260
Another explanation may be a physiological or "overshoot" adaptation of the growth plate to the increased eccentric muscle force that is characteristic of OSD(OSD and mobility secondary to muscle force). A third hypothesis might be that an idiopathic laxity of the epiphysis alters the distribution of forces in the tibial tuberosity, thus giving rise to OSD (secondary OSD). Since this lateral mobility of the tibial tuberosity in healthy persons as well as in OSD patients, as far as I am aware, has not yet been described, I would like to hear others’ opinions and experiences of this physical sign. movement.
26 Paul Desmondsingel, 3069 XT Rotterdam, Netherlands
PIETER OUT
1. Ogden JA, Southwick WO. Osgood-Schlatter’s disease and tibial tuberosity development. Clin Orthop 1976, 116: 180-89. 2. Katoh K. An analysis of quadriceps muscle force in boys with Osgood-Schlatter disease. Nippon Seikeigeka Gakkai Zasshi 1988; 62: 523-33.
Road accidents in Catalonia SIR,-During a recent visit to Barcelona a senior physician friend offered to drive me north to Figueres, to the Dali museum. It being a Sunday we made a leisurely start after two very pleasant coffees well laced with brandy. In the front seat of a large American car my attempt to put on a seat belt caused some hilarity and an indication that such behaviour was not expected of real men. We stopped on the way at an excellent restaurant and had aperitifs and two bottles of wine between three of us, and after liqueurs we returned to the motorway. This is typical Catalonian hospitality, but could such generosity be at least a partial explanation of the rising death rates in road traffic accidents (July 13, p 122). Postgraduate Dean’s Office, School of Medicine, University of Leicester, Leicester Royal Infirmary, Leicester LE2 7LX, UK
Cosmetic surgery
Worried obstetricians SIR,-Mrs Brahams (June 29, p 1597) highlights the concerns that obstetricians have with increased litigation. Identical anxieties have been voiced in an editorial in the British Journal of Obstetrics and Gynaecology.l I agree with, for example, the need to expedite the legal process and to try to make the adversarial process of law seem fairer to both parties. However, we must look at ways in which the problem might be prevented. Unless we modify three major factors which predispose families to going to law, I see no alternative to a rising tide of litigation: (1) In the vast majority of cases settled out of court or coming to court the standard of care has fallen below acceptable standards. Although in some cases this may not have led to neurological sequelae, the case would have been much easier to defend had the care been satisfactory. The difficulties usually arise through inadequate staffing, in numbers or in seniority. The remedies are obvious, often unpalatable and/or expensive-eg, hiring more senior staff or closing small, isolated, ill-supported obstetric units. (2) It is very expensive to look after a profoundly handicapped person and as more devices are developed to make life for patients and families more bearable, these costs are going to increase. Awards by the courts of up to illmillion are, therefore, entirely justified: that is what it costs, especially when one adds in 24-hour nursing care after the parents of a profoundly handicapped person have died. No-fault compensation will not work unless it is very generous and compensates to the level of court settlement.1 Until that happens those "lucky" enough to have some identifiable deficiency in their perinatal care will continue to seek restitution in the courts. This will leave other handicapped patients, with no antecedent medical mistake, hopelessly disadvantaged financially if all that no-fault compensation offers is something derisory like the 10 000 given (unjustifiably in my opinion) to those purportedly damaged by whooping cough vaccine. (3) Care for the handicapped in the UK is appalling. Anyone who has had to battle with, for example, assessors for the Attendance Allowance Board or with a local authority to get a house altered for the wheelchair bound fully understand why people go to law. Providing adequate and readily available care for the handicapped is central to any reduction in litigation. Those who sue are often not vindictive or adversarial, as is endorsed by the fact that they go back to the same obstetrician and hospital for subsequent pregnancies. They are merely trying to get a decent deal for their handicapped child, and their justifiable perception of the bureaucracy they face is that it will continue to fail them-so they turn to the courts in the hope that a large settlement will allow them to look after their child properly. It is cheaper for the Government to pay out for cases lost, plus legal fees, rather than provide all handicapped children with the level of care available should they achieve a large court victory. Is this why they duck the issue? Rosie
Maternity Hospital, Cambridge CB2 2SW, UK
S. BRANDON
N. R. C. ROBERTON
(July 6, p 48) on "A new image for plastic analysis of the average plastic surgeon’s workload. I see no time allocated to cosmetic surgery-so why do some plastic surgeons claim that they are the only surgeons who are trained and adept at these procedures? Some of them have no interest in cosmetic surgery: they neither approve of it nor practise SIR,-Your
note
surgery" refers
to an
it. The British Association of Cosmetic Surgeons (BACS) was founded over ten years ago by surgeons from various surgical disciplines united by an interest in cosmetic surgery as a specialty in its own right. The association was founded to promote the study and practice of cosmetic surgery and to act as a forum for the interchange of information and ideas and to promote the highest standards of surgery. The entry criteria are strict. All members have to possess the FRCS and have proven competence in cosmetic surgery. They must do cosmetic surgery as a major part of their practice or full time. Many recent advances in this specialty have been introduced to the UK by BACS members. Because there is inadequate training in cosmetic surgery in the National Health Service and because no accreditation is available, many members of the BACS received their training and experience in the private sector or overseas. Those who regard cosmetic surgery as "unnecessary, frivolous, or trivial" are behind the times. There is a great demand for cosmetic surgery, and it has become a well-recognised specialty fulfilling an important service to the public. Why, suddenly, do plastic surgeons wish to change their image to one dissociated from cosmetic surgery when for the past few years many of them argued publicly that theirs was the only specialty for these operations. Some plastic surgeons denigrate colleagues who do not belong to their associations and who practise cosmetic surgery full time and have been doing so successfully for many years. This is an attempt to prevent others practising in what they claim as their territory. The British Association of Plastic Surgeons’ questionnaire survey, to which your note refers, shows that there is no basis for this claim. British Association of Cosmetic Surgeons, 17 Harley Street, London W1 N 1 DA, UK
ANDREW SKANDEROWICZ, Secretary
Enterococcus faecium with high-level resistance to gentamicin SIR,-Dr Woodford and colleagues report (June 1, p 1356) eight isolates of Enterococcus faecium with high-level gentamicin resistance (HLGR), noting that hitherto there had been only a few similar isolates from the USA, but suggesting that the prevalence might be wider than it appears. We report that HLGR E faecium is not only prevalent in Singapore, but is associated with high-level penicillin resistance (HLPR; ref 1, 2 and unpublished observations).
1. Clements RV. Editorial:
1991; 98: 423-26.
litigation in obstetrics and gynaecology.
Br
J Obstet Gynaeol
From
September
to
isolates identified in
November, 1989,
our
laboratory
52 of 898 enterococcal
were
E
faecium,3 showing
Another explanation may be a physiological or "overshoot" adaptation of the growth plate to the increased eccentric muscle force that is characteristic of OSD(OSD and mobility secondary to muscle force). A third hypothesis might be that an idiopathic laxity of the epiphysis alters the distribution of forces in the tibial tuberosity, thus giving rise to OSD (secondary OSD). Since this lateral mobility of the tibial tuberosity in healthy persons as well as in OSD patients, as far as I am aware, has not yet been described, I would like to hear others’ opinions and experiences of this physical sign. movement.
26 Paul Desmondsingel, 3069 XT Rotterdam, Netherlands
PIETER OUT
1. Ogden JA, Southwick WO. Osgood-Schlatter’s disease and tibial tuberosity development. Clin Orthop 1976, 116: 180-89. 2. Katoh K. An analysis of quadriceps muscle force in boys with Osgood-Schlatter disease. Nippon Seikeigeka Gakkai Zasshi 1988; 62: 523-33.
Road accidents in Catalonia SIR,-During a recent visit to Barcelona a senior physician friend offered to drive me north to Figueres, to the Dali museum. It being a Sunday we made a leisurely start after two very pleasant coffees well laced with brandy. In the front seat of a large American car my attempt to put on a seat belt caused some hilarity and an indication that such behaviour was not expected of real men. We stopped on the way at an excellent restaurant and had aperitifs and two bottles of wine between three of us, and after liqueurs we returned to the motorway. This is typical Catalonian hospitality, but could such generosity be at least a partial explanation of the rising death rates in road traffic accidents (July 13, p 122). Postgraduate Dean’s Office, School of Medicine, University of Leicester, Leicester Royal Infirmary, Leicester LE2 7LX, UK
Cosmetic surgery
Worried obstetricians SIR,-Mrs Brahams (June 29, p 1597) highlights the concerns that obstetricians have with increased litigation. Identical anxieties have been voiced in an editorial in the British Journal of Obstetrics and Gynaecology.l I agree with, for example, the need to expedite the legal process and to try to make the adversarial process of law seem fairer to both parties. However, we must look at ways in which the problem might be prevented. Unless we modify three major factors which predispose families to going to law, I see no alternative to a rising tide of litigation: (1) In the vast majority of cases settled out of court or coming to court the standard of care has fallen below acceptable standards. Although in some cases this may not have led to neurological sequelae, the case would have been much easier to defend had the care been satisfactory. The difficulties usually arise through inadequate staffing, in numbers or in seniority. The remedies are obvious, often unpalatable and/or expensive-eg, hiring more senior staff or closing small, isolated, ill-supported obstetric units. (2) It is very expensive to look after a profoundly handicapped person and as more devices are developed to make life for patients and families more bearable, these costs are going to increase. Awards by the courts of up to illmillion are, therefore, entirely justified: that is what it costs, especially when one adds in 24-hour nursing care after the parents of a profoundly handicapped person have died. No-fault compensation will not work unless it is very generous and compensates to the level of court settlement.1 Until that happens those "lucky" enough to have some identifiable deficiency in their perinatal care will continue to seek restitution in the courts. This will leave other handicapped patients, with no antecedent medical mistake, hopelessly disadvantaged financially if all that no-fault compensation offers is something derisory like the 10 000 given (unjustifiably in my opinion) to those purportedly damaged by whooping cough vaccine. (3) Care for the handicapped in the UK is appalling. Anyone who has had to battle with, for example, assessors for the Attendance Allowance Board or with a local authority to get a house altered for the wheelchair bound fully understand why people go to law. Providing adequate and readily available care for the handicapped is central to any reduction in litigation. Those who sue are often not vindictive or adversarial, as is endorsed by the fact that they go back to the same obstetrician and hospital for subsequent pregnancies. They are merely trying to get a decent deal for their handicapped child, and their justifiable perception of the bureaucracy they face is that it will continue to fail them-so they turn to the courts in the hope that a large settlement will allow them to look after their child properly. It is cheaper for the Government to pay out for cases lost, plus legal fees, rather than provide all handicapped children with the level of care available should they achieve a large court victory. Is this why they duck the issue? Rosie
Maternity Hospital, Cambridge CB2 2SW, UK
S. BRANDON
N. R. C. ROBERTON
(July 6, p 48) on "A new image for plastic analysis of the average plastic surgeon’s workload. I see no time allocated to cosmetic surgery-so why do some plastic surgeons claim that they are the only surgeons who are trained and adept at these procedures? Some of them have no interest in cosmetic surgery: they neither approve of it nor practise SIR,-Your
note
surgery" refers
to an
it. The British Association of Cosmetic Surgeons (BACS) was founded over ten years ago by surgeons from various surgical disciplines united by an interest in cosmetic surgery as a specialty in its own right. The association was founded to promote the study and practice of cosmetic surgery and to act as a forum for the interchange of information and ideas and to promote the highest standards of surgery. The entry criteria are strict. All members have to possess the FRCS and have proven competence in cosmetic surgery. They must do cosmetic surgery as a major part of their practice or full time. Many recent advances in this specialty have been introduced to the UK by BACS members. Because there is inadequate training in cosmetic surgery in the National Health Service and because no accreditation is available, many members of the BACS received their training and experience in the private sector or overseas. Those who regard cosmetic surgery as "unnecessary, frivolous, or trivial" are behind the times. There is a great demand for cosmetic surgery, and it has become a well-recognised specialty fulfilling an important service to the public. Why, suddenly, do plastic surgeons wish to change their image to one dissociated from cosmetic surgery when for the past few years many of them argued publicly that theirs was the only specialty for these operations. Some plastic surgeons denigrate colleagues who do not belong to their associations and who practise cosmetic surgery full time and have been doing so successfully for many years. This is an attempt to prevent others practising in what they claim as their territory. The British Association of Plastic Surgeons’ questionnaire survey, to which your note refers, shows that there is no basis for this claim. British Association of Cosmetic Surgeons, 17 Harley Street, London W1 N 1 DA, UK
ANDREW SKANDEROWICZ, Secretary
Enterococcus faecium with high-level resistance to gentamicin SIR,-Dr Woodford and colleagues report (June 1, p 1356) eight isolates of Enterococcus faecium with high-level gentamicin resistance (HLGR), noting that hitherto there had been only a few similar isolates from the USA, but suggesting that the prevalence might be wider than it appears. We report that HLGR E faecium is not only prevalent in Singapore, but is associated with high-level penicillin resistance (HLPR; ref 1, 2 and unpublished observations).
1. Clements RV. Editorial:
1991; 98: 423-26.
litigation in obstetrics and gynaecology.
Br
J Obstet Gynaeol
From
September
to
isolates identified in
November, 1989,
our
laboratory
52 of 898 enterococcal
were
E
faecium,3 showing
