358
Letters to the Editor
area in the right upper lobe was noted; partial pleurectomy was performed. Ten weeks later a left thoracotomy was carried out; torrential bleeding from the pulmonary artery, which was surrounded with necrotic tumour tissue, necessitated a pneumonectomy. She went slowly downhill and died 3 months later, at home. It was particularly interesting, from the physiological point of view, that at the time when she attended with bilateral pneumothoraces she was completely asymptomatic, and had noticed only mild dyspnoea earlier that same day when engaging in strenuous physical exertion. Incidentally, the patient reported by Singh and colleagues (2) and cited by O'Leary (1), is not the first report of such a case; a patient with bilateral pneumothoraces due to metastatic lung involvement 18 months after amputation of the right arm for synovial-cell sarcoma was included in the series reported by Dines and his colleagues in 1973 (3). N.J.C. SNELL Host Defence Unit National Heart and Lung Institute Emmanuel Kaye Building Manresa Road London SW3 6LR, U.K.
References I. O'Leary C, El Soussi M, Cowie J. Spontaneous bilateral pneumothoraces from synovial cell sarcoma. Respir Med 1991; 85: 533-534. 2. Singh H, Singh N, Kaur R. Bilateral spontaneous pneumothorax with pulmonary metastases from synovial cell sarcoma. BrJDis Chest 1977; 71:211-212. 3. Dines D, Cortese D, Brennan M, Hahn R, Payne W. Malignant pulmonary neoplasms predisposing to spontaneous pneumothorax. Mayo Clin Proc 1973; 48: 541-544.
Dear Editor
Who needs referral to the hospital asthma specialist? Dr Bucknall's review (1) of referral to the hospital asthma specialist follows largely along the BTS guidelines and expands them to some degree. However, she does not tackle a very important area, whether referral should be obligatory or at least strongly suggested if the patient him/herself requests onward referral. With the advent of the Patients Charter this is put into more precise focus. However, it has always been my belief that if a patient consistently requests referral to a specialist for whatever condition, that should be
acquiesced to by the General Practitioner unless there are extremely good reasons why not. It may well be that the hospital consultant will say no more and do no more than the General Practitioner has already done, but the patients themselves will feel that 'no stone has been left unturned'. Our General Practitioner colleagues might feel that this a slur upon their ability, but this is in no way so. However hard one argues for control of the majority of asthma in General Practice there will always be patients who feel that they need to see a consultant and really will not be satisfied that all is being done that could be done until this happens. Recently a very sad case of a young girl was made known to me whose G P refused persistent requests from her father for referral on to hospital which culminated in the girl dying from acute severe asthma. The patient's reason for wishing to be referred may be many and varied, some of which were covered in Dr Bucknall's review but I do believe this is a fundamental point which needs to be addressed. J. G. AYRES Department of Respiratory Medicine East Birmingham Hospital Bordesley Green East Birmingham B9 5ST, U.K. 12 December 1991
Reference I. Bucknall CE. Who needs referral to the hospital asthma specialist? Respir Med 1991; 85: 453-455.
Dear Editor
Patient education, self management plans and peak flow measurement We note with interest the above brief review (1). In contrast to Dr Brewis we note a number of recent adult studies (2,3,4) all of which show an improvement in asthma control with an education programme. The different locations of these studies appear to make the results generalizable. A study of both adults and children (2) in a rural based primary care setting showed a clear benefit from both a symptom and peak flow based action plan. In the study by Mayo et al. (3) an action plan-based educational programme reduced significantly relapse to the Emergency Room and multiple readmissions to hospital. We feel that issues that need to be addressed in the future include: confirming Charlton's study regarding peak flow meters and their lack of use in a primary care
Letters to the Editor
setting, studies to determine whether there is a subset of patients, particularly in those discharged from the hospital with poor perception of symptoms, who would benefit from a peak flow meter, and finally, the costeffectiveness of educational programmes in general, need to be evaluated. J. M. FITZGERALD,D SWAN AND M. O. TURNER UBC Respiratory Clinic Main Floor 2775 Heather Street Vancouver General Hospital Vancouver BC, Canada V5Z 3J5
various other outpatient settings. A contribution of education to the improved outcome seems likely but other factors may have produced the result and the techniques are too diffusely described to be generalizable. The educational programme described by Bailey et al. (4) achieved nothing more than improved 'adherence' to a uniform treatment protocol in the educated group. Further work along the lines suggested by Drs Fitzgerald, Swan and Turner is certainly needed. Meanwhile, I am sure that those committed to helping patients with asthma will continue to invest time in behaviour-changing education despite rather patchy scientific support for their efforts.
References 1. Brewis RAL. Patient education, self management plans and peak flow measurement. Respir Med 1991; 85: 457-462. 2. Charlton I, Charlton G, Broomfield J, Mullee MA. Evaluation of peak flow and symptoms only management plans for control of asthma in general practice. Br MedJ 1990: 301: 1355--1359. 3. Mayo PH, Richman J, Harris HW. Results of a program to reduce admissions for adult asthma. Ann Intern Med 1990; 112: 864-871. 4. Bailey WC, Richards JM, Brooks CM, Soong S, Windsor RA, Manzella BA. A randomized trial to improve selfmanagement practices of adults with asthma. Arch Intern Med 1990; 150: 1664-1668.
Reply to the letter from Drs Fitzgerald, Swan and Turner I am grateful to Drs Fitzgerald, Swan and Turner for their comments and reference to recent work. The omission of the three papers they note can be traced back to the origin of my review as one of the background working papers prepared for the production of the Guidelines in the summer of 1990 ( 1 ) - before any of them were available. It was certainly not my intention then to deny the value of educational effort, but merely to observe that it remains remarkably difficult to prove its value using controlled techniques evolved for testing effectiveness of medicines. The difficulty continues. The study by Charlton et al. (2) showed improvement in asthma compared with previous experience after the introduction of a nurse-run asthma clinic in general practice embodying instructed behavioural change. The paper is very valuable for this and other reasons although it does not offer a demonstration of the effect of educational activity versus matched 'uneducated' control. The study by Mayo et al. (3) compared intensive but otherwise unremarkable, individualized and non-systematic outpatient management in a single clinic with ordinary care in
359
R. A. L. BREWIS Royal Victoria Infirmary Newcastle upon Tyne N E I 4LP, U.K.
5 February 1992 References 1. Harrision BDW, Partridge MR. The management of asthma in the early 1990s. Respir Med 1991; 85: 353-354. 2. Charlton I, Charlton G, Broomfield J, Mullee MA. Evaluation ofpeak flow and symptoms only management plans for control of asthma in general practice. Br MedJ 1990; 301: 1355-1359. 3. Mayo PH, Richman J, Harris HW. Results of a program to reduce admissions for adult asthma. Ann Intern Med 1990; 112: 864-871. 4. Bailey WC, Richards JM, Brooks CM, Soong S, Windsor RA, Manzella BA. A randomized trial to improve selfmanagement practices of adults with asthma. Arch Intern Med 1990; 150: 1664-1668.
Dear Editor Symptomatic hypercalcaemia in lung cancer We read with interest the paper by Campbell et al. (1) in which it was shown that clinical improvement justifies the use o f treatment against hypercalcaemia even in patients with advanced lung cancer although the life expectancy among these cases is poor. The investigators used steroids, calcitonin, mithramycin or aminohydroxypropylidene bisphosphonate infusions (APD) either as monotherapy or in combination. We have performed a pilot trial to study the effect of oral clodronate, another bisphosphonate, to treat seven male patients (age 64-78 years) having squamous cell lung cancer with painful rib metastases and symptomatic hypercalcaemia. Adjusted serum calcium ranged from 3.4 to 3"7 mmol I- t with a mean of 3.5mmol 1-~. Serum creatinine was between 130 and 190/zmmoll -~ in all patients. Bone metastases
Letters to the Editor
area in the right upper lobe was noted; partial pleurectomy was performed. Ten weeks later a left thoracotomy was carried out; torrential bleeding from the pulmonary artery, which was surrounded with necrotic tumour tissue, necessitated a pneumonectomy. She went slowly downhill and died 3 months later, at home. It was particularly interesting, from the physiological point of view, that at the time when she attended with bilateral pneumothoraces she was completely asymptomatic, and had noticed only mild dyspnoea earlier that same day when engaging in strenuous physical exertion. Incidentally, the patient reported by Singh and colleagues (2) and cited by O'Leary (1), is not the first report of such a case; a patient with bilateral pneumothoraces due to metastatic lung involvement 18 months after amputation of the right arm for synovial-cell sarcoma was included in the series reported by Dines and his colleagues in 1973 (3). N.J.C. SNELL Host Defence Unit National Heart and Lung Institute Emmanuel Kaye Building Manresa Road London SW3 6LR, U.K.
References I. O'Leary C, El Soussi M, Cowie J. Spontaneous bilateral pneumothoraces from synovial cell sarcoma. Respir Med 1991; 85: 533-534. 2. Singh H, Singh N, Kaur R. Bilateral spontaneous pneumothorax with pulmonary metastases from synovial cell sarcoma. BrJDis Chest 1977; 71:211-212. 3. Dines D, Cortese D, Brennan M, Hahn R, Payne W. Malignant pulmonary neoplasms predisposing to spontaneous pneumothorax. Mayo Clin Proc 1973; 48: 541-544.
Dear Editor
Who needs referral to the hospital asthma specialist? Dr Bucknall's review (1) of referral to the hospital asthma specialist follows largely along the BTS guidelines and expands them to some degree. However, she does not tackle a very important area, whether referral should be obligatory or at least strongly suggested if the patient him/herself requests onward referral. With the advent of the Patients Charter this is put into more precise focus. However, it has always been my belief that if a patient consistently requests referral to a specialist for whatever condition, that should be
acquiesced to by the General Practitioner unless there are extremely good reasons why not. It may well be that the hospital consultant will say no more and do no more than the General Practitioner has already done, but the patients themselves will feel that 'no stone has been left unturned'. Our General Practitioner colleagues might feel that this a slur upon their ability, but this is in no way so. However hard one argues for control of the majority of asthma in General Practice there will always be patients who feel that they need to see a consultant and really will not be satisfied that all is being done that could be done until this happens. Recently a very sad case of a young girl was made known to me whose G P refused persistent requests from her father for referral on to hospital which culminated in the girl dying from acute severe asthma. The patient's reason for wishing to be referred may be many and varied, some of which were covered in Dr Bucknall's review but I do believe this is a fundamental point which needs to be addressed. J. G. AYRES Department of Respiratory Medicine East Birmingham Hospital Bordesley Green East Birmingham B9 5ST, U.K. 12 December 1991
Reference I. Bucknall CE. Who needs referral to the hospital asthma specialist? Respir Med 1991; 85: 453-455.
Dear Editor
Patient education, self management plans and peak flow measurement We note with interest the above brief review (1). In contrast to Dr Brewis we note a number of recent adult studies (2,3,4) all of which show an improvement in asthma control with an education programme. The different locations of these studies appear to make the results generalizable. A study of both adults and children (2) in a rural based primary care setting showed a clear benefit from both a symptom and peak flow based action plan. In the study by Mayo et al. (3) an action plan-based educational programme reduced significantly relapse to the Emergency Room and multiple readmissions to hospital. We feel that issues that need to be addressed in the future include: confirming Charlton's study regarding peak flow meters and their lack of use in a primary care
Letters to the Editor
setting, studies to determine whether there is a subset of patients, particularly in those discharged from the hospital with poor perception of symptoms, who would benefit from a peak flow meter, and finally, the costeffectiveness of educational programmes in general, need to be evaluated. J. M. FITZGERALD,D SWAN AND M. O. TURNER UBC Respiratory Clinic Main Floor 2775 Heather Street Vancouver General Hospital Vancouver BC, Canada V5Z 3J5
various other outpatient settings. A contribution of education to the improved outcome seems likely but other factors may have produced the result and the techniques are too diffusely described to be generalizable. The educational programme described by Bailey et al. (4) achieved nothing more than improved 'adherence' to a uniform treatment protocol in the educated group. Further work along the lines suggested by Drs Fitzgerald, Swan and Turner is certainly needed. Meanwhile, I am sure that those committed to helping patients with asthma will continue to invest time in behaviour-changing education despite rather patchy scientific support for their efforts.
References 1. Brewis RAL. Patient education, self management plans and peak flow measurement. Respir Med 1991; 85: 457-462. 2. Charlton I, Charlton G, Broomfield J, Mullee MA. Evaluation of peak flow and symptoms only management plans for control of asthma in general practice. Br MedJ 1990: 301: 1355--1359. 3. Mayo PH, Richman J, Harris HW. Results of a program to reduce admissions for adult asthma. Ann Intern Med 1990; 112: 864-871. 4. Bailey WC, Richards JM, Brooks CM, Soong S, Windsor RA, Manzella BA. A randomized trial to improve selfmanagement practices of adults with asthma. Arch Intern Med 1990; 150: 1664-1668.
Reply to the letter from Drs Fitzgerald, Swan and Turner I am grateful to Drs Fitzgerald, Swan and Turner for their comments and reference to recent work. The omission of the three papers they note can be traced back to the origin of my review as one of the background working papers prepared for the production of the Guidelines in the summer of 1990 ( 1 ) - before any of them were available. It was certainly not my intention then to deny the value of educational effort, but merely to observe that it remains remarkably difficult to prove its value using controlled techniques evolved for testing effectiveness of medicines. The difficulty continues. The study by Charlton et al. (2) showed improvement in asthma compared with previous experience after the introduction of a nurse-run asthma clinic in general practice embodying instructed behavioural change. The paper is very valuable for this and other reasons although it does not offer a demonstration of the effect of educational activity versus matched 'uneducated' control. The study by Mayo et al. (3) compared intensive but otherwise unremarkable, individualized and non-systematic outpatient management in a single clinic with ordinary care in
359
R. A. L. BREWIS Royal Victoria Infirmary Newcastle upon Tyne N E I 4LP, U.K.
5 February 1992 References 1. Harrision BDW, Partridge MR. The management of asthma in the early 1990s. Respir Med 1991; 85: 353-354. 2. Charlton I, Charlton G, Broomfield J, Mullee MA. Evaluation ofpeak flow and symptoms only management plans for control of asthma in general practice. Br MedJ 1990; 301: 1355-1359. 3. Mayo PH, Richman J, Harris HW. Results of a program to reduce admissions for adult asthma. Ann Intern Med 1990; 112: 864-871. 4. Bailey WC, Richards JM, Brooks CM, Soong S, Windsor RA, Manzella BA. A randomized trial to improve selfmanagement practices of adults with asthma. Arch Intern Med 1990; 150: 1664-1668.
Dear Editor Symptomatic hypercalcaemia in lung cancer We read with interest the paper by Campbell et al. (1) in which it was shown that clinical improvement justifies the use o f treatment against hypercalcaemia even in patients with advanced lung cancer although the life expectancy among these cases is poor. The investigators used steroids, calcitonin, mithramycin or aminohydroxypropylidene bisphosphonate infusions (APD) either as monotherapy or in combination. We have performed a pilot trial to study the effect of oral clodronate, another bisphosphonate, to treat seven male patients (age 64-78 years) having squamous cell lung cancer with painful rib metastases and symptomatic hypercalcaemia. Adjusted serum calcium ranged from 3.4 to 3"7 mmol I- t with a mean of 3.5mmol 1-~. Serum creatinine was between 130 and 190/zmmoll -~ in all patients. Bone metastases
