889
paediatric practice over the past decade.
Because it is "sometimes
difficult for those referring to such services (ie, general paediatricians and community paediatricians) to decide when the disadvantages of referral: distance, potential loss of continuity, lack of familiarity with local support and, on occasion, fragmentation in the care of the whole child, are outweighed by genuine clinical need and advantage" we asked contributors to consider how far there was evidence justifying the changes in practice in these subspecialties of paediatrics over the past five years. We could have organised a conference on growth and
development, on psychiatry, or on international child health, as implied by the editorial-but this was not the occasion, vitally important though these topics are. Furthermore, we disagree with your narrow view that "the" challenge for the next few years must be to ensure that well-accepted advances and protocols of therapy put into effect and become available to all children. Admirable sentiments but limited. Are we to do nothing to prevent pre-term birth and reduce congenital malformations; to prevent sudden infant death syndrome; to reduce childhood accidents; to cope with child sexual abuse; to reduce the incidence of severe developmental delay; or to ameliorate behavioural disorder in childhood? Although improved service delivery or social intervention may well help in some of these areas, it is difficult to be certain, and there is often little evidence of the efficacy. What are the "well accepted advances and protocols of therapy" that will enable us to find effective treatments and preventive and curative strategies for them or for epilepsy, cerebral palsy, arthritis, diabetes, cancer, bone-marrow failure, or the other specialty areas covered in the volume? Indeed there are many children in suboptimum health with physical and emotional disorders in the UK. It is, however, an illusion to feel that general paediatricians alone or even the medical profession as a whole can cure all their problems in the short term. Of course, such problems should be addressed where possible. Of course, paediatricians should contribute to this process, and there are many leaders in the specialty who have done much in this regard. There are, however, many other children with suboptimum health who may be helped by technical and scientific innovations. Paediatric subspecialists and clinical scientists generally have a duty to contribute to and assess such innovations. Such was the goal of the conference reported in the volume, to which your editorial takes are
exception. In my view "children’s departments in medical schools" have a to future children and families extending far beyond the routine application of today’s received wisdom.
duty
Department of Child Health, University of Manchester, Stopford Building, Manchester M13 9PT, UK
ROBERT BOYD, Former chairman, Academic Board, British Paediatric Association
SiR,—The Royal College of Physicians conference, which you discuss in your Aug 24 editorial, was a highly selective review of some aspects of paediatric specialty practice. In fairness, I do not think it claimed to be anything else. Most of the conference was even more tertiary flavoured than the published proceedings’ indicate. Community paediatrics was the first paper on the first day, before some attenders arrived: the general practice contribution was the last item on the second day, delivered after many had already left. This timetabling reflected, I am sure, the accurate view of the organisers that these two subjects were of little interest to many at the conference. Your correspondents on this subject (Sept 14, p 698) have over-reacted to your less than felicitous teasing, and in so doing have missed the point. Paediatrics must have a scientific cutting edge that is forward-looking and often highly technical. It must also have a broad base, involving the health (sic) care of the many children who never see a paediatrician (at least in hospital), in which medicine is not entirely a science and probably never will be, and in which liasion with primary care is, as you rightly point out, an area neglected by most paediatricians. The issues you raise are those of balance and effective communication between leading edge and base, given that all that happens at one is not necessarily relevant to the other. Your editorial’s fmal sentence misleads in suggesting that paediatricians can "go back" to roots in child health and
development (my emphasis). Most paediatric specialty practice has highly selective background based on interest in morbidity in a hospital context. Advances such as integration into paediatrics of the crucial developmental dimension throughout childhood, and acceptance by the paediatric establishment of the relevance of "population paediatrics" have not yet been reflected in traditional happenings such as Royal College of Physicians conferences and British Paediatric Association annual meetings. This will obviously have to change. Preventive and community roots already exist, and are themselves receiving much needed pruning and shaping. Hospital-based paediatric practice, also suitably shaped, should be grafted onto this stock, enabling vigorous and effective growth of the whole, to which we all contribute. Issues of balance, priorities, a
and communication remain to be tackled. Institute of Child Health, Royal Liverpool Children’s Liverpool L12 2AP, UK 1.
Hospital Alder Hey,
MICHAEL ROGERS
Eyre J, Boyd R, eds. Paediatric specialty practice. Physicians, 1991.
Measures of alcohol
London:
Royal College of
dependence
SIR,-Have any of those who commend the CAGE questionnaire (Sept 7, p 627) as a way of detecting alcoholics ever asked the questions of themselves? They are: Have you ever felt that you should Cut down on your drinking? Have others Annoyed you by criticising your drinking? Have you ever felt Guilty about your drinking? Have you ever had a drink in the morning to steady your nerves or get rid of a hangover (Eye-opener)? Many of us, looking back over our (misspent) youth, would say "yes" to at least two or three of those questions. Or have those working in the field of alcoholism never been young? Surely "do you" or "have you" would produce a more precise instrument? Old Manor Cottage, Church Road,
Bacton, Stowmarket IP14 4LN, UK
ANN KENT
Alcoholism treatment and the Minnesota model SiR,—Dr Brewer (July 20, p 191) comments on our report (June 22, p 1550). Our randomised studyl showed that a Minnesota
inpatient unit achieves a higher one-year abstinence rate among employed alcoholics than the leading Finnish traditional inpatient unit (14% vs 1 -9%, p < 0-05). About 40% of study patients had not been treated (outpatient or inpatient) for their alcoholism before. The Minnesota unit was started at 1981 and our study was done in 1985-86, thus initial enthusiasm for the method had probably waned and does
not account
for the differences in
treatment
outcome.
Brewer cites Andreasson and colleagues’ study2 as an example showing no difference in outcome between outpatient treatment, Minnesota inpatient treatment, or no treatment. That study, however, cannot be analysed in terms of treatment outcome, since it failed (as stated by Andreasson et al). No properly executed trials comparing outpatient treatment and Minnesota inpatient treatment have been published as far as we are aware. Our pilot study (unpublished), which included two outpatient groups in addition to the two inpatient groups, also failed because of unsuccessful randomisation. The reason is simple-if an alcoholic has a choice between inpatient treatment (four weeks or longer) and outpatient treatment, he or she almost always selects the latter. Since our trial’ showed a significant difference in drinking outcome between two inpatient units, those showing no difference in treatment outcome between inpatient and outpatient treatment are not relevant, unless a Minnesota inpatient unit is studied. We find no irony in our recommendation to use laboratory markers in the evaluation of treatment outcome. We have shown3
that treatment outcome is highly dependent on the variables used to it. Thus, for example, at the 8-month follow-up visit,1 72-6% of patients were drinking in a controlled manner (on average less than 40 g ethanol daily) according to a structured interview.
measure
paediatric practice over the past decade.
Because it is "sometimes
difficult for those referring to such services (ie, general paediatricians and community paediatricians) to decide when the disadvantages of referral: distance, potential loss of continuity, lack of familiarity with local support and, on occasion, fragmentation in the care of the whole child, are outweighed by genuine clinical need and advantage" we asked contributors to consider how far there was evidence justifying the changes in practice in these subspecialties of paediatrics over the past five years. We could have organised a conference on growth and
development, on psychiatry, or on international child health, as implied by the editorial-but this was not the occasion, vitally important though these topics are. Furthermore, we disagree with your narrow view that "the" challenge for the next few years must be to ensure that well-accepted advances and protocols of therapy put into effect and become available to all children. Admirable sentiments but limited. Are we to do nothing to prevent pre-term birth and reduce congenital malformations; to prevent sudden infant death syndrome; to reduce childhood accidents; to cope with child sexual abuse; to reduce the incidence of severe developmental delay; or to ameliorate behavioural disorder in childhood? Although improved service delivery or social intervention may well help in some of these areas, it is difficult to be certain, and there is often little evidence of the efficacy. What are the "well accepted advances and protocols of therapy" that will enable us to find effective treatments and preventive and curative strategies for them or for epilepsy, cerebral palsy, arthritis, diabetes, cancer, bone-marrow failure, or the other specialty areas covered in the volume? Indeed there are many children in suboptimum health with physical and emotional disorders in the UK. It is, however, an illusion to feel that general paediatricians alone or even the medical profession as a whole can cure all their problems in the short term. Of course, such problems should be addressed where possible. Of course, paediatricians should contribute to this process, and there are many leaders in the specialty who have done much in this regard. There are, however, many other children with suboptimum health who may be helped by technical and scientific innovations. Paediatric subspecialists and clinical scientists generally have a duty to contribute to and assess such innovations. Such was the goal of the conference reported in the volume, to which your editorial takes are
exception. In my view "children’s departments in medical schools" have a to future children and families extending far beyond the routine application of today’s received wisdom.
duty
Department of Child Health, University of Manchester, Stopford Building, Manchester M13 9PT, UK
ROBERT BOYD, Former chairman, Academic Board, British Paediatric Association
SiR,—The Royal College of Physicians conference, which you discuss in your Aug 24 editorial, was a highly selective review of some aspects of paediatric specialty practice. In fairness, I do not think it claimed to be anything else. Most of the conference was even more tertiary flavoured than the published proceedings’ indicate. Community paediatrics was the first paper on the first day, before some attenders arrived: the general practice contribution was the last item on the second day, delivered after many had already left. This timetabling reflected, I am sure, the accurate view of the organisers that these two subjects were of little interest to many at the conference. Your correspondents on this subject (Sept 14, p 698) have over-reacted to your less than felicitous teasing, and in so doing have missed the point. Paediatrics must have a scientific cutting edge that is forward-looking and often highly technical. It must also have a broad base, involving the health (sic) care of the many children who never see a paediatrician (at least in hospital), in which medicine is not entirely a science and probably never will be, and in which liasion with primary care is, as you rightly point out, an area neglected by most paediatricians. The issues you raise are those of balance and effective communication between leading edge and base, given that all that happens at one is not necessarily relevant to the other. Your editorial’s fmal sentence misleads in suggesting that paediatricians can "go back" to roots in child health and
development (my emphasis). Most paediatric specialty practice has highly selective background based on interest in morbidity in a hospital context. Advances such as integration into paediatrics of the crucial developmental dimension throughout childhood, and acceptance by the paediatric establishment of the relevance of "population paediatrics" have not yet been reflected in traditional happenings such as Royal College of Physicians conferences and British Paediatric Association annual meetings. This will obviously have to change. Preventive and community roots already exist, and are themselves receiving much needed pruning and shaping. Hospital-based paediatric practice, also suitably shaped, should be grafted onto this stock, enabling vigorous and effective growth of the whole, to which we all contribute. Issues of balance, priorities, a
and communication remain to be tackled. Institute of Child Health, Royal Liverpool Children’s Liverpool L12 2AP, UK 1.
Hospital Alder Hey,
MICHAEL ROGERS
Eyre J, Boyd R, eds. Paediatric specialty practice. Physicians, 1991.
Measures of alcohol
London:
Royal College of
dependence
SIR,-Have any of those who commend the CAGE questionnaire (Sept 7, p 627) as a way of detecting alcoholics ever asked the questions of themselves? They are: Have you ever felt that you should Cut down on your drinking? Have others Annoyed you by criticising your drinking? Have you ever felt Guilty about your drinking? Have you ever had a drink in the morning to steady your nerves or get rid of a hangover (Eye-opener)? Many of us, looking back over our (misspent) youth, would say "yes" to at least two or three of those questions. Or have those working in the field of alcoholism never been young? Surely "do you" or "have you" would produce a more precise instrument? Old Manor Cottage, Church Road,
Bacton, Stowmarket IP14 4LN, UK
ANN KENT
Alcoholism treatment and the Minnesota model SiR,—Dr Brewer (July 20, p 191) comments on our report (June 22, p 1550). Our randomised studyl showed that a Minnesota
inpatient unit achieves a higher one-year abstinence rate among employed alcoholics than the leading Finnish traditional inpatient unit (14% vs 1 -9%, p < 0-05). About 40% of study patients had not been treated (outpatient or inpatient) for their alcoholism before. The Minnesota unit was started at 1981 and our study was done in 1985-86, thus initial enthusiasm for the method had probably waned and does
not account
for the differences in
treatment
outcome.
Brewer cites Andreasson and colleagues’ study2 as an example showing no difference in outcome between outpatient treatment, Minnesota inpatient treatment, or no treatment. That study, however, cannot be analysed in terms of treatment outcome, since it failed (as stated by Andreasson et al). No properly executed trials comparing outpatient treatment and Minnesota inpatient treatment have been published as far as we are aware. Our pilot study (unpublished), which included two outpatient groups in addition to the two inpatient groups, also failed because of unsuccessful randomisation. The reason is simple-if an alcoholic has a choice between inpatient treatment (four weeks or longer) and outpatient treatment, he or she almost always selects the latter. Since our trial’ showed a significant difference in drinking outcome between two inpatient units, those showing no difference in treatment outcome between inpatient and outpatient treatment are not relevant, unless a Minnesota inpatient unit is studied. We find no irony in our recommendation to use laboratory markers in the evaluation of treatment outcome. We have shown3
that treatment outcome is highly dependent on the variables used to it. Thus, for example, at the 8-month follow-up visit,1 72-6% of patients were drinking in a controlled manner (on average less than 40 g ethanol daily) according to a structured interview.
measure
