- Email: [email protected]
TEACHING GOOD ANTIMICROBIAL PRESCRIBING
1224 group of highly selected, motivated addicts. There are many such groups, all needing a different approach but too many people lump
them together and
impose a preconceived treatment policy. ANN DALLY,
13 Devonshire Place, London WIN 1PB
President, AIDA
PLASTIC BULLETS IN RIOT CONTROL
SIR,-It was encouraging to read Mr Rocke’s comparison of injuries from plastic bullets with those caused by rubber bullets p 919). These weapons have been used in Northern Ireland for crowd control for over ten years. However, there has been a remarkable dearth of medical evidence about the injuries they cause. Good objective evidence is needed in view of the controversy over the use of plastic bullets. Over the past year or so police forces in England have been trained and equipped to use them. In ten police authorities chief constables have been instructed by their local police committees to get rid of stocks of plastic bullets. The committees regard them as too dangerous for crowd control and judge that they would be counterproductive in a riot. Last October, while medical representative on an inquiry in Belfast into deaths and injuries caused by plastic bullets, I saw some injuries caused by plastic bullets. The inquirywas organised by the Association for Legal Justice and leading members of the church in Northern Ireland. Other members of the panel included a professor of law, a member of the European Parliament, a barrister, and representatives from the National Council for Civil Liberties and the British Society for Social Responsibility in Science. The inquiry was shocked both by the severity of the injuries caused and by the way in which plastic bullets have been used by the security forces. Police and Army regulations state that these bullets should be used only as a last resort, should be fired at the lower parts of the body, and should not be used at a range of less than 20 m unless there is a direct threat to the security forces. From evidence we heard it seems that the death rate cited by Rocke (1 per 4000 rounds used) is low enough for the soldiers to feel they can use these weapons whenever they wish. We questioned witnesses in great detail and were left with no doubt whatsoever that these weapons are being misused. How else can the deaths of the 11 and 14 year old girls mentioned in Rocke’s paper be explained? Indeed, of the fourteen deaths due to rubber and plastic bullets in the past 12 years in Northern Ireland six have been in children, and children as young as 5 and 6 years have received severe injuries requiring hospital care. Plastic bullets replaced rubber ones because they are more accurate, so that ringleaders can be "picked out". US Congressmen have criticised the use of plastic bullets in Northern Ireland; the European Parliament has called for a ban, as have the Labour, Liberal and Social Democratic parties. Surely, in the light of the serious injuries Rocke has described, doctors should speak out against the continuing use of plastic bullets in Northern Ireland and against the arming of the police in England with such weapons.
(April 23,
363 Hahfax Road,
Wadsley Bridge, Sheffield S6 IAF
A. P. REDGRAVE
Several years ago, the microbiology department at Nottingham started a course in antimicrobial chemotherapy which is taught for a six-week period in the spring term of the third year. In this medical school the third year leads to a bachelor of medical sciences degree which all students take before embarking on their clinical studies. Our chemotherapy course is one of several options from which the students can choose, and about one-fifth of the students in any one year are able to enrol. Surprisingly, and gratifyingly, the course has turned out to be very popular with the students, some of whom have even expressed the opinion that colleagues who have not taken the course are at a disadvantage during their clinical studies. Medical school preclinical courses have sometimes been criticised for forgetting to teach the practicalities of subjects in their efforts to achieve scientific excellence. The failure to instil good prescribing habits in young doctors may be a case in point. Department of Microbiology, University Hospital, Queen’s Medical Centre, Nottingham NG7 2UH
DAVID GREENWOOD
DRINKING DURING PREGNANCY
SIR,-We read with interest the letter from Dr English and Dr Bower (May 14, p 1111) commenting both on your March 26 editorial and on the article from our group in the same issue (p 663). In our study 147 of the 900 patients were teetotallers, and 10-9% of their babies had birthweights below the 10th centile. In the light drinkers, the corresponding percentage is 8 - 3, in the moderate drinkers 10 - 0, and in the heavy drinkers 17 - 4. This suggests that adverse effects occur only when 100 g of alcohol per week is the level of consumption. The list of possible confounding variables is almost endless. Fortunately, social class (which we corrected for) is highly correlated with maternal age and parity, and one would not expect the estimated relative risk to change much if further adjustment for these factors is carried out. Malnutrition is not a problem in our West London population. We agree that logistic regression is the way to deal with many confounding variables, and are now doing additional analyses with this method. When maternal age is adjusted for, in addition to smoking, the estimated relative risk for heavy drinking is 2’ 13. We agree that the drinking-by-smoking interaction is nowhere near
significant, although we would merely point out that, as English comment in discussing drinking during pregnancy, non-significance means simply that it could be due to and- Bower themselves
chance not that it does not exist. Our data on drinking during pregnancy were, as English and Bower note, from the first trimester. Non-response to the questionnaire was much more a feature of those who were teetotallers before pregnancy, 60 of the 147 (41 %) not responding, while the non-response rate in the remaining 753 was just 14%. We would never wish to imply that drinking during pregnancy is harmless, rather that reduction in level of drinking should precede pregnancy (and, indeed, continue during it) if harm is to be avoided. Reducing drinking, or stopping altogether, after the first missed period may be too late. J. T. WRIGHT Charing Cross Hospital Medical School, London W6 8RF K. D. MACRAE
TEACHING GOOD ANTIMICROBIAL PRESCRIBING
SiR,—Your editorial on antimicrobial prescribing (May 14, p 1084) highlights the problems of inappropriate antibiotic use and cites the Bristol experience in which the effect of an educational programme aimed at improving prescribing was studied. The general failure of the Bristol workers to achieve their aims was attributed to the fact that most antibiotic prescriptions are written by junior staff who frequently change and thus elude the influence of short-term educational projects. Another possibility is that the junior staff were inadequately taught while they were in medical school. 1
Redgrave AP. Plastic bullets:
the medical facts. World Med 1983; (Feb
5): 52-55.
BUTTER
SiR,—Mr Roberts (April 23, p 929) is misleading. No national or international working party has reached different conclusions about the importance of reducing consumption of saturated fat in general and butter in particular because of its unfavourable fatty acid composition and cholesterol content. The scientific nutritional assessment of butter rests on its own merits unrelated as to what fat if any might take its place. If there were no suitable alternatives with likely protective properties, such as reducing serum cholesterol and susceptibility to thrombosis, restriction of butter consumption would be even more important. In most human affairs, however
them together and
impose a preconceived treatment policy. ANN DALLY,
13 Devonshire Place, London WIN 1PB
President, AIDA
PLASTIC BULLETS IN RIOT CONTROL
SIR,-It was encouraging to read Mr Rocke’s comparison of injuries from plastic bullets with those caused by rubber bullets p 919). These weapons have been used in Northern Ireland for crowd control for over ten years. However, there has been a remarkable dearth of medical evidence about the injuries they cause. Good objective evidence is needed in view of the controversy over the use of plastic bullets. Over the past year or so police forces in England have been trained and equipped to use them. In ten police authorities chief constables have been instructed by their local police committees to get rid of stocks of plastic bullets. The committees regard them as too dangerous for crowd control and judge that they would be counterproductive in a riot. Last October, while medical representative on an inquiry in Belfast into deaths and injuries caused by plastic bullets, I saw some injuries caused by plastic bullets. The inquirywas organised by the Association for Legal Justice and leading members of the church in Northern Ireland. Other members of the panel included a professor of law, a member of the European Parliament, a barrister, and representatives from the National Council for Civil Liberties and the British Society for Social Responsibility in Science. The inquiry was shocked both by the severity of the injuries caused and by the way in which plastic bullets have been used by the security forces. Police and Army regulations state that these bullets should be used only as a last resort, should be fired at the lower parts of the body, and should not be used at a range of less than 20 m unless there is a direct threat to the security forces. From evidence we heard it seems that the death rate cited by Rocke (1 per 4000 rounds used) is low enough for the soldiers to feel they can use these weapons whenever they wish. We questioned witnesses in great detail and were left with no doubt whatsoever that these weapons are being misused. How else can the deaths of the 11 and 14 year old girls mentioned in Rocke’s paper be explained? Indeed, of the fourteen deaths due to rubber and plastic bullets in the past 12 years in Northern Ireland six have been in children, and children as young as 5 and 6 years have received severe injuries requiring hospital care. Plastic bullets replaced rubber ones because they are more accurate, so that ringleaders can be "picked out". US Congressmen have criticised the use of plastic bullets in Northern Ireland; the European Parliament has called for a ban, as have the Labour, Liberal and Social Democratic parties. Surely, in the light of the serious injuries Rocke has described, doctors should speak out against the continuing use of plastic bullets in Northern Ireland and against the arming of the police in England with such weapons.
(April 23,
363 Hahfax Road,
Wadsley Bridge, Sheffield S6 IAF
A. P. REDGRAVE
Several years ago, the microbiology department at Nottingham started a course in antimicrobial chemotherapy which is taught for a six-week period in the spring term of the third year. In this medical school the third year leads to a bachelor of medical sciences degree which all students take before embarking on their clinical studies. Our chemotherapy course is one of several options from which the students can choose, and about one-fifth of the students in any one year are able to enrol. Surprisingly, and gratifyingly, the course has turned out to be very popular with the students, some of whom have even expressed the opinion that colleagues who have not taken the course are at a disadvantage during their clinical studies. Medical school preclinical courses have sometimes been criticised for forgetting to teach the practicalities of subjects in their efforts to achieve scientific excellence. The failure to instil good prescribing habits in young doctors may be a case in point. Department of Microbiology, University Hospital, Queen’s Medical Centre, Nottingham NG7 2UH
DAVID GREENWOOD
DRINKING DURING PREGNANCY
SIR,-We read with interest the letter from Dr English and Dr Bower (May 14, p 1111) commenting both on your March 26 editorial and on the article from our group in the same issue (p 663). In our study 147 of the 900 patients were teetotallers, and 10-9% of their babies had birthweights below the 10th centile. In the light drinkers, the corresponding percentage is 8 - 3, in the moderate drinkers 10 - 0, and in the heavy drinkers 17 - 4. This suggests that adverse effects occur only when 100 g of alcohol per week is the level of consumption. The list of possible confounding variables is almost endless. Fortunately, social class (which we corrected for) is highly correlated with maternal age and parity, and one would not expect the estimated relative risk to change much if further adjustment for these factors is carried out. Malnutrition is not a problem in our West London population. We agree that logistic regression is the way to deal with many confounding variables, and are now doing additional analyses with this method. When maternal age is adjusted for, in addition to smoking, the estimated relative risk for heavy drinking is 2’ 13. We agree that the drinking-by-smoking interaction is nowhere near
significant, although we would merely point out that, as English comment in discussing drinking during pregnancy, non-significance means simply that it could be due to and- Bower themselves
chance not that it does not exist. Our data on drinking during pregnancy were, as English and Bower note, from the first trimester. Non-response to the questionnaire was much more a feature of those who were teetotallers before pregnancy, 60 of the 147 (41 %) not responding, while the non-response rate in the remaining 753 was just 14%. We would never wish to imply that drinking during pregnancy is harmless, rather that reduction in level of drinking should precede pregnancy (and, indeed, continue during it) if harm is to be avoided. Reducing drinking, or stopping altogether, after the first missed period may be too late. J. T. WRIGHT Charing Cross Hospital Medical School, London W6 8RF K. D. MACRAE
TEACHING GOOD ANTIMICROBIAL PRESCRIBING
SiR,—Your editorial on antimicrobial prescribing (May 14, p 1084) highlights the problems of inappropriate antibiotic use and cites the Bristol experience in which the effect of an educational programme aimed at improving prescribing was studied. The general failure of the Bristol workers to achieve their aims was attributed to the fact that most antibiotic prescriptions are written by junior staff who frequently change and thus elude the influence of short-term educational projects. Another possibility is that the junior staff were inadequately taught while they were in medical school. 1
Redgrave AP. Plastic bullets:
the medical facts. World Med 1983; (Feb
5): 52-55.
BUTTER
SiR,—Mr Roberts (April 23, p 929) is misleading. No national or international working party has reached different conclusions about the importance of reducing consumption of saturated fat in general and butter in particular because of its unfavourable fatty acid composition and cholesterol content. The scientific nutritional assessment of butter rests on its own merits unrelated as to what fat if any might take its place. If there were no suitable alternatives with likely protective properties, such as reducing serum cholesterol and susceptibility to thrombosis, restriction of butter consumption would be even more important. In most human affairs, however