supplemental statement. Morbid Mortal Wkly Rep 25: 221, 1976 10. MARKS MI, ELLER JJ: Intradermal influenza immunization. Am Rev Respir Dis 103: 579, 1971 11. BARRY DW, MAYNER RE, STATON E, Ct al: Comparative trial of influenza vaccines: I. Immunogenicity of whole virus and split product vaccines in man. Am I Epidemiol 104: 34, 1976 12. BARRY DW, MAYNER RE, HocHsmIN HD, et al: Comparative trial of influenza vaccines: II. Adverse reactions in children and adults. Am J Epidemiol 104: 47, 1976
Investigation and treatment of allergic asthma To the editor: I read with interest the controversy between Dr. Collins-Williams and Dr. Freedman about the efficacy of detection and treatment of allergies (Can Med Assoc J 114:1086, 1976). I was quite agog as I tried to comprehend a biochemical and immune assessment, but finally gave up because of time and lack of technical knowledge with regard to the abbreviated forms and biochemical terminology. I wish I could have taken time to understand it completely. As a hypnotherapist and one who studies psychobiology I have treated a great number of patients with allergy. With the present treatment system I find it very difficult to do other than totally exhaust the history, the clinical picture and the treatment in two or three sessions. I realize I am referring to psychologically associated allergies, but it is my opinion that they form a large proportion of all allergies. In fact, I have yet to see any patient in the office whose allergy or allergies could not be totally related to psychological sensitization. I obviously have a totally different perspective on allergy. JOHN GEAR, MD Erickson Institute of Medical Hypnosis Ste. 212, Hopedale Mall 1515 Rebecca St. Oakville, ON
To the editor: Drs. Collins-Williams and Freedman seem to be arguing about two different things as far as the radioallergosorbent test (RAST) is concerned. Prick and RAST tests are most reliable with pollen allergens and are least reliable with food allergens. The Rinkel group of allergists in the United States found in a survey (which included subjects with food allergy) and here I quote from memory - a 75% correlation between history and results of prick and RAST tests; their figures seem to be midway between the results quoted by Drs. Collins-Williams and Freedman. Considering again the findings of the Rinkel group, I would say that Dr. Collins-Williams is correct in stating that asthma can be helped. However, with asthma and hay fever the build-up
period for immunization by the filtration technique is kept to an average of six injections. I do not believe in the build-up type of desensitization and use the technique called neutralization, which avoids build-up completely. I agree that desensitization is nowhere near 100% perfect by any method, but it seems to be a lot safer than the use of potent drugs. IvoR L. GLAISHER, MD 900 Midtown Centre Regina, SK
[In the view of the executive committee of the American Academy of Allergy there is no evidence to substantiate the validity of the Rinkel method. Readers who wish to pursue this matter are referred to the following two references: I. GOLBERT TM: A review of controversial diagnostic and therapeutic techniques employed in allergy. / Allergy din Immunol 56: 170, 1975 2. LOWELL FC: Some untested diagnostic and therapeutic procedures in clinical allergy (E). Ibid. p 168
-Ed.]
Diabetic day-care unit To the editor: The authors of the two papers on a diabetic day-care unit (Can Med Assoc J 114: 777, 780; 1976) have performed a distinct service in reporting their evaluation, however optimistic, of the work of their unit. It is to be hoped they will enlarge their series and continue follow-up, as they suggest, since the brief period of observation does not lend a crushing weight of credibility to their initial conclusions. The major weakness in evaluation is the measurement of blood glucose concentration at random times. In a study of this calibre one would have expected a more scientific approach. The "improvement" among 24 insulin-treated diabetics from 13 values over 300 mg at the first visit to 4 at the final visit may have been due simply to a change in the time of day of the measurement. Furthermore, it hardly seems appropriate to calculate the mean of 24 random blood glucose readings and express the statistical significance of the difference of this mean from that of a further 24 random readings an unknown time later. We need to know whether the expenditure of a great deal of effort in training personnel, developing facilities and requiring diabetics to attend clinics to supplement and complement the family physician's task is really as worth while as in theory it ought to be. The subject remains debatable. DAVID RUSSELL AMIES, FRCP(C], FACP 200 Walter Scott Building Moose Jsw SK
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To the editor: Dr. Amies has referred to some limitations of our study describing the development and application of an index to evaluate diabetes control. The results reported, which covered a relatively few weeks of observation for each patient, demonstrated significant improvement in a large number of cases. Undoubtedly more studies with longer periods of observation are required. We agree that the subject of diabetic day-care units is debatable and encourage Dr. Amies and other physicians responsible for the care of diabetic patients to contribute to the debate by applying either the index described or another. The point about random v. fasting plasma glucose determinations is more controversial. Random values undoubtedly vary more than fasting values. On the other hand, one important aim of our study was to develop an index that could be applied to as many circumstances of practice as possible. We chose not to require patients to forego breakfast at home on the day of each visit to the unit. Further, we wished to avoid the need for some patients to visit a laboratory first thing in the morning and keep an appointment at the diabetic unit later in the day. As far as can be determined no bias was introduced by doing determinations randomly. There is no reason to think that patients were seen at the final visit at a time of day that would have resulted in their plasma glucose values being significantly lower than at the initial visit. This being so, the statistical analysis appears appropriate. BERNICE KING, RN, B SC N WILLIAM B. SPAULDING, MD, FRCPICJ, FACP Diabetic day-care unit McMaster University Medical Centre 1200 Main St. Hamilton, ON
Munchausen variant To the editor: We recently encountered a patient with an interesting variant of Munchausen's syndrome. A 24-year-old Black American man came to the emergency department of the Montreal General Hospital with a history of "mitral click syndrome" while taking propranolol. He complained of atypical chest pain. Results of physical examination and electrocardiography were normal. He was referred to the cardiology clinic, where an echocardiogram was ordered. He returned the same day to the emergency department; the physical examination again yielded normal findings. He was noted to have somewhat paranoid ideation and struck the examining physician without provocation. He eventually left this hospital and was admitted to another major Montreal hospital, where results of serial electrocar-