- Email: [email protected]
SIDE-EFFECTS OF SYNTHETIC SALMON AND HUMAN CALCITONIN
594
SIR,-Your Feb. 5 editorial (p. 280) emphasises some of the principles that should govern the use of intravenous megadose methylprednisolone in the treatment of multisystem disorders. We have seen cardiovascular complications of this treatment, particularly in renal allograft recipients. A 55-year-old man went into asystole 15 min after the end of an infusion of methylprednisolone 30 mg/kg, given over 20 min as part of our routine post-transplant care, and died. A 49-year-old man sustained an uncomplicated transmural anterior myocardial infarction during a similar methylprednisolone infusion after transplantation. A 22-year-old man with a history of malignant hypertension was given methylprednisolone on the same protocol, and towards the end of the infusion episodes of supraventricular tachycardia developed which were effectively treated. A 64-year-old man with rapidly progressive renal failure and polyarteritis nodosa had an extensive anteroseptal myocardial infarction during the intravenous infusion of methylprednisolone 30 mg/kg over 30 min. He made a good recovery. These clinical events led us to study the changes in the circulation during methylprednisolone infusion. Six male renal allograft recipients aged 17-54 years were studied during the course of methylprednisolone infusion as part of routine post-transplant care. The patients were studied on day 9 after renal transplantation, when renal function was stable and serum creatinine was less than 200 fmol/1. All were taking oral prednisolone 45 mg and azathioprine 1 - 5 mg/kg body weight daily. All had been given intravenous methylprednisolone 30 mg/kg body weight on days 1, 3, 5, and 7 after transplantation without clinical complications. The patients rested supine and the forearm arteriovenous fistula was cannulated with two 16 gauge needles for measurement of cardiac output by dye dilution. Heart rate was monitored on an ECG recorder and blood pressure was recorded by’Arteriosonde’. Haemodynamic measurements were made 10 min before, just before, and twice 10 min apart during the 20 min infusion of methylprednisolone, and, 10,20, and 30 min after the infusion. Control infusions were done in all patients with 100 ml of 5% dextrose over 20 min. The results are shown in the table. 5% dextrose had no effect on heart rate, arterial pressure, cardiac index, or total peripheral HAEMODYNAMIC CHANGES DURING INTRAVENOUS METHYLPREDNISOLONE INFUSION
anaesthetised dogs,4and normal man.’ Our patients had a normal to high cardiac output as a consequence of anaemia, an arteriovenous fistula, and possible hypervolaemia. In addition it is possible that in our patients the metabolism of methylprednisolone is abnormal or that vascular reactivity to endogenous vasopressor agents is modified by methylprednisolone. This possibility is supported by our observation that plasma noradrenaline levels are raised in renal show increased pressor responsiveness to transplant recipients, who infused noradrenaline.6 Many patients with multisystem disorders will be prone, by the nature of their underlying disease, to unpredictable cardiovascular events and occasional arrhythmias. Our renal transplant recipients clearly differ in many respects from patients with other multisystem disorders who may be given methylprednisolone intravenously. While further observations on the effects of megadose intravenous methylprednisolone are being made in other groups of patients we feel that it would be prudent to measure blood pressure and heart rate and to monitor the ECG during such treatment in all patients. Department of Renal Medicine, University of Southampton, St Mary’s Hospital, Portsmouth
as mean t
SEM.
resistance. During the methylprednisolone infusion the cardiac index fell significantly. Heart rate did not change during or after the infusion. By the end of the infusion mean arterial pressure was 13 mm Hg higher than before the infusion. The rise in systolic pressure in individuals ranged from 18 to 27 mm Hg. Total peripheral resistance rose significantly during the course of infusion. No abnormalities of cardiac rhythm were observed. Sudden death during or immediately after infusion of methylprednisolone may occur in renal transplant recipients and a variety of bizarre ECG complexes have been seen.I,2Some of these abnormalities may be a consequence of the rapid rise in blood pressure which we have demonstrated, but myocardial toxicity of methylprednisolone has not been excluded. The effects of methylprednisolone that we have found differ from those seen in rats subject to experimental circulatory shock,33 SS, Morrell RM. Intravenous methylprednisolone sodium succinate: Adverse reported in association with immunosuppressive therapy Transplant Proc 1973; 5: 1145-46. McDougal BA, Whittier FC, Cross DE. Sudden death after bolus steroid therapy for acute rejection. Transplant Proc 1976; 8: 493-96. Altura BM, Altura BT. Peripheral vascular actions of glucocorticoids and their relationship to protection in circulatory shock. J Pharmacol Exp Ther 1975; 190:
1. Stubbs
reactions
2. 3
300-05.
R. S. SMITH
SIDE-EFFECTS OF SYNTHETIC SALMON AND HUMAN CALCITONIN
SIR,-Synthetic calcitonins are wiody used for the treatment of Paget’s bone disease. The first had the porcine calcitonin structure. Then followed synthetic salmon calcitonin which was much more potent than porcine calcitonin. Human calcitonin has also been synthesised; in biological activity it seems to be more potent than porcine but less potent than salmon calcitonin, though few comparative studies have been published. Unwanted effects of calcitonin are said to occur in up to 10% of patients, although stopping treatment is not always required.2The most important side-effects include gastrointestinal symptoms (nausea, vomiting, abdominal pain, diarrhoea) and vascular symptoms (flushing, tingling of the hands). Pain at the site of injection, urinary frequency, rash, and an unpleasant metallic taste have also been described. We have compared the side-effects in clinical usage of salmon (sCT) and human (hCT) calcitonin as part of a larger study to evaluate the analgesic activity of calcitonin in man. 36 patients with bone metastases or postmenopausal osteoporosis were treated with sCT (100 MRC units daily), hCT (100 MRC units daily), or placebo (one ampoule of 0-9% saline daily) intramuscularly for 15 consecutive days. Patients were asked daily about unwanted effects, always by the same physician who recorded on a check-list the severity of each
symptom (0 = absent Data
D. J. WARREN PO3 6AD
to
4 = severe).
The results (see table) suggest that unwanted effects are common with hCT than with sCT and that they are also
more more
T, Andersen K, Veljlsted H. Immediate hemodynamic effect of pharmacological doses of methylprednisolone in dogs, and the influence of speed of
4. Husum B, Palm
injection. Acta Anaesthesiol Scand 1980; 24: 61-64. E, Stubbs SS, Seckman CE, Hearron MS. Effects of a single large intravenous dose of methylprednisolone sodium succinate. Clin Pharmacol Ther 1970, 11: 711. 6. Smith RS, Warren DJ. Adrenergic components of hypertension after renal transplantation. Clin Sci Mol Med 1981; 61: 187s-190s 1. Gennari C, Chierichetti SM, Vibelli C, Francini G, Maioli E, Gonnelli S. Acute effects of salmon, human and porcine calcitonin on plasma calcium and cyclic AMP levels in Man. Curr Ther Res 1981; 30: 1024-32. 2. Singer FR, Freoricks RS, Minkin C. Salmon calcitonin therapy for Paget’s disease of bone. Arthr Rheum 1976; 23: 1148-54 5. Novak
SIDE EFFECTS OBSERVED IN PATIENTS ON PLACEBO
(hCT) OR SALMON (SCT) CALCITONIN
(p) OR HUMAN
595 severe, the ratio between the sum of the severity scores and the number of events observed being 23 for hCT and 18 for sCT. Pain at the site of injection seems to be a common problem with hCT, since it was found in 5 of 12 patients. Injection site pain was recorded in only 1 each of the sCT and placebo treatment groups. sCT is an effective drug for treatment of Paget’s bone disease, hypercalcaemia of malignancy, and, probably, for postmenopausal osteoporosis. Preliminary data from our other studies (unpublished) have shown definite analgesic activity for sCT, while hCT does not seem to have such activity. More data are needed on the cost-benefit ratio of hCT therapy. Institute of Medical
Symptomatology,
C. GENNARI
University of Siena Institute of
Gerontology and Geriatry,
accords with the conclusions of the McMaster group,any such innovations must be contingent on further corroborative studies. Department of Internal Medicine, University of Stellenbosch, Tygerberg, 7505 South Africa
R. F. GLEDHILL
M. PASSERI
University of Parma Medical Department,
S. M. CHIERICHETTI M. PIOLINI
Sandoz SpA, 20135 Milan, Italy
EVALUATING CLINICAL COMPETENCE IN STUDENTS
SIR,-Structured practical examinations have been introduced in attempt to improve the assessment of clinical competence of students.l,2 At this university the clinical ability of fourth year medical students is assessed by the objective structured clinical examination (OSCE)3 described by Harden and Gleeson.1 The internal medicine OSCE includes a test of neurological skill, in which students do a physical examination (P) and answer questions (Q) on their findings. Examiners use behavioural check lists4to rate the observed performance of the students, marks being awarded for thoroughness (PJ, general proficiency (Pp) and attitude to the patient (Pa); and the questions are of the single true-false type. In 1980 (n= 143) and in 1981 (n= l70), the correlation between P,p., and Q score was weak (r=0-25 and r=0-18, respectively). These findings were surprising; we had expected that students who were judged the more competent in performance would also be the more proficient in observing clinical signs. Moreover, Harden et al.5 reported a highly significant correlation between PtPa score and Q score in a similar test of cardiological skills (r=0’58, p<0 00 1). However, in 1980 and in 1981, dissimilar patient problems were used and different faculty staff examined at each daily session, which could have biased the results. Furthermore, general proficiency and attitude to the patient might be considered dimensions of competence distinct from that required for noting manifest signs; these competences, though, were included in the study cited. In 1982, students (n=121) were assessed on similar patient problems; physical examination was judged by a pair from four examiners, one of whom examined on all 4 days, and their individual ratings were combined. The correlation coefficients between Ptpa, PIp, and Pt score and Q score were 0-14, 0 - 16, and 0 . 17, respectively. In whatever way these findings might be explained, they do suggest the 1980 and 1981 results were probably recording the same phenomenon-namely, that appraisal of performance does not reflect student ability to evaluate the patient’s neurological state. Support for such a conclusion is provided by a recent report from McMaster University,6 in which a more comprehensive evaluation an
of clinical skills was studied. 1 Harden
The acquisition of diagnostic skills is a key objective in undergraduate medical education. This experience at Stellenbosch suggests that, as presently administered, the OSCE instrument is yielding an ambiguous account of such skills. Until the practical implications of a thorough and generally proficient observed performance are adequately resolved, efforts to improve the accuracy of assessing clinical competence in fourth year medical students should perhaps concentrate rather on testing student ability to detect, elicit, and register. While the concept of shifting the emphasis in clinical skills evaluation from process to outcome
RM, Gleeson FA Assessment of clinical competence using an objective structured clinical examination (OSCE): ASME medical education booklet no 8. Med Educ 1979; 13: 39. 2. Newble DI, Elmslie RG. A new approach to the final examinations in medicine and surgery Lancet 1981; ii: 517-18 3 Wassermann HP, Slabbert BR, Van Zyl JJ. Die objektiefstruktureerde Kliniese Eksamen (OSKE). S Afr Med J 1982; 61: 325-30. 4 Andrew BJ. The use of behavioural checklists to assess physical examination skills. J Med Educ 1977; 52: 589-91. 5. Harden RM, Stevenson M, Wilson Downie W, Wilson GM. Assessment of clinical competence using objective structured examination. Br Med J 1975; i: 447-51. 6. Harper AC, Roy WB, Norman GR, Rand CA, Feighter JW. Difficulties in clinical skills evaluation Med Educ 1983; 17: 24-27
CARDIOPULMONARY RESUSCITATION TRAINING IN THE USA
SIR,-In reference to your Dec. 11 editorial on cardiopulmonary resuscitation (CPR), we would point out that the Joint Commission on Accreditation no longer requires that every physician on a hospital staff receive .CPR training. According to the 1983 standards, "staff members should be encouraged to participate in pertinent self-assessment programs and in basic cardiopulmonary resuscitation training"’. We understand that the regulation was changed from a requirement to a suggestion because of protests from doctors. There is great variation among American hospitals in the level of CPR training required for doctors and other health professionals. Although the studies you cited point out the benefits of bystander initiated CPR, this has not always carried over to hospital staff. We believe that the life-saving potential of CPR training should be reason enough for all American hospitals to develop in-house CPR programmes, but the diversity of the medical care system is such that this has not been done. One suggestion for implementation has been successful at the University Hospital of Cleveland where the 1400 physicians are required to be trained in basic life support. Sharon Lyon, CPR coordinator, has trained physicians to train other physicians.In this way a basic rapport exists so that the physicians feel comfortable with one another and training is conducted at their level. Advances are being made in both lay and professional CPR training, but we are far from the stage in which all physicians in American hospitals receive training. Warren
Hospital, Phillipsburg, New Jersey 08865, USA
WILLIAM F. HANISEK ROBERT B. MCMANMON PATRICIA A. MATHEWS
RESIGNATION OF SOVIET PSYCHIATRISTS
Six,-The resignation of the All Union Society of Neuro-
pathologists
and
Psychiatrists
from the World
Psychiatric
Association, the subject of Dr Wynn’s article (Feb. 19, p. 406), came no surprise to many doctors who had noticed the severe harassment of Soviet psychiatrists in many scientific meetings by a lobby of psychiatrists whose aim is political gain. Of course there is transcultural variation in the diagnostic criteria for schizophrenia. "Sluggish schizophrenia" could have an equivalent in the DSM III and 8th ICD classifications. The simple type, latent schizophrenia, and even the acute undifferentiated schizophrenia are some variations. Despite more than half a century of discussions, there still exist many opposing views about the classification of mental illness. Soviet psychiatrists use the diagnosis sluggish schizophrenia in their cultural setting, in which they are as
hospitals. Joint Commission on Accreditation of Hospitals, Chicago, Illinois, 1983: 100 Implications of in-house CPR instruction extend beyond hospital into community. Hospitals Dec. 1, 1982: 48.
1. Accreditation manual for
2.
SIR,-Your Feb. 5 editorial (p. 280) emphasises some of the principles that should govern the use of intravenous megadose methylprednisolone in the treatment of multisystem disorders. We have seen cardiovascular complications of this treatment, particularly in renal allograft recipients. A 55-year-old man went into asystole 15 min after the end of an infusion of methylprednisolone 30 mg/kg, given over 20 min as part of our routine post-transplant care, and died. A 49-year-old man sustained an uncomplicated transmural anterior myocardial infarction during a similar methylprednisolone infusion after transplantation. A 22-year-old man with a history of malignant hypertension was given methylprednisolone on the same protocol, and towards the end of the infusion episodes of supraventricular tachycardia developed which were effectively treated. A 64-year-old man with rapidly progressive renal failure and polyarteritis nodosa had an extensive anteroseptal myocardial infarction during the intravenous infusion of methylprednisolone 30 mg/kg over 30 min. He made a good recovery. These clinical events led us to study the changes in the circulation during methylprednisolone infusion. Six male renal allograft recipients aged 17-54 years were studied during the course of methylprednisolone infusion as part of routine post-transplant care. The patients were studied on day 9 after renal transplantation, when renal function was stable and serum creatinine was less than 200 fmol/1. All were taking oral prednisolone 45 mg and azathioprine 1 - 5 mg/kg body weight daily. All had been given intravenous methylprednisolone 30 mg/kg body weight on days 1, 3, 5, and 7 after transplantation without clinical complications. The patients rested supine and the forearm arteriovenous fistula was cannulated with two 16 gauge needles for measurement of cardiac output by dye dilution. Heart rate was monitored on an ECG recorder and blood pressure was recorded by’Arteriosonde’. Haemodynamic measurements were made 10 min before, just before, and twice 10 min apart during the 20 min infusion of methylprednisolone, and, 10,20, and 30 min after the infusion. Control infusions were done in all patients with 100 ml of 5% dextrose over 20 min. The results are shown in the table. 5% dextrose had no effect on heart rate, arterial pressure, cardiac index, or total peripheral HAEMODYNAMIC CHANGES DURING INTRAVENOUS METHYLPREDNISOLONE INFUSION
anaesthetised dogs,4and normal man.’ Our patients had a normal to high cardiac output as a consequence of anaemia, an arteriovenous fistula, and possible hypervolaemia. In addition it is possible that in our patients the metabolism of methylprednisolone is abnormal or that vascular reactivity to endogenous vasopressor agents is modified by methylprednisolone. This possibility is supported by our observation that plasma noradrenaline levels are raised in renal show increased pressor responsiveness to transplant recipients, who infused noradrenaline.6 Many patients with multisystem disorders will be prone, by the nature of their underlying disease, to unpredictable cardiovascular events and occasional arrhythmias. Our renal transplant recipients clearly differ in many respects from patients with other multisystem disorders who may be given methylprednisolone intravenously. While further observations on the effects of megadose intravenous methylprednisolone are being made in other groups of patients we feel that it would be prudent to measure blood pressure and heart rate and to monitor the ECG during such treatment in all patients. Department of Renal Medicine, University of Southampton, St Mary’s Hospital, Portsmouth
as mean t
SEM.
resistance. During the methylprednisolone infusion the cardiac index fell significantly. Heart rate did not change during or after the infusion. By the end of the infusion mean arterial pressure was 13 mm Hg higher than before the infusion. The rise in systolic pressure in individuals ranged from 18 to 27 mm Hg. Total peripheral resistance rose significantly during the course of infusion. No abnormalities of cardiac rhythm were observed. Sudden death during or immediately after infusion of methylprednisolone may occur in renal transplant recipients and a variety of bizarre ECG complexes have been seen.I,2Some of these abnormalities may be a consequence of the rapid rise in blood pressure which we have demonstrated, but myocardial toxicity of methylprednisolone has not been excluded. The effects of methylprednisolone that we have found differ from those seen in rats subject to experimental circulatory shock,33 SS, Morrell RM. Intravenous methylprednisolone sodium succinate: Adverse reported in association with immunosuppressive therapy Transplant Proc 1973; 5: 1145-46. McDougal BA, Whittier FC, Cross DE. Sudden death after bolus steroid therapy for acute rejection. Transplant Proc 1976; 8: 493-96. Altura BM, Altura BT. Peripheral vascular actions of glucocorticoids and their relationship to protection in circulatory shock. J Pharmacol Exp Ther 1975; 190:
1. Stubbs
reactions
2. 3
300-05.
R. S. SMITH
SIDE-EFFECTS OF SYNTHETIC SALMON AND HUMAN CALCITONIN
SIR,-Synthetic calcitonins are wiody used for the treatment of Paget’s bone disease. The first had the porcine calcitonin structure. Then followed synthetic salmon calcitonin which was much more potent than porcine calcitonin. Human calcitonin has also been synthesised; in biological activity it seems to be more potent than porcine but less potent than salmon calcitonin, though few comparative studies have been published. Unwanted effects of calcitonin are said to occur in up to 10% of patients, although stopping treatment is not always required.2The most important side-effects include gastrointestinal symptoms (nausea, vomiting, abdominal pain, diarrhoea) and vascular symptoms (flushing, tingling of the hands). Pain at the site of injection, urinary frequency, rash, and an unpleasant metallic taste have also been described. We have compared the side-effects in clinical usage of salmon (sCT) and human (hCT) calcitonin as part of a larger study to evaluate the analgesic activity of calcitonin in man. 36 patients with bone metastases or postmenopausal osteoporosis were treated with sCT (100 MRC units daily), hCT (100 MRC units daily), or placebo (one ampoule of 0-9% saline daily) intramuscularly for 15 consecutive days. Patients were asked daily about unwanted effects, always by the same physician who recorded on a check-list the severity of each
symptom (0 = absent Data
D. J. WARREN PO3 6AD
to
4 = severe).
The results (see table) suggest that unwanted effects are common with hCT than with sCT and that they are also
more more
T, Andersen K, Veljlsted H. Immediate hemodynamic effect of pharmacological doses of methylprednisolone in dogs, and the influence of speed of
4. Husum B, Palm
injection. Acta Anaesthesiol Scand 1980; 24: 61-64. E, Stubbs SS, Seckman CE, Hearron MS. Effects of a single large intravenous dose of methylprednisolone sodium succinate. Clin Pharmacol Ther 1970, 11: 711. 6. Smith RS, Warren DJ. Adrenergic components of hypertension after renal transplantation. Clin Sci Mol Med 1981; 61: 187s-190s 1. Gennari C, Chierichetti SM, Vibelli C, Francini G, Maioli E, Gonnelli S. Acute effects of salmon, human and porcine calcitonin on plasma calcium and cyclic AMP levels in Man. Curr Ther Res 1981; 30: 1024-32. 2. Singer FR, Freoricks RS, Minkin C. Salmon calcitonin therapy for Paget’s disease of bone. Arthr Rheum 1976; 23: 1148-54 5. Novak
SIDE EFFECTS OBSERVED IN PATIENTS ON PLACEBO
(hCT) OR SALMON (SCT) CALCITONIN
(p) OR HUMAN
595 severe, the ratio between the sum of the severity scores and the number of events observed being 23 for hCT and 18 for sCT. Pain at the site of injection seems to be a common problem with hCT, since it was found in 5 of 12 patients. Injection site pain was recorded in only 1 each of the sCT and placebo treatment groups. sCT is an effective drug for treatment of Paget’s bone disease, hypercalcaemia of malignancy, and, probably, for postmenopausal osteoporosis. Preliminary data from our other studies (unpublished) have shown definite analgesic activity for sCT, while hCT does not seem to have such activity. More data are needed on the cost-benefit ratio of hCT therapy. Institute of Medical
Symptomatology,
C. GENNARI
University of Siena Institute of
Gerontology and Geriatry,
accords with the conclusions of the McMaster group,any such innovations must be contingent on further corroborative studies. Department of Internal Medicine, University of Stellenbosch, Tygerberg, 7505 South Africa
R. F. GLEDHILL
M. PASSERI
University of Parma Medical Department,
S. M. CHIERICHETTI M. PIOLINI
Sandoz SpA, 20135 Milan, Italy
EVALUATING CLINICAL COMPETENCE IN STUDENTS
SIR,-Structured practical examinations have been introduced in attempt to improve the assessment of clinical competence of students.l,2 At this university the clinical ability of fourth year medical students is assessed by the objective structured clinical examination (OSCE)3 described by Harden and Gleeson.1 The internal medicine OSCE includes a test of neurological skill, in which students do a physical examination (P) and answer questions (Q) on their findings. Examiners use behavioural check lists4to rate the observed performance of the students, marks being awarded for thoroughness (PJ, general proficiency (Pp) and attitude to the patient (Pa); and the questions are of the single true-false type. In 1980 (n= 143) and in 1981 (n= l70), the correlation between P,p., and Q score was weak (r=0-25 and r=0-18, respectively). These findings were surprising; we had expected that students who were judged the more competent in performance would also be the more proficient in observing clinical signs. Moreover, Harden et al.5 reported a highly significant correlation between PtPa score and Q score in a similar test of cardiological skills (r=0’58, p<0 00 1). However, in 1980 and in 1981, dissimilar patient problems were used and different faculty staff examined at each daily session, which could have biased the results. Furthermore, general proficiency and attitude to the patient might be considered dimensions of competence distinct from that required for noting manifest signs; these competences, though, were included in the study cited. In 1982, students (n=121) were assessed on similar patient problems; physical examination was judged by a pair from four examiners, one of whom examined on all 4 days, and their individual ratings were combined. The correlation coefficients between Ptpa, PIp, and Pt score and Q score were 0-14, 0 - 16, and 0 . 17, respectively. In whatever way these findings might be explained, they do suggest the 1980 and 1981 results were probably recording the same phenomenon-namely, that appraisal of performance does not reflect student ability to evaluate the patient’s neurological state. Support for such a conclusion is provided by a recent report from McMaster University,6 in which a more comprehensive evaluation an
of clinical skills was studied. 1 Harden
The acquisition of diagnostic skills is a key objective in undergraduate medical education. This experience at Stellenbosch suggests that, as presently administered, the OSCE instrument is yielding an ambiguous account of such skills. Until the practical implications of a thorough and generally proficient observed performance are adequately resolved, efforts to improve the accuracy of assessing clinical competence in fourth year medical students should perhaps concentrate rather on testing student ability to detect, elicit, and register. While the concept of shifting the emphasis in clinical skills evaluation from process to outcome
RM, Gleeson FA Assessment of clinical competence using an objective structured clinical examination (OSCE): ASME medical education booklet no 8. Med Educ 1979; 13: 39. 2. Newble DI, Elmslie RG. A new approach to the final examinations in medicine and surgery Lancet 1981; ii: 517-18 3 Wassermann HP, Slabbert BR, Van Zyl JJ. Die objektiefstruktureerde Kliniese Eksamen (OSKE). S Afr Med J 1982; 61: 325-30. 4 Andrew BJ. The use of behavioural checklists to assess physical examination skills. J Med Educ 1977; 52: 589-91. 5. Harden RM, Stevenson M, Wilson Downie W, Wilson GM. Assessment of clinical competence using objective structured examination. Br Med J 1975; i: 447-51. 6. Harper AC, Roy WB, Norman GR, Rand CA, Feighter JW. Difficulties in clinical skills evaluation Med Educ 1983; 17: 24-27
CARDIOPULMONARY RESUSCITATION TRAINING IN THE USA
SIR,-In reference to your Dec. 11 editorial on cardiopulmonary resuscitation (CPR), we would point out that the Joint Commission on Accreditation no longer requires that every physician on a hospital staff receive .CPR training. According to the 1983 standards, "staff members should be encouraged to participate in pertinent self-assessment programs and in basic cardiopulmonary resuscitation training"’. We understand that the regulation was changed from a requirement to a suggestion because of protests from doctors. There is great variation among American hospitals in the level of CPR training required for doctors and other health professionals. Although the studies you cited point out the benefits of bystander initiated CPR, this has not always carried over to hospital staff. We believe that the life-saving potential of CPR training should be reason enough for all American hospitals to develop in-house CPR programmes, but the diversity of the medical care system is such that this has not been done. One suggestion for implementation has been successful at the University Hospital of Cleveland where the 1400 physicians are required to be trained in basic life support. Sharon Lyon, CPR coordinator, has trained physicians to train other physicians.In this way a basic rapport exists so that the physicians feel comfortable with one another and training is conducted at their level. Advances are being made in both lay and professional CPR training, but we are far from the stage in which all physicians in American hospitals receive training. Warren
Hospital, Phillipsburg, New Jersey 08865, USA
WILLIAM F. HANISEK ROBERT B. MCMANMON PATRICIA A. MATHEWS
RESIGNATION OF SOVIET PSYCHIATRISTS
Six,-The resignation of the All Union Society of Neuro-
pathologists
and
Psychiatrists
from the World
Psychiatric
Association, the subject of Dr Wynn’s article (Feb. 19, p. 406), came no surprise to many doctors who had noticed the severe harassment of Soviet psychiatrists in many scientific meetings by a lobby of psychiatrists whose aim is political gain. Of course there is transcultural variation in the diagnostic criteria for schizophrenia. "Sluggish schizophrenia" could have an equivalent in the DSM III and 8th ICD classifications. The simple type, latent schizophrenia, and even the acute undifferentiated schizophrenia are some variations. Despite more than half a century of discussions, there still exist many opposing views about the classification of mental illness. Soviet psychiatrists use the diagnosis sluggish schizophrenia in their cultural setting, in which they are as
hospitals. Joint Commission on Accreditation of Hospitals, Chicago, Illinois, 1983: 100 Implications of in-house CPR instruction extend beyond hospital into community. Hospitals Dec. 1, 1982: 48.
1. Accreditation manual for
2.