We believe that our comments are justified not only as a criticism to this report by Dr C O'Callaghan and colleagues but also to an earlier study by the same authors.4 H P VAN BEVER K N DESAGER
Department of Paediatrics and Immunology, University Hospital Antwerp, 2520 Edegem, Belgium 1 O'Callaghan C, Milner AD, Swarbrick A. Paradoxical bronchoconstriction in wheezing infants after nebulised preservative free iso-osmolar ipratropium bromide. Br Med J7 1989;299: 1433-4. (9 December.) 2 Stocks J, Godfrey S. Nasal resistance during infancy. Respir Physiol 1978;34:233-46. 3 Fine JM, Gordon T, Thompson JE, Sheppard D. The role of titratable acidity in acid aerosol-induced bronchoconstriction. Am Rev Respir Dis 1987;135:826-30. 4 O'Callaghan C, Milner AD, Swarbrick A. Paradoxical deterioration in lung function after nebulised salbutamol in wheezy infants. Lancet 1986;ii: 1424-5.
AUTHORS' REPLY, -We wish to reply to the criticisms of Drs H P Van Bever and K N Desager as follows. Firstly, we agree that a double blind control trial would have been preferable, but unfortunately other studies that we have carried out have shown that ipratropium bromide blocks the bronchoconstrictor effect in a high proportion of babies (unpublished data). We have not seen either a bronchoconstrictor response to saline or any subsequent blocking in any of our numerous studies. Secondly, we agree that nasal resistance is relatively more important in infants than in adults. We have, however, repeated these studies in a small group of babies who have tolerated an oral airway without waking up, thereby bypassing the nasal airway. This yielded the same pattern of results. We also cannot agree that the nasal airway does not affect measurements obtained by using either a squeeze jacket or intraoesophageal balloon system unless, again, an oral airway is in place. Thirdly, we have shown that when ipratropium bromide is given as an aerosol through a spacer device no paradoxical deterioration occurs, indicating that the effect must be due to the carrier solution.' As the solution is isotonic and preservative free we assume that the effects observed must be due to the acidity. Finally, we wish to refer Drs Van Bever and Desager to three papers on the bronchoconstrictor effect of inhaled acidic solutions.24 A D MILNER
C O'CALLAGHAN
Department of Child Health,
University Hospital, Nottingham NG7 2UH 1 O'Callaghan C, Milner AD, Swarbrick A. Spacer device with facemask attachment for giving bronchodilators to infants with asthma. Br MedJ 1989;298:160-1. 2 Utell J, Morrow PE, Speers DM, Darling J, Hyde RW. Airway responses to sulfate and sulfuric acid aerosols in asthmatics. Am Rev Respir Dis 1983;128:444-50. 3 Fine JM, Gordon T, Thompson JE, Sheppard D. The role of titrable acidity in acid aerosol-induced bronchoconstriction. Am Rev Respir Dis 1987;135:826-30. 4 Balmes JR, Fine JM, Christian D, Gordon T, Sheppard D. Acidity potentiates bronchoconstriction induced by hypoosmolar aerosols. Am Rev Respir Dis 1988;138:35-9.
Avoidable factors contributing to death of children with head
injury SIR,-We agree with Dr P M Sharples and colleagues' that there is more to be gained from ensuring that patients with head injuries gain access to the best care currently available than from attempts to reverse established severe brain damage. Having reviewed avoidable deaths from head injuries in children in the Northern region, the authors recommend that existing guidelines for the
398
management of head injuries should be extended to take account of children. United Kingdom guidelines for adults were published in 1984,2 but these were adopted formally in the Northern region only in December 1987. They were therefore unlikely to have had much influence on practice during the period of this review (1979-86). Elsewhere, comparison of practice before and after the adoption of formal policies has shown reduced mortality and morbidity from acute traumatic intracranial haematomas." Our studies of the risk factors for this complication have recently been extended to include children (p 398)." Although children develop haematoma less often than adults, the same risk factors were found to apply, and our report recommends that guidelines for children need differ little from those used in adults.' A study of adults and children attending accident and emergency departments after head injury has also been completed, and this also shows less difference between the two age groups than might beexpected." A D MENDELOW
Newcastle General Hospital, Newcastle upon Tyne NE4 6BE G M T TEASDALE B JENNETT
Southern General Hospital, Glasgow GS 1 4TF I Sharples PM, Storey A, Avnsley-Green A, Evrc JA. Avoidable factors contributinig to death of childrcn with hcad injury. BrMtfedj 1990;300:87-91. 13 January.) 2 Anonymous. Guidelines for initial management after head injury in adults. Br Med.7 1984;288:983-5. 3 'I'easdale G, Galbraith S, Murray L, Ward 1P, Gentleman D, McKean M. Management of traumatic intracranial haematoma.
BrMedJ7 1982;285:1695-7. 4 IMendelow AD, Karmi MZ, Paul KS, Fuller GAG, Gillingham FJ. Extradural haematoma: effect of delayed treatment.
BrMedj 1979;i: 1240-2. 5 Teasdale GM, Murray G, Anderson E, et al. Risks of an acutc traumatic intracranial haematoma in childreni and adults: implications for the management of head in jutries. Br Med 7 1990;300:398. (10 February.) 6 Brookes M, McMillan R, Cully S, et al. Head injuries in accident/ emergency departments: how different are clildren from adults?7 Epidemiol Community Health (in press).
Quality of life after surgery for benign oesophageal stricture SIR,-We cannot see how the data of Dr B N M Jayawardhana- and colleagiues' justify their final conclusion-that is, that more elderly patients should be considered for surgery for oesophageal stricture. An operative mortality of 13 7% for elective surgery in a non-malignant condition and failure to improve dysphagia in 8 81% of the survivors are not obvious recommendations for their surgical approach. We are extremely surprised that they found so many patients in whom endoscopic stricture dilatation was impossible or unsuccessful. Modern techniques of oesophageal dilatation have rendered almost all peptic oesophageal strictures amenable to safe and effective dilatation." In some young and fit patients, for whom frequent dilatation becomes irksome, antireflux surgery (without stricture resection) may be desirable,". but for older and higher risk patients dilatation on demand will almost always keep them swallowing welland alive. JOHN R BENNETT C M S ROYSTON
Hull Royal Infirmarv, Hull HU3 2JZ I Jayawardhana BNMI, Moghissi K, Knox J. Quality of life of elderly people atter surgery f'or benign oesoplhagcal stricture. BrMfedj 1989;299:1503-4. 16 December. 2 Tytgat GNJ. Dilatation therapy of benign esophageal stenosis.
W'orldj Surg 1989;13:142-8. 3 Wesdorp ICE, Bartelsman JPWM1, den Hartog Jager FCA, Huibregtse K, T'ytgat GN. Results of conservative treatment of benign esophageal strictures: a follow-up study in 100 patients. (lasiroentetrologv 1982;82:487-93.
4 WVatson A. Reflux strictture of the oesophagus. Br 7 Surg 1987 ;74:443-8. S Stirling MC, Orringer MB. The combined Collis-Nissen operation for esophageal reflux strictures. Ann Thorac Surg 1988;45: 148-57.
AUTHOR'S REPLY,-Twelve of 124 patients died in the postoperative period, a mortality of 9 7%. Four patients were unable to be discharged due to their physical state and lack of community support. They died later in hospital at six, eight, nine, and 11 weeks. All departments that deal with patients aged over 70 years will experience those who recover from the presenting illness but not sufficiently to be discharged and will eventually die in hospital. Failure to improve dysphagia in 8/8% of survivors is not an unacceptable result for audited long term follow up. Postoperative dilatation was required in only two patients and then only twice during follow up of two and a half and 13 years. The remaining four patients were observed for between two and nine years and did not require further dilatation. Tytgat and Wesdorp et al'l2 claim success with rates between 80% and 90% and do not measure quality of life-the main purpose of our paper. We have shown a 79% cure rate rather than just success.' The rate of referral for surgery from physicians and general practitioners for patients in whom dilatation had been irksome was 9-5 per annum, an incidence of 0-0095 per thousand population. Dilatation is not without complications.`'5 Elderly people are not all frail, and the improved quality of life with a high cure rate suggests that surgery should be considered for all patients in whom frequent dilatations have become irksome. At no stage have we advocated surgery instead of dilatation as a primary treatment for any patient with benign oesophageal stricture. B N M JAYAWARDHANA Departmeiit of Medicine for the Elderly, Bartiet General Hospital, High Barnet, Hertfordshire EN5 3DJ I 'Ivtgat GNJ. Dilatation therapy of benign esophageal stenosis. Wa"orldJ7Surg 1989;13:142-8. 2 Wesdorp ICE, Bartelsman JFWM, den Hartog Jager FCA, Huibregtse K, Tytgat GN. Gastroenterology 1982;82:487-93. 3 Mioghissi K. Instrumental perforations of the oesophagus. Brj
Hosp Med 1988;39:231-6. 4 Pillay SP, Ward M, Cowen A, ei al. Oesophageal ruptures and perforations-a review. MedJ Aust 1989;150:246-52. 5 Baillie J. Increasing the safety of gastrointestinal endoscopy. BrJ Hosp Med 1988;40:233.
Scottish hearts but British habits SIR, -Dr Henry J Dargie makes an impassioned plea for a serious effort to prevent coronary heart disease in Scotland.' While his advocacy of the holistic approach to health in general is worthy of wholehearted support we should nevertheless recognise the limitations and inadequacies of this approach specifically in relation to the prevention of coronary heart disease. Dr Dargie touches on some of these in his remarks on the three major "risk factors." Further comment, however, is necessary. As Dr Dargie rightly highlights, in the Scottish heart health study serum cholesterol concentrations bore no relation to mortality from coronary heart disease. In spite of this, particularly during the past two or three years, Scots have been implored to reduce their serum cholesterol concentrations by dietary means specifically to reduce mortality from coronary heart disease. Similarly, doctors are encouraged to control high blood pressure not only for the prevention of strokes, in which control may have a part to play, but also to help prevent coronary heart disease in spite of repeatedly negative results in various international trials.2 Striking differences were noted by Dr Dargie in
BMJ VOLUME 300
10 FEBRUARY 1990
Department of Paediatrics and Immunology, University Hospital Antwerp, 2520 Edegem, Belgium 1 O'Callaghan C, Milner AD, Swarbrick A. Paradoxical bronchoconstriction in wheezing infants after nebulised preservative free iso-osmolar ipratropium bromide. Br Med J7 1989;299: 1433-4. (9 December.) 2 Stocks J, Godfrey S. Nasal resistance during infancy. Respir Physiol 1978;34:233-46. 3 Fine JM, Gordon T, Thompson JE, Sheppard D. The role of titratable acidity in acid aerosol-induced bronchoconstriction. Am Rev Respir Dis 1987;135:826-30. 4 O'Callaghan C, Milner AD, Swarbrick A. Paradoxical deterioration in lung function after nebulised salbutamol in wheezy infants. Lancet 1986;ii: 1424-5.
AUTHORS' REPLY, -We wish to reply to the criticisms of Drs H P Van Bever and K N Desager as follows. Firstly, we agree that a double blind control trial would have been preferable, but unfortunately other studies that we have carried out have shown that ipratropium bromide blocks the bronchoconstrictor effect in a high proportion of babies (unpublished data). We have not seen either a bronchoconstrictor response to saline or any subsequent blocking in any of our numerous studies. Secondly, we agree that nasal resistance is relatively more important in infants than in adults. We have, however, repeated these studies in a small group of babies who have tolerated an oral airway without waking up, thereby bypassing the nasal airway. This yielded the same pattern of results. We also cannot agree that the nasal airway does not affect measurements obtained by using either a squeeze jacket or intraoesophageal balloon system unless, again, an oral airway is in place. Thirdly, we have shown that when ipratropium bromide is given as an aerosol through a spacer device no paradoxical deterioration occurs, indicating that the effect must be due to the carrier solution.' As the solution is isotonic and preservative free we assume that the effects observed must be due to the acidity. Finally, we wish to refer Drs Van Bever and Desager to three papers on the bronchoconstrictor effect of inhaled acidic solutions.24 A D MILNER
C O'CALLAGHAN
Department of Child Health,
University Hospital, Nottingham NG7 2UH 1 O'Callaghan C, Milner AD, Swarbrick A. Spacer device with facemask attachment for giving bronchodilators to infants with asthma. Br MedJ 1989;298:160-1. 2 Utell J, Morrow PE, Speers DM, Darling J, Hyde RW. Airway responses to sulfate and sulfuric acid aerosols in asthmatics. Am Rev Respir Dis 1983;128:444-50. 3 Fine JM, Gordon T, Thompson JE, Sheppard D. The role of titrable acidity in acid aerosol-induced bronchoconstriction. Am Rev Respir Dis 1987;135:826-30. 4 Balmes JR, Fine JM, Christian D, Gordon T, Sheppard D. Acidity potentiates bronchoconstriction induced by hypoosmolar aerosols. Am Rev Respir Dis 1988;138:35-9.
Avoidable factors contributing to death of children with head
injury SIR,-We agree with Dr P M Sharples and colleagues' that there is more to be gained from ensuring that patients with head injuries gain access to the best care currently available than from attempts to reverse established severe brain damage. Having reviewed avoidable deaths from head injuries in children in the Northern region, the authors recommend that existing guidelines for the
398
management of head injuries should be extended to take account of children. United Kingdom guidelines for adults were published in 1984,2 but these were adopted formally in the Northern region only in December 1987. They were therefore unlikely to have had much influence on practice during the period of this review (1979-86). Elsewhere, comparison of practice before and after the adoption of formal policies has shown reduced mortality and morbidity from acute traumatic intracranial haematomas." Our studies of the risk factors for this complication have recently been extended to include children (p 398)." Although children develop haematoma less often than adults, the same risk factors were found to apply, and our report recommends that guidelines for children need differ little from those used in adults.' A study of adults and children attending accident and emergency departments after head injury has also been completed, and this also shows less difference between the two age groups than might beexpected." A D MENDELOW
Newcastle General Hospital, Newcastle upon Tyne NE4 6BE G M T TEASDALE B JENNETT
Southern General Hospital, Glasgow GS 1 4TF I Sharples PM, Storey A, Avnsley-Green A, Evrc JA. Avoidable factors contributinig to death of childrcn with hcad injury. BrMtfedj 1990;300:87-91. 13 January.) 2 Anonymous. Guidelines for initial management after head injury in adults. Br Med.7 1984;288:983-5. 3 'I'easdale G, Galbraith S, Murray L, Ward 1P, Gentleman D, McKean M. Management of traumatic intracranial haematoma.
BrMedJ7 1982;285:1695-7. 4 IMendelow AD, Karmi MZ, Paul KS, Fuller GAG, Gillingham FJ. Extradural haematoma: effect of delayed treatment.
BrMedj 1979;i: 1240-2. 5 Teasdale GM, Murray G, Anderson E, et al. Risks of an acutc traumatic intracranial haematoma in childreni and adults: implications for the management of head in jutries. Br Med 7 1990;300:398. (10 February.) 6 Brookes M, McMillan R, Cully S, et al. Head injuries in accident/ emergency departments: how different are clildren from adults?7 Epidemiol Community Health (in press).
Quality of life after surgery for benign oesophageal stricture SIR,-We cannot see how the data of Dr B N M Jayawardhana- and colleagiues' justify their final conclusion-that is, that more elderly patients should be considered for surgery for oesophageal stricture. An operative mortality of 13 7% for elective surgery in a non-malignant condition and failure to improve dysphagia in 8 81% of the survivors are not obvious recommendations for their surgical approach. We are extremely surprised that they found so many patients in whom endoscopic stricture dilatation was impossible or unsuccessful. Modern techniques of oesophageal dilatation have rendered almost all peptic oesophageal strictures amenable to safe and effective dilatation." In some young and fit patients, for whom frequent dilatation becomes irksome, antireflux surgery (without stricture resection) may be desirable,". but for older and higher risk patients dilatation on demand will almost always keep them swallowing welland alive. JOHN R BENNETT C M S ROYSTON
Hull Royal Infirmarv, Hull HU3 2JZ I Jayawardhana BNMI, Moghissi K, Knox J. Quality of life of elderly people atter surgery f'or benign oesoplhagcal stricture. BrMfedj 1989;299:1503-4. 16 December. 2 Tytgat GNJ. Dilatation therapy of benign esophageal stenosis.
W'orldj Surg 1989;13:142-8. 3 Wesdorp ICE, Bartelsman JPWM1, den Hartog Jager FCA, Huibregtse K, T'ytgat GN. Results of conservative treatment of benign esophageal strictures: a follow-up study in 100 patients. (lasiroentetrologv 1982;82:487-93.
4 WVatson A. Reflux strictture of the oesophagus. Br 7 Surg 1987 ;74:443-8. S Stirling MC, Orringer MB. The combined Collis-Nissen operation for esophageal reflux strictures. Ann Thorac Surg 1988;45: 148-57.
AUTHOR'S REPLY,-Twelve of 124 patients died in the postoperative period, a mortality of 9 7%. Four patients were unable to be discharged due to their physical state and lack of community support. They died later in hospital at six, eight, nine, and 11 weeks. All departments that deal with patients aged over 70 years will experience those who recover from the presenting illness but not sufficiently to be discharged and will eventually die in hospital. Failure to improve dysphagia in 8/8% of survivors is not an unacceptable result for audited long term follow up. Postoperative dilatation was required in only two patients and then only twice during follow up of two and a half and 13 years. The remaining four patients were observed for between two and nine years and did not require further dilatation. Tytgat and Wesdorp et al'l2 claim success with rates between 80% and 90% and do not measure quality of life-the main purpose of our paper. We have shown a 79% cure rate rather than just success.' The rate of referral for surgery from physicians and general practitioners for patients in whom dilatation had been irksome was 9-5 per annum, an incidence of 0-0095 per thousand population. Dilatation is not without complications.`'5 Elderly people are not all frail, and the improved quality of life with a high cure rate suggests that surgery should be considered for all patients in whom frequent dilatations have become irksome. At no stage have we advocated surgery instead of dilatation as a primary treatment for any patient with benign oesophageal stricture. B N M JAYAWARDHANA Departmeiit of Medicine for the Elderly, Bartiet General Hospital, High Barnet, Hertfordshire EN5 3DJ I 'Ivtgat GNJ. Dilatation therapy of benign esophageal stenosis. Wa"orldJ7Surg 1989;13:142-8. 2 Wesdorp ICE, Bartelsman JFWM, den Hartog Jager FCA, Huibregtse K, Tytgat GN. Gastroenterology 1982;82:487-93. 3 Mioghissi K. Instrumental perforations of the oesophagus. Brj
Hosp Med 1988;39:231-6. 4 Pillay SP, Ward M, Cowen A, ei al. Oesophageal ruptures and perforations-a review. MedJ Aust 1989;150:246-52. 5 Baillie J. Increasing the safety of gastrointestinal endoscopy. BrJ Hosp Med 1988;40:233.
Scottish hearts but British habits SIR, -Dr Henry J Dargie makes an impassioned plea for a serious effort to prevent coronary heart disease in Scotland.' While his advocacy of the holistic approach to health in general is worthy of wholehearted support we should nevertheless recognise the limitations and inadequacies of this approach specifically in relation to the prevention of coronary heart disease. Dr Dargie touches on some of these in his remarks on the three major "risk factors." Further comment, however, is necessary. As Dr Dargie rightly highlights, in the Scottish heart health study serum cholesterol concentrations bore no relation to mortality from coronary heart disease. In spite of this, particularly during the past two or three years, Scots have been implored to reduce their serum cholesterol concentrations by dietary means specifically to reduce mortality from coronary heart disease. Similarly, doctors are encouraged to control high blood pressure not only for the prevention of strokes, in which control may have a part to play, but also to help prevent coronary heart disease in spite of repeatedly negative results in various international trials.2 Striking differences were noted by Dr Dargie in
BMJ VOLUME 300
10 FEBRUARY 1990
