THE DISABLED MEDICAL STUDENT

1280 NEW HEARTS FOR BABIES is not always perfect. While replacement of grossly deformed infant hearts may be challenging and exciting, the procedure and the maintenance of a normal life thereafter-and the wholly unexplored problem of whether further transplantations might be needed as the child grows-are such formidable calls on resources in any country that their place in the responsible delivery of health care must be very seriously questioned. Surgeons, physicians, and parents should learn to accept that biology can go awry and that technical feats may not right it again; in the context of malformed hearts incompatible with prolonged survival, many parents are young enough to try again.

SIR,-Embryological development

the

British Cardiac Society, 2 Beaumont Street, London W1N 2DX

M. F. OLIVER, President

believe patients and doctors are better served if inaccuracies in sucl advertisements are dealt with openly. Massam seems upset when I suggest that marketing department have any intent to mislead. In my view such intention is highl: likely. Drug companies rightly pride themselves on the amount o information they hold about their own products and indeed use th existence of such data banks as an argument against generi, substitution, for they assert that a company new to marketing thei product could not conceivably offer an information service of: depth comparable to their own. We must assume that senio management have access to these data, and accordingly the act o producing misleading material as described in the examples abovl must be regarded as deliberate. I still maintain that the corrections and sanctions suggested in m, original letter (Nov 10, p 1097) offer important advantages. It woul( be refreshing if full-page announcements correcting th advertisements discussed above were soon to appear in the relevan

journal. UNCONVINCING REASSURANCE FROM THE ABPI

SIR,-Mr Massam’s reassurance (Nov 17, p 1159) can have no credibility while misleading advertisements remain commonplace. For example, in the current issue of one medical weekly over onethird of the 28 full-page advertisements for drugs breach the Medicines Act. Six of them (those for ’Hismanal’, ’Acepril’, ’Dyazide’, ’Froben’, ’Spiroprop’, and ’Natrilix’) print side-effects and warnings in such a size and style as to be essentially illegible and so breach the Medicines (Advertising to Medical and Dental Practitioners) Regulations 1978. Five others make claims which are misleading and breach the Medicines Act either because they contradict the data sheet or because they do not reflect current knowledge relating to the drug’s uses and effects: (1) An advertisement for ’Keflex’ (cephalexin, Lilly) implies that the advantage of keflex is that is does not cause rashes-"Nobody needs a rash from an antibiotic ... So next time your patient needs an antibiotic prescribe Keflex". This statement contradicts warnings in the company’s data sheet which states that keflex can cause "rash, urticaria and angio-oedema". The small print of the advertisement, which by law should give relevant information from the data sheet, makes no mention of rash in the section on sideeffects. (2) An advertisement for ’Vibramycin’ (doxycycline, Pfizer) is concerned with the image of the drug as expensive and claims that the drug "costs about the same as many leading antibiotics, 7 days therapy 2 caps first day, 1 cap subsequent days-54p". Surprisingly, however, the actual price is 3.90, an amount many times greater than that for oxytetracycline which provides comparable antibiotic activity for 32p per week. (3) According to an advertisement for ’Zovirax’ (acyclovir, Wellcome) "for the best results treatment [of cold sores] should begin as soon as possible during an attack preferably during the prodrome". However, current evidence suggests that treatment1 helps only if it is started within about 8 h of the onset of symptoms. To imply that patients might benefit if treatment is started late is misleading and wastes money. (4) An advertisement for ’Arelix’ (piretanide, Hoechst), marketed for hypertension, claims that the drug "acts directly on the cause of raised vessel tension". This is a startling claim since the cause of raised peripheral resistance is still unknown. It is very unlikely to be established from experiments on cultured cells, on which the company bases its assertions.2,3 (5) The last misleading advertisement is one from a series for ’Augmentin’ (amoxycillin plus clavulanate, Beecham) which has been concerning clinical pharmacologists recently. Clever histograms in these advertisements all imply that augmentin is more effective than other antibiotics for certain clinical conditions-in this instance ear, nose, or throat infections in children. But the data shown give in vitro sensitivities of bacterial isolates which do not necessarily relate to clinical effect. There is no evidence of greater clinical efficacy than for amoxycillin alone. While breaches continue to occur at this rate I see no point in referring misleading advertisements to the Association of the British Pharmaceutical Industry. Until they become a rarity I

Department of Pharmacology Clinical Pharmacology, St George’s Hospital Medical School,

JOE COLLIER

London SW 17 1. Anon 2 Alton

Drug Ther Bull 1984; 22: 85 JF, Chipperfield AR, Lamb JF, Ogden P, Simmons

NL The

passive furosemide-sensitive transmembrane potassium transport Biochim Biophys Acta 1981; 646: 389.

3 Brown CDA, Simmons NL A comparison passive potassium fluxes and chloride origin J Physiol 1981, 322: 25P

in

occurence of cultured cells

of the actions of certain loop diuretics upon cultured epithelium cells of renal

secretion in

THE DISABLED MEDICAL STUDENT

SIR,-I agree with Elizabeth Crow (Nov 10, p 1102) that UK medical schools should consider more qualities in prospective medical students than academic brilliance and mere absence of physical disability. When I was studying medicine in Tanzania there was one medical student and one house-officer with a physical disability. Both these people have proved most conscientious and empathic in their work as doctors. One of these doctors has contributed more to medical science through research than have most of those who were not obviously disabled and those who were high marks scorers. 62 Hunton Road,

Birmingham B23 6AH

JOSEPH K. MUGENDI

...

SIR,-If ever there was a cast-iron case for legislation against discrimination against the disabled it is Miss Crow’s letter. At the House of Commons on Nov 20 a Consultative Conference with Organisations of and for People with Disabilities was organised by the Labour Party, which has committed itself to singling out the disabled for special help, including legislation: would that this could be an all-party Parliamentary group commitment. 1 Bryanston Square, London W1H 4FE

DAVID MORRIS

SiR,-I agree with Miss Crow that for most disabled people with a determination to succeed the greatest handicap they are likely to face is other people’s attitudes. However, it is not quite true that in Third World countries disabled students who wish to study medicine are less disadvantaged. I also speak from personal experience. I had polio at the age of two, which affected three of my limbs to variable extents. It may be that, to others, I appear severely disabled, but I am not handicapped from doing a clinician’s duties. I was accepted as a medical student in the University of Baghdad on academic grounds but was rejected after a medical examination. If it were not for the intervention of the president, who reinstated me after being petitioned, I would never have had a career in medicine. What is important to mention here are the lessons I have learnt in over twelve years as a medical student and doctor. The rejection was a challenge and my response to it was to excel. Disabilities can be assets in the sense that they may strengthen a person’s resolve to make use of what talents he has. Obviously each individual must choose a field where his particular disability does not constitute a hindrance.

1281

Very often one encounters what seems to be prejudice which is not by proven competence. Although this has set me back on occasions, I am confident that I will reach my objectives by overcome

to do. No matter how unfair this seems to be, experience teaches one to accept it-perhaps with some resentment-as a reality of life. However, I find that the respect of my colleagues and the confidence of my patients are ample rewards for my efforts.

perseverance and harder work than others have

Glasgow and West of Scotland Blood Transfusion Service, Regional Laboratories, Law Hospital,

HASAN I. ATRAH

Carluke, Lanarkshire ML8 5ES

BODY COMPUTED TOMOGRAPHY

SIR,-I was interested to read your Oct 27 editorial on whole body computerised tomography (CT) but was disappointed by the level of argument and the curious logic. You state that the question of "whether

a test or

treatment, CT in this

instance, is effective

at

controlling disease within our society (definitely needed)" is nowadays to be regarded as "fashionable". I am alarmed at the prospect of a health service which adopted tests and treatments at times when this question might not be "fashionable". Your editorial begins by summarising the ways in which CT body scanning may currently be used, and then shows that such scanners rarely save lives (one exception being the planning of more effective radiotherapy regimens). You end after a superficial overview of budgetary considerations with the amusing suggestion that because this is all but tantamount "both patients and clinicians want CT to need"-thus, apparently, two wants equals one need. I am not antagonistic to the development of CT scanning and have an open mind on its possible benefits. However, the sensible use of CT scanners is not helped by the level of argument in this editorial, ...

which is

not

up to the usual standards of The Lancet.

Stockport Health Authority, Hazel Grove, StockportSK7 5AB

CHRISTOPHER A. ElR T

SiR,—You present a useful review of the applications and potential advantages of the whole-body CT scanner, both for clinicians and patients. However, it is dangerous to suggest that when clinicians and patients want something "this is all but need". This oversimplification of the concept of need could fit a very wide range of clinical activities and does not help health authorities choose amongst projects. Need is relative: we need basic food and shelter more than we need a Rolls-Royce, even though we may want all three. So it is in medicine; individuals have different needs for different kinds of diagnostic and therapeutic activities, and patients may have different problems, with different options for treatment and different prognoses. Many of the conditions discussed in your editorial are very serious but uncommon. Unfortunately, even with CT scans, the prognosis is often little altered. We need more information about the comparative benefits on a population basis before district health authorities can make rational decisions. CT scanning cannot be considered in isolation, and it is in the context of all the other competing demands that the wide international disparities in provision of scanners (1in 800 000 to 1 in 40 000) should be viewed. tantamount to

Department

of Community Health London School of Hygiene and

Tropical Medicine, London WC1E 7HT

JENNY ROBERTS HUGH SANDERSON

NEBULISERS IN DOMICILIARY PRACTICE

SIR,-We were interested to read your Oct 6 editorial on the use of

domiciliary nebulisers for patients with chronic obstructive airway disease. We have done a randomised double-blind crossover study consisting of three one-month periods, in which we compared the effects of ipratropium bromide 120 g delivered by a metered dose inhaler against two different doses of the same drug (125 g and 500 pg) delivered by a compressor-driven nebuliser. Patients used both a

pressurised aerosol and the compressor-driven nebuliser throughout the study, each containing active drug or placebo, according to the randomisation schedule. Thirty-two patients (average age 57 years, SD 12) with severe airflow obstruction (mean peak expiratory flow rate 192±77 1/min) were studied. They had a maximum documented reversibility of over 20% (mean 55%, range 25-200%), and an improvement of over 13% (mean 26%, range 13-56%) in the peak expiratory flow rate to a test dose of 120 g of ipratropium bromide delivered by a multidose inhaler. In the twenty patients who completed the trial, no significant differences were found between the treatment periods when comparisons were made of the weekly averages for the morning peak expiratory flow rate, evening peak expiratory flow rate, reversibility, diurnal variation in the peak expiratory flow rate, and bronchodilator and steroid usage. Tests of lung function improved significantly during the clinical trial but overall there was no significant difference between treatments. There was no change in the 6 min walking distance, and symptom scores also showed no overall difference between treatments except for cough, which was worse when patients were receiving the 500 pg nebuliser solution of ipratropium bromide. The end-of-trial patient preferences and the proportion of patients who dropped out of the trial on the different regimens were not significantly different. We could not demonstrate that in domiciliary practice the delivery of ipratropium bromide by a nebuliser is of greater clinical benefit than its administration by a multidose inhaler under doubleblind conditions. It therefore appears that the technique itself does not

make any difference

to

the

treatment

of asthma

or

exercise

performance, and any claimed improvements are therefore likely to be due to an increase in delivered dosage when the compressordriven aerosols are used. This is clearly not the case with ipratropium bromide used in this study but could be important in patients receiving sympathomimetic bronchodilators. urgent need for controlled clinical studies on sympathomimetic bronchodilators in domiciliary practice on these lines, and their results should be carefully assessed before public money is spent on the routine provision of compressor-driven nebulisers in the home. There is

an

Llandough Hospital, Penarth, South Glamorgan CF6

1XX

A. PETER SMITH K. A. GUNAWARDENA

SIR,-A rapid increase in the use of nebulisers at home is taking place in this area at least, outside the influence of trained respiratory physicians. The potential dangers in the widespread use of nebulisers in patients at risk from death from asthma who do not receive or understand or who forget instructions are illustrated in the following case history. A 72-year-old widow who lived alone had acquired asthma at the age of 50. She attended the chest clinic regularly but had to be admitted to hospital, once a year on average because of acute, severe asthma. Peak flow rates, forced expired volume in 1 s, and forced vital capacity measurements varied from being unrecordable to 250 1/min, 1 - 3 litres, and 21 litres, respectively, after recovery. Her asthma was usually adequately controlled with regular inhaled ,-stimulant bronchodilators, inhaled corticosteroid prophylaxis, oral theophyllines, and small doses of prednisolone (5-10 mg daily). In hospital severe exacerbations always responded to inhaled 92 -stimulant bronchodilator delivered by a gas-driven nebuliser, intravenous infusions of aminophylline, and an increased dose of prednisolene. Mild mitral regurgitation had been present for years, and an echocardiogram suggested old rheumatic disease with moderate left-ventricular function. She became impressed with nebuliser therapy in hospital and bought an electric compressor from a company whose address was supplied by her general practitioner. She received full instructions from him to the effect that should an acute attack of asthma fail to respond to salbutamol 1 ml (5 mg) via the nebuliser she should ring for medical help

immediately. On June 23, 1984, she had an attack of acute, severe asthma and treated herself with salbutamol as prescribed but without relief. She took a second and then a third dose before calling her doctor, who arrived within half an hour and found her dead.