Britain find themselves in the uncomfortable role of gatekeepers or rationers of secondary health care, which for the majority in Britain is rationed by queueing. There is no such queue for primary health care, and general practitioners are attempting to care for an infinitely demanding public with a finite and relatively diminishing resource.
Canadian physicians should take care not to be led down any path that ends up in their working harder for less or acting as stooges for a system that has inadequate resources to meet demand. Lindsay Pritchett, MB, BS Wadena Medical Clinic Box 280 Wadena, Sask.
Diagnostic testing in chronlc urticaria and angioedema C
hronic urticaria and angioedema are often frustrating for the patient and the physician. The cause is generally unknown. Textbooks list numerous diseases that can lead to these conditions, and occasionally such an underlying disease is found. However, when there is no obvious evidence of this, extensive investigation on a speculative basis is not rewarding. Among the investigations that seem to be useless are allergy skin tests. Nevertheless, most patients that I see with chronic urticaria and angioedema have had many such tests. The chapter on urticaria and angioedema in a standard text lists a lot of diagnostic tests that may be relevant, but allergy skin tests are not included.' I cannot think of a single case of chronic urticaria or angioedema in which such tests were useful. Ordering or performing a large number of procedures, in1528
CAN MED ASSOC J 1992; 146 (9)
cluding allergy skin tests, for people with urticaria and angioedema can be an expression of frustration at ignorance of the cause. The practice is also expensive. A more productive approach would be to limit tests to those cases in which there are specific indications or the condition is unusually unresponsive to treatment. There are three facts that people with chronic urticaria and angioedema need to be given: (1) most people with these conditions are otherwise healthy and are suffering from an isolated skin problem, (b) the problem usually disappears by itself, and (c) in most cases reasonable ongoing control and comfort can be provided through the skilful use of medicines (often based on trial and error) and occasionally by dietary changes or avoidance of the medication that is responsible. Jerry Dolovich, MD, FRCPC Department of Pediatrics McMaster University Hamilton, Ont.
Reference 1. Kaplan AP: Urticaria and angioedema. In Middleton E Jr, Reed CE, Ellis EF et al (eds): Allergy: Principles and Practice, Mosby, St. Louis, 1988: 1377-1401
Not just another statistic A
an epidemiologist I frequently use the hospital statistics routinely gathered by the provinces' to describe the epidemiologic aspects of ectopic pregnancy in Canada. I have often considered how fortunate we are to have such data available through a collection system that guarantees the privacy of individuals.2 A recent discussion of the privacy of vital statistics with a
woman who is trying to conceive revealed a completely unforeseen consequence of this data collection. Two years ago she had an incomplete spontaneous abortion for which she required dilatation and curettage. A friend, who happens to be in the pro-choice camp, commented that this would add to the statistics on abortion. Not wishing to be counted among those who chose to terminate a pregnancy she asked her family physician if, indeed, her miscarriage would be counted among the induced abortions in Canada. The physician did not know but agreed that it was an interesting question. About a year later the woman had a second spontaneous abortion. This time she did not consult her physician out of fear that she would add to the statistics on induced abortion again. I believe that she would have delayed seeking medical help even if she had had complications. Fortunately, she had none. Statistics on legally induced abortions are compiled by Statistics Canada and published in annual reports.3 Spontaneous or induced abortions that require a hospital stay are recorded in the provincial hospital databases and classified on the basis of the written diagnosis, coded according to the International Classification of Diseases.4 In the data available for 1989-90 from the Hospital Medical Records Institute 26.4% of admissions for abortion were coded as ICD 634 (spontaneous abortion), 67.8% were coded as ICD 635 or 638 (legally induced abortion) and 5.8% were coded as 637 (unspecified abortion). Clearly, in most cases spontaneous and induced abortions are distinguished. There is no systematic collection or reporting of the occurrence of spontaneous pregnancy loss (before 20 weeks) that does not result in a hospital stay. Therefore, women treated as outpatients for spontaneous abortions add to neither the hospital LE
ler MAI 1992
Canadian physicians should take care not to be led down any path that ends up in their working harder for less or acting as stooges for a system that has inadequate resources to meet demand. Lindsay Pritchett, MB, BS Wadena Medical Clinic Box 280 Wadena, Sask.
Diagnostic testing in chronlc urticaria and angioedema C
hronic urticaria and angioedema are often frustrating for the patient and the physician. The cause is generally unknown. Textbooks list numerous diseases that can lead to these conditions, and occasionally such an underlying disease is found. However, when there is no obvious evidence of this, extensive investigation on a speculative basis is not rewarding. Among the investigations that seem to be useless are allergy skin tests. Nevertheless, most patients that I see with chronic urticaria and angioedema have had many such tests. The chapter on urticaria and angioedema in a standard text lists a lot of diagnostic tests that may be relevant, but allergy skin tests are not included.' I cannot think of a single case of chronic urticaria or angioedema in which such tests were useful. Ordering or performing a large number of procedures, in1528
CAN MED ASSOC J 1992; 146 (9)
cluding allergy skin tests, for people with urticaria and angioedema can be an expression of frustration at ignorance of the cause. The practice is also expensive. A more productive approach would be to limit tests to those cases in which there are specific indications or the condition is unusually unresponsive to treatment. There are three facts that people with chronic urticaria and angioedema need to be given: (1) most people with these conditions are otherwise healthy and are suffering from an isolated skin problem, (b) the problem usually disappears by itself, and (c) in most cases reasonable ongoing control and comfort can be provided through the skilful use of medicines (often based on trial and error) and occasionally by dietary changes or avoidance of the medication that is responsible. Jerry Dolovich, MD, FRCPC Department of Pediatrics McMaster University Hamilton, Ont.
Reference 1. Kaplan AP: Urticaria and angioedema. In Middleton E Jr, Reed CE, Ellis EF et al (eds): Allergy: Principles and Practice, Mosby, St. Louis, 1988: 1377-1401
Not just another statistic A
an epidemiologist I frequently use the hospital statistics routinely gathered by the provinces' to describe the epidemiologic aspects of ectopic pregnancy in Canada. I have often considered how fortunate we are to have such data available through a collection system that guarantees the privacy of individuals.2 A recent discussion of the privacy of vital statistics with a
woman who is trying to conceive revealed a completely unforeseen consequence of this data collection. Two years ago she had an incomplete spontaneous abortion for which she required dilatation and curettage. A friend, who happens to be in the pro-choice camp, commented that this would add to the statistics on abortion. Not wishing to be counted among those who chose to terminate a pregnancy she asked her family physician if, indeed, her miscarriage would be counted among the induced abortions in Canada. The physician did not know but agreed that it was an interesting question. About a year later the woman had a second spontaneous abortion. This time she did not consult her physician out of fear that she would add to the statistics on induced abortion again. I believe that she would have delayed seeking medical help even if she had had complications. Fortunately, she had none. Statistics on legally induced abortions are compiled by Statistics Canada and published in annual reports.3 Spontaneous or induced abortions that require a hospital stay are recorded in the provincial hospital databases and classified on the basis of the written diagnosis, coded according to the International Classification of Diseases.4 In the data available for 1989-90 from the Hospital Medical Records Institute 26.4% of admissions for abortion were coded as ICD 634 (spontaneous abortion), 67.8% were coded as ICD 635 or 638 (legally induced abortion) and 5.8% were coded as 637 (unspecified abortion). Clearly, in most cases spontaneous and induced abortions are distinguished. There is no systematic collection or reporting of the occurrence of spontaneous pregnancy loss (before 20 weeks) that does not result in a hospital stay. Therefore, women treated as outpatients for spontaneous abortions add to neither the hospital LE
ler MAI 1992
