the senior nurse on duty at each shift recorded all admissions, overnight stays, and day cases, categorising them as of high, medium, or low dependency, along the lines recommended by the British Paediatric Association/British Association for Perinatal Paediatrics’ for use in neonatal care. High-dependency beds require a nurse in attendance at all times-ie, at least 4 WTE per bed to allow for 24 hour cover and leave. Medium dependency beds require at least 2 and low-dependency at least I WTE per bed. Hospital admission records show that 3421 children were admitted in 1985 with a bed occupancy rate of 46%. Our audit recorded that 3910 children had used inpatient facilities; the extra children were day cases, previous inpatients seen for review, and children sent by a general practitioner for assessment. The usage of the wards varied month to month, the peak being in December, January, and February. The miniinum nursing level to provide a year-round service was calculated from the mean bed usage over a year (table) and was found to be 21 % higher than the existing establishment or an extra 6 trained children’s nurses. However, this addition would not correct all the understaffing during the peak
Services. London: HMSO, 1976. BPA/BAPS Joint Committee on Nursing. Children’s wards and their nurse staffing in the UK 1980. London: Brinsh Paediatric Association, 1981.
not
months. CATEGORIES OF DEPENDENCY AND NURSES
REQUIRED
Children in hospital need specialised nursing care which not only takes account of their clinical needs but also caters for their emotional vulnerability.2 Ten years ago the Court report3 recommended at least 5 trained staff for every 20 beds. In 1980 41 % of children’s wards in England and Wales had lower nurse/bed ratios than thiS.4 Paediatricians have found it difficult to persuade managers of the need to increase the nursing establishment on their wards because the commonly used methods of audit take no account of the specialised needs of children in hospital. Our audit records bed usage by nursing dependency rather than by simply counting occupied beds. One-third of the children in this survey were in high or medium dependency beds. The categories of dependency and associated nursing establishment were extrapolated from those recommended for care of the newborn. Although these recommendations are not accepted by the Department of Health and Social Security, they are recognised by a House of Commons Select Committee on Social Services. ’
We thank Dr Sarah Stewart-Brown and Prof David Baum for their comments.
A. M. EMOND V. H. JONES T. L. CHAMBERS
Children’s Department, Southmead Hospital, Bristol BS10 5NB 1.
Categories of babies receiving neonatal 1985.
care.
London: British Paediatric
Association,
DEMAND FOR ORGAN TRANSPLANTATION IN CHILDREN
SIR,-Dr Harrison’s estimate (Dec 13, p 1383) of the size of the
supply of organs for transplantation in children if anencephalic fetuses were to be used as donors of "spare parts" seems reasonable enough. But the statements about demand require considerably more documentation before they can be accepted as credible. Do the parents of all children with an organ failure which makes them eligible for organ transplantation demand transplantation? There are enough questions about the quality of life after organ transplant’ to make one wonder. Are surgeons responding to need-or are they creating a need to which they respond? The words of fashion designer Diana Vreeland come to mind here. When asked to explain her phenomenal success, she replied: "Give ’em what they don’t know they want." 90 La Cuesta Drive, Greenbrae, California 94904, USA
1.
WILLIAM A. SILVERMAN
Christopherson LK. Quality of life. Organ transplantation and artificial organs. Int J Technology Assessment Health Care-1986; 2: 553-62.
CONFIDENTIALITY OF PRE-EMPLOYMENT
HEALTH SCREENING
.
SiR,-Aris Mariner and colleagues (Dec 6, pl337) are concerned about the confidentiality of pre-employment health screening. I am a consultant adviser in occupational health for several health authorities in the South-East. Our procedure is that all health questionnaires are filled in privately by the applicant and sent in a sealed envelope to the occupational health department, where the forms are seen by the medical and nursing staff. The applicants are assessed on the basis of their health questionnaire and medical interview/examination. At no time are the forms seen by anyone outside the department. We require a detailed health questionnaire within the health authority to assess any aspect of the applicant’s health which could cause concern at work. Equally we have to match the person to the job and the job to the person. These health questionnaires, together with other notes, are kept confidentially in the occupational health department with no access apart from the department’s staff. The clerical staff are only involved with the filing of these documents and these staff are also subject to the rules of confidentiality that no information must be divulged outside the department. Our system is good and reasonable, and we advocate it to other areas. Occupational Health Department, Eastbourne Health Authority, District General Hospital, Eastbourne, East Sussex BN21 2UD
J. M. DAVIDSON
PSYCHIATRIC PATIENTS AND THEIR NOTES
SIR,-Dr Sergeant (Dec 6, p 1322) supports his argument that psychiatric patients would be harmed by reading their medical records by citing extracts from studies which reached a many
different conclusion. He reports that Stein’ "found that 32% of the 102 psychiatric inpatients felt more pessimistic after reading their case-notes and 51 % were upset by some of the entries". This is accurate, but far from the whole picture. Stein wrote: "The vast majority of the patients (77, or 92 %) were in favor of open medical records. They felt that access to their medical records during hospitalization helped them to better understand their problems (75, or 86%) and take a more active role in their treatment (72, or 85%)". Furthermore, 68 % said that access had afforded an opportunity to correct inaccuracies; 84% felt comfortable about reading their records and 71 % felt more self-confident as a result. Stein then went on to say: "However, a substantial minority felt more pessimistic after reading their records (26, or 32%) and roughly half of the
163
patients 51%)".
said they were upset by some of what they read (43, or Stein concluded that "the benefits seem to outweigh the
costs".
Sergeant states that 26 % of staff knew of at least one patient who had been harmed. But he does not acknowledge that Stein suggests they may all have been referring to the same one or two patients; that 70% of staff believed access "helped the treatment of most patients"; and that none thought that access was generally harmful. He cites McFarlane’s study2 in which psychiatric patients with major psychoses saw their records and says of it only that there were "no differences between those granted access to their current hospital records and those who were not". McFarlane found no difference on matters such as refusal of medication, but reported that those who saw their records were "more likely to have correct information about their condition and treatment" and that viewing the record had sometimes proved helpful by "allaying suspicions, developing trust and even in achieving consent for a specific treatment". McFarlane concluded that access was not detrimental and could be used as a therapeutic tool. Most of those who argue for a right of access accept the need for some limitation in a minority of cases, perhaps to allow access to be deferred until after a period of acute disturbance. But the published evidence suggests that the crucial safeguard is the presence of staff to explain what is seen in the record and that, given this, access is not generally harmful—on the contrary, it may be of great value. ,
Campaign for Freedom of Information, 3 Endsleigh Street, London WC1H ODD
MAURICE FRANKEL
1 Stein EJ, Furedy RL, Simonton MJ, Neuffer CH. Patient access to medical records on a psychiatric inpatient unit. Am J Psychiatry 1979; 136: 327-29. 2 McFarlane WJG, Bowman RG, MacInnes M. Patient access to hospital records. Can J Psychiatry 1980; 25: 497-502
LEGAL INTERFERENCE AND CLINICAL FREEDOM
SIR,-I have the dilemma of sharing the views of both Dr Lunn (Jan 3, p 45) and Dr Tomlin (Dec 6, p 1337) about the safety of patients when anaesthetised. The presence of a vigilant anaesthetist may appear to be a first requirement of minimal monitoring of the anaesthetised patient. This does not solve Tomlin’s logistic difficulty of caring for his anaesthetised patient in the operating room and also his patients in the recovery area. Nor does it address the circumstances where patients are, for practical purposes, anaesthetised for hours or days in the intensive care unit and are receiving intravenous opioids, hypnotics, and muscle relaxants administered intermittently or by infusion (by nurses). It is not my experience that an anaesthetist is physically present at all times at the bedside of patients anaesthetised in this way. There surely must be a middle course somewhere between the views expressed by Tomlin and Lunn. Whether anaesthetists have assistants who are paramedics, nurse anaesthetists, or (as now) nurses trained or training in intensive care, I would hope that the law could recognise that delegation of responsibility in anaesthesia (and other medical specialties is a fact of life. Shackleton Department of Anaesthetics, Southampton General Hospital, Southampton SO9 4XY
FATTY ACID
J. M. MANNERS
&bgr;-OXIDATION DEFECTS AND SUDDEN INFANT DEATH
SIR,-Dr Bennett and colleagues (Dec 20/27, p 1470) state that our population of sudden infant death (SIDS) related cases in which we found inherited disorders of fat oxidation1 was highly selected. There may have been selection in the sense that our interest in fatty acid-p-oxidation defects was known but there has not been a true selection on our part. However, we are not claiming that 60% of SIDS
fat oxidation defect. Within eleven cases, near-miss SIDS cases and their siblings, and infants reacting abnormally to immunisation) 13 had a fat-oxidation defect. These 13 infants had an abnormal odour. The perception of such an odour (sweaty feet odour in the room or an acrid, fatty smell on the breath or skin) is the starting point for our biochemical investigations. These disorders cases are
related
to a
months, among 39 children (siblings of SIDS
are
thought to be rare in the general population but our clinical and
biochemical investigations in infants without
a
SIDS-related
problem allowed us to recognise 37 cases of multiple acyl-CoA dehydrogenase deficiency, ethylmalonic-adipicaciduria, or medium-chain acyl-CoA dehydrogenase deficiency. These potentially severe disorders may not be so infrequent, and it is not surprising that they may be encountered in families with SIDS antecedents. It seems too early to try to determine the exact frequency of such disorders in the general population of infants or in SIDS families. In every pioneering study, the typical cases appear first, those without problems of diagnosis. Later on, with more detailed and more sensitive methods, problems of interpretation arise. For example, in mid-November, we introduced a rapid screening method for medium-chain acyl-CoA dehydrogenase deficiency, measuring octanoic acid in plasma and urine before and after alkaline hydrolysis. Normally, there is no detectable octanoic acid in plasma, and urinary concentrations are 1-3 umol/mmol creatinine. Among 15 siblings of SIDS cases, near-miss SIDS cases, or infants with abnormal reactions after an immunisation, selected on the perception of an acrid, fatty smell on their skin, and studied under normal conditions, we have found 8 infants with plasma octanoic values between 9 and 45 Nmol/I (mean 20). In 7 patients whose urine was studied, the level of free octanoic acid was above 3 /lffiol/mmol before alkaline hydrolysis and increased sharply afterwards. Are these infants homozygous or heterozygous for mediumchain acyl-CoA dehydrogenase deficiency? Should we wait for a metabolic crisis to confirm the diagnosis and begin treatment? Study of octanoate oxidation by leucocytes will help us to confirm the diagnosis in some cases. However, it seems that the octanoate oxidation rate has no predictive value for disease severity. With the same residual octanoate oxidation rate, some patients have expressed the disease clinically. Others have not: are they "time bombs" or will they never express the disease? This is a new challenge-whether to treat or not to treat such infants, who may be at risk for SIDS. Paediatric Clinic, Hôpital de la Salpêtrière, 75651 Pans, France
JEAN-PAUL HARPEY
Biochemistry Laboratory, CHU Necker-Enfants Malades, Paris
CHRISTIANE CHARPENTIER
INSERM U 134, Hôpital de la Salpêtrière
MARION PATURNEAU-JOUAS
1.
2
Harpey J-P, Charpentier C, Coudé M, Divry P, Patumeau-Jouas M. Sudden infant death syndrome (SIDS) and multiple acyl-CoA dehydrogenase deficiency (MADD), ethylmalonic-adipic (EMA-AD) aciduria or systemic carnitine deficiency (SCD). 24th annual symposium of Society for the Study of Inborn Errors of Metabolism (Amersfoort, Netherlands, September, 1986) abstr 56. Duran M, Hofkamp M, Rhead WJ, et al. Sudden child death and "healthy" affected family members with medium-chain acyl-coenzyme A dehydrogenase deficiency. Pediatrics 1986, 78: 1052-57.
STREPTOCOCCUS BOVIS BACTERAEMIA AND ITS ASSOCIATION WITH ALIMENTARY-TRACT NEOPLASM
SiR,—Following Klein and colleagues’1 description in 1977 of two patients with Streptococcus bovis endocarditis and adenocarcinoma of the colon several publications have reported Strep bovis endocarditis coincident with cancer of the However, there is still no proof of a causal gastrointestinal connection between these observations. Most reports have been anecdotal and there have been few series; such series, numbering 29-36 patients with Strep bovis bacteraemia, have revealed a frequency of gastrointestinal neoplasm, polyposis, or other gastrointestinal disorder of between 17 and 55%. Another difficulty is the identification of Strep bovis in clinical laboratories.’ Furthermore, the interval between bacteraemia and recognition of the neoplasm has not been established. Since colonic cancer has an estimate doubling time of 626 days clinical recognition of a bacteraemia
or
tract.
up to 7 years,S Finally, we need to know the natural incidence of the gastrointestinal neoplasm in this
malignant disease could take population.
We have analysed 90 cases of Strep bovis bacteraemia (table). The strains were collected in the period 1951-80 and identified in the