936
myself, and the patients had great difficulty in communicating with junior house officer. History taking and attending to acutely ill patients when language is a barrier can result in delays and misleading information which can be detrimental for patient care. I propose that all EC graduates should have linguistic assessment before registration in the country where they wish to work to identify those who may benefit from language courses, which could perhaps be financed by the EC. my
Department of Medicine and Therapeutics, University of Aberdeen, Foresterhill, Aberdeen AB9 2ZD, UK
A short list at the
IZHAR H. KHAN
Royal Free
SIR,-A note in your issue of March 14 on the case being brought by Dr Vivian Fonseca against the Royal Free Hospital School of Medicine alleges racial discrimination. As chairman of Council of the School of Medicine I inquired into the basis of Dr Fonseca’s case (I cannot reply in detail because the matter is sub judice) but there are several errors in your report. Despite the comments in your final paragraph, I believe that the School, in considering the applicants for appointment, applied formal procedures generally accepted in the University of London and other universities. We short-listed four applicants who gained the most votes in order of merit (all of whom, contrary to what you say, were accredited) and made our decision on selection for appointment to an academic post in accordance with academic criteria. Incidentally, the school denies vigorously any racial discrimination on its part. The candidate appointed is not of white British origin. Royal Free Hospital School of Medicine, University of London, London NW3 2PF, UK
L. H. L. COHEN
Treatment of early breast cancer SIR,-Some of your correspondents (Feb 15, p 423; March 14, p 675) seem reluctant to accept an important therapeutic role for ovarian suppression in young women with early breast cancer. Ovarian suppression is disparaged by being described as oldfashioned in comparison with modem chemotherapy. There is also a tendency to make the unreliable assumption that tamoxifen has the clinical effects as ovarian suppression in young women. We agree that there is little point in undertaking randomised trials merely to compare ovarian suppression with chemotherapy. Irrespective of trial outcome, will women have more to gain by receiving both treatments than either on its own? Future studies should aim to make chemotherapy and endocrine therapy effective partners, and trials are needed to test the added benefits of combined chemo-endocrine therapy. An important subsidiary aim of such studies should be to identify those women who would most benefit from combined modality treatment rather than endocrine therapy or chemotherapy alone. The UK National Adjuvant Breast Cancer (ABC) Trial has been launched to address these questions with the intended accrual of at least 5000 patients over the next three years. Individual participants or existing collaborative groups in the UK and overseas are invited to take part in this important initiative. same
Clinical Trials and Statistics Unit, Section of Epidemiology, Institute of Cancer Research, Sutton, Surrey SM2 5NG, UK
JUDITH M. BLISS JOHN R. YARNOLD
Hypernatraemia, acute diarrhoea, rehydration therapy to
and oral
SIR,-Dr Fayad and colleagues (Feb 15, p 389) were courageous report the unacceptably high frequency of hypematraemia that
occurred
early stages of the introduction of oral in rehydration therapy Egypt. Many of us who are interested in this treatment for acute diarrhoeal disease in infants and children knew of these early results and feared that they might not be published. The most important variable responsible for hypematraemia seems to be misuse of the oral rehydration solution (ORS), largely as a result of improper mixing to provide overconcentrated ORS, but
during
the
this is combined with restriction of other fluids-most importantly Once these difficulties were identifed and corrected, hyematraemia decreased to below that recorded when ORS was first formally introduced. The value of oral rehydration therapy is undisputed but, as this study shows, the solutions should be correctly prepared and, when the World Health Organisation ORS is used during the maintenance phase, additional free water should be given to avoid sodium overload. Are there other ways of reducing the risk of hypematraemia development during oral rehydration therapy? Fayad et al rightly comment on this, stating "there is a case, therefore, for reducing... the sodium content of ORS to 60-75 mmol/1, which is clinically as effective as 90 mmol/1 in the treatment of dehydration". We reviewed the many publications on sodium content of ORS and came to a similar conclusion.’ The stool sodium content in most cases of acute diarrhoea in infants and children is usually fairly low (30-40 mmol/1) and only exceeds 80-90 mmol/1 in cholera, which is not the major cause of acute diarrhoea in infants and children. There is a second advantage to reducing the sodium content of ORSnamely, that it allows a reduction in ORS osmolality. We have shown in various perfusion model systems in animals and man the potential benefit of hypotonic ORS,z-4 and a preliminary clinical study indicates that hypotonic glucose-electrolyte ORS can, like cereal-based ORS, reduce stool volume.S Indeed, the therapeutic benefit of complex substrate ORS may depend largely on the low initial osmolality (about 160 mOsm/kg). The European Society of Paediatric Gastroenterology and Nutrition has endorsed the findings of a European Working Group, which strongly supports the view that hypotonic ORS is the way forward for European children.6 There could be a case for extending these recommendations to other geographical locations. water.
Department of Gastroenterology, St Bartholomew’s Hospital, London EC1A 7BE, UK
M. J. G. FARTHING
EJ, Cunha-Ferreira R, Walker-Smith JA, Farthing MJG. Sodium content of oral rehydration solutions: a reappraisal. Gut 1989; 30: 1610-21. 2. Rolston DDK, Borodo MM, Kelly MJ, Dawson AM, Farthing MJG. Efficacy of oral rehydration solutions in a rat model of secretory diarrhoea. J Pediatr Gastroenterol Nutr 1987, 6: 624-30. 3. Da Cunha-Ferreira RMC, Elliott EJ, Watson AJM, Brennan E, Walker-Smith JA, Farthing MJG Dominant role for osmolality in the efficacy of glucose and glycine-containing oral rehydration solutions: studies in a rat model for secretory diarrhoea. Acta Paediatr 1992; 81: 46-50. 4. Hunt JB, Elliott EJ, Fairclough PD, Clark ML, Farthing MJG. Water and solute absorption from hypotomc glucose-electrolyte solutions in human jejunum. Gut 1 Elliott
1992, 33: 479-83. 5.
solutions
6.
Patrick MK. Companson of two oral rehydration children with gastroenteritis in Australia, Clin Therap 1990; 12
Cleghorn GJ, Shepherd RW, in
(suppl A):81-85. European Society of Paediatric Gastroenterology and Nutrition Working Group. Recommendation for composition of oral rehydration for the children of Europe J Pediatr Gastroenterol Nutr 1992; 14: 113-15.
PCR for confirmation of Brazilian fever
purpuric
SIR,-Brazilian purpuric fever (BPF), an infectious disease of children with a case-fatality rate of more than 60%," was first recognised in 1984. It is usually preceded by conjunctivitis and is caused by a specific clone of Haemophilus influenzae biogroup aegyptius known as the "BPF clone".4 Before 1989, the areas known to be affected by BPF were limited to the two adjacent Brazilian states of Sao Paulo and Parana and to Australia, where the illness is caused by a different cloned In 1989 BPF was identified in a third Brazilian state (Mato Grosso).6 Confirmation requires isolation of H influenzae biogroup aegyptius from a sterile site such as blood or cerebrospinal fluid (CSF) or specific clinical criteria in combination with negative laboratory results, such as antigen detection, to exclude other common bacterial diseases. No serological tests are yet available to help with the diagnosis. It is often difficult to confirm cases in Brazil because, in a few areas, blood samples are not routinely collected for culture and even when they are the culture is often negative. Any isolates obtained are often not characterised beyond the genus level or preserved for future characterisation. Antigen detection tests to exclude disease caused by Neisseria meningitidis, H influenzae type b, or Streptococcus pneumoniae are not widely available in Brazil.
myself, and the patients had great difficulty in communicating with junior house officer. History taking and attending to acutely ill patients when language is a barrier can result in delays and misleading information which can be detrimental for patient care. I propose that all EC graduates should have linguistic assessment before registration in the country where they wish to work to identify those who may benefit from language courses, which could perhaps be financed by the EC. my
Department of Medicine and Therapeutics, University of Aberdeen, Foresterhill, Aberdeen AB9 2ZD, UK
A short list at the
IZHAR H. KHAN
Royal Free
SIR,-A note in your issue of March 14 on the case being brought by Dr Vivian Fonseca against the Royal Free Hospital School of Medicine alleges racial discrimination. As chairman of Council of the School of Medicine I inquired into the basis of Dr Fonseca’s case (I cannot reply in detail because the matter is sub judice) but there are several errors in your report. Despite the comments in your final paragraph, I believe that the School, in considering the applicants for appointment, applied formal procedures generally accepted in the University of London and other universities. We short-listed four applicants who gained the most votes in order of merit (all of whom, contrary to what you say, were accredited) and made our decision on selection for appointment to an academic post in accordance with academic criteria. Incidentally, the school denies vigorously any racial discrimination on its part. The candidate appointed is not of white British origin. Royal Free Hospital School of Medicine, University of London, London NW3 2PF, UK
L. H. L. COHEN
Treatment of early breast cancer SIR,-Some of your correspondents (Feb 15, p 423; March 14, p 675) seem reluctant to accept an important therapeutic role for ovarian suppression in young women with early breast cancer. Ovarian suppression is disparaged by being described as oldfashioned in comparison with modem chemotherapy. There is also a tendency to make the unreliable assumption that tamoxifen has the clinical effects as ovarian suppression in young women. We agree that there is little point in undertaking randomised trials merely to compare ovarian suppression with chemotherapy. Irrespective of trial outcome, will women have more to gain by receiving both treatments than either on its own? Future studies should aim to make chemotherapy and endocrine therapy effective partners, and trials are needed to test the added benefits of combined chemo-endocrine therapy. An important subsidiary aim of such studies should be to identify those women who would most benefit from combined modality treatment rather than endocrine therapy or chemotherapy alone. The UK National Adjuvant Breast Cancer (ABC) Trial has been launched to address these questions with the intended accrual of at least 5000 patients over the next three years. Individual participants or existing collaborative groups in the UK and overseas are invited to take part in this important initiative. same
Clinical Trials and Statistics Unit, Section of Epidemiology, Institute of Cancer Research, Sutton, Surrey SM2 5NG, UK
JUDITH M. BLISS JOHN R. YARNOLD
Hypernatraemia, acute diarrhoea, rehydration therapy to
and oral
SIR,-Dr Fayad and colleagues (Feb 15, p 389) were courageous report the unacceptably high frequency of hypematraemia that
occurred
early stages of the introduction of oral in rehydration therapy Egypt. Many of us who are interested in this treatment for acute diarrhoeal disease in infants and children knew of these early results and feared that they might not be published. The most important variable responsible for hypematraemia seems to be misuse of the oral rehydration solution (ORS), largely as a result of improper mixing to provide overconcentrated ORS, but
during
the
this is combined with restriction of other fluids-most importantly Once these difficulties were identifed and corrected, hyematraemia decreased to below that recorded when ORS was first formally introduced. The value of oral rehydration therapy is undisputed but, as this study shows, the solutions should be correctly prepared and, when the World Health Organisation ORS is used during the maintenance phase, additional free water should be given to avoid sodium overload. Are there other ways of reducing the risk of hypematraemia development during oral rehydration therapy? Fayad et al rightly comment on this, stating "there is a case, therefore, for reducing... the sodium content of ORS to 60-75 mmol/1, which is clinically as effective as 90 mmol/1 in the treatment of dehydration". We reviewed the many publications on sodium content of ORS and came to a similar conclusion.’ The stool sodium content in most cases of acute diarrhoea in infants and children is usually fairly low (30-40 mmol/1) and only exceeds 80-90 mmol/1 in cholera, which is not the major cause of acute diarrhoea in infants and children. There is a second advantage to reducing the sodium content of ORSnamely, that it allows a reduction in ORS osmolality. We have shown in various perfusion model systems in animals and man the potential benefit of hypotonic ORS,z-4 and a preliminary clinical study indicates that hypotonic glucose-electrolyte ORS can, like cereal-based ORS, reduce stool volume.S Indeed, the therapeutic benefit of complex substrate ORS may depend largely on the low initial osmolality (about 160 mOsm/kg). The European Society of Paediatric Gastroenterology and Nutrition has endorsed the findings of a European Working Group, which strongly supports the view that hypotonic ORS is the way forward for European children.6 There could be a case for extending these recommendations to other geographical locations. water.
Department of Gastroenterology, St Bartholomew’s Hospital, London EC1A 7BE, UK
M. J. G. FARTHING
EJ, Cunha-Ferreira R, Walker-Smith JA, Farthing MJG. Sodium content of oral rehydration solutions: a reappraisal. Gut 1989; 30: 1610-21. 2. Rolston DDK, Borodo MM, Kelly MJ, Dawson AM, Farthing MJG. Efficacy of oral rehydration solutions in a rat model of secretory diarrhoea. J Pediatr Gastroenterol Nutr 1987, 6: 624-30. 3. Da Cunha-Ferreira RMC, Elliott EJ, Watson AJM, Brennan E, Walker-Smith JA, Farthing MJG Dominant role for osmolality in the efficacy of glucose and glycine-containing oral rehydration solutions: studies in a rat model for secretory diarrhoea. Acta Paediatr 1992; 81: 46-50. 4. Hunt JB, Elliott EJ, Fairclough PD, Clark ML, Farthing MJG. Water and solute absorption from hypotomc glucose-electrolyte solutions in human jejunum. Gut 1 Elliott
1992, 33: 479-83. 5.
solutions
6.
Patrick MK. Companson of two oral rehydration children with gastroenteritis in Australia, Clin Therap 1990; 12
Cleghorn GJ, Shepherd RW, in
(suppl A):81-85. European Society of Paediatric Gastroenterology and Nutrition Working Group. Recommendation for composition of oral rehydration for the children of Europe J Pediatr Gastroenterol Nutr 1992; 14: 113-15.
PCR for confirmation of Brazilian fever
purpuric
SIR,-Brazilian purpuric fever (BPF), an infectious disease of children with a case-fatality rate of more than 60%," was first recognised in 1984. It is usually preceded by conjunctivitis and is caused by a specific clone of Haemophilus influenzae biogroup aegyptius known as the "BPF clone".4 Before 1989, the areas known to be affected by BPF were limited to the two adjacent Brazilian states of Sao Paulo and Parana and to Australia, where the illness is caused by a different cloned In 1989 BPF was identified in a third Brazilian state (Mato Grosso).6 Confirmation requires isolation of H influenzae biogroup aegyptius from a sterile site such as blood or cerebrospinal fluid (CSF) or specific clinical criteria in combination with negative laboratory results, such as antigen detection, to exclude other common bacterial diseases. No serological tests are yet available to help with the diagnosis. It is often difficult to confirm cases in Brazil because, in a few areas, blood samples are not routinely collected for culture and even when they are the culture is often negative. Any isolates obtained are often not characterised beyond the genus level or preserved for future characterisation. Antigen detection tests to exclude disease caused by Neisseria meningitidis, H influenzae type b, or Streptococcus pneumoniae are not widely available in Brazil.
