Journal of the Royal Society of Medicine Volume 84 August 1991
see the real consequence of increase in poverty and cuts in the benefits on children. There is no annual Government report about children. The only Quango set up for this purpose (the Children's Committee) was abolished in 1982 and most of the data which now exists comes from academic bodies. The Children's Act 1989 will attempt to start data collection and gave a chance to rethink practices. Generally the policies for children suffer from Departmental isolationism in Whitehall. We need to direct a lot of time and money at this problem, if not just for simple humanity but for self-interest, for the future of the country lies with these children.
The second speaker at this meeting was the President of the Open Section, Dr Zarrina Kurtz, from the Institute of Child Health of the University of London. She traced the history of ill health in infants and childhood from the 16th century. Survival was the key concern and she showed that by the middle of the 19th century, a third ofthe children still died before the end of childhood. In the current century, death rates have fallen considerably, probably due to better social environmental conditions and the reduction in the incidence and sequelae of infectious diseases. Dr Kurtz drew attention to the disadvantaged in social classes IV and V; some of the improvements were due to the shift in maternal age, parity and social class rather than any medical or social improvement. Early deaths before 28 days are recorded as neonatal mortality and these were largely caused by low birthweight; this situation has improved in all developed countries. Subsequently, for the next 11 months after birth there is less improvement in infant mortality. The neonatal improvement may be because society has put a lot of effort and resources into the intensive care of the low birthweight baby. Later in the first year of life, the single most important cause of morbidity is the Sudden Infant Death Syndrome (SIDS). There is some evidence that improved socio-economic conditions might reduce the number of SIDS deaths and much research is going to this area.
Letters to the Editor Preference is given to letters commenting on contributions recently published in the JRSM. They should not exceed 300 words and should be typed double-spaced.
Percutaneous transluminal coronary angioplasty in the treatment of patients with multivessel coronary artery disease We enjoyed reading the review on percutaneous transluminal coronary angioplasty (PTCA) by Glazier and Piessens (April 1991 JRSM, p 224). To complete the review, we feel that coronary artery stenting should have been mentioned. The use of stenting in vascular disease has been investigated since the
Children in the UK are generally more healthy but a small proportion still suffer from chronic diseases which have a significant effect on children's activities; about 3.5% of children aged between 5 and 15 years are so affected and two-thirds of these have more than one disability. Dr Kurtz reminded us that the treatments themselves sometimes leave significant problems, both physically and psychologically. Cerebral palsy is still a major problem and its treatment tends to be very patchy. Many children are not receiving basic therapy, for example a weekly visit to the physiotherapist. Children with disability or handicap often come from homeless families with lone parent who may be unemployed or in unskilled occupation. The children with such health problems tend to live in inner city districts. A high proportion of resources are allocated by age group, clustering around the time of birth and the elderly (over 65 years). Data must be collected on childhood and organizations such as the Bristol Child Project and Riverside Project in Newcastle are such initiatives. Dr Kurtz concluded by insisting that in the United Kingdom we must listen carefully to the advice given by the United Nations who calls upon member countries to ensure that the lives and normal development of children should have first call upon society's concerns, that children should be able to depend upon that commitment in good times and bad. Discussion by members of the Open Section was wide. The patchiness of services was commented upon and the lack of data about the needs of children to be planned for are difficult to obtain. Separation of the funding from the delivery service leads to much bureaucratic time wasting and this may be worse under the new Health Service. The need for a Children's Ombudsman was considered and studies were needed on children's rights. The Scottish Child Care Review has already recommended such a step and members of the Open Section considered it was time for the Government to institute one over England and Wales.
Geoffrey Chamberlain Secretary, Open Section
work of Dotter' in 1969, although its application in coronary vessels is a more recent event. In coronary artery disease, stents may be placed primarily at the time of PTCA to avoid short term complications of the procedure including abrupt occlusion which is usually due to dissection with secondary thrombosis and spasm. This complication has an incidence of up to 5% and is usually treated by emergency bypass surgery which is associated with a higher morbidity and mortality than elective procedures. By stenting of the dilated segment, any dissection that occurs cannot cause occlusion as it is firmly held in place by the stent. In a series of 495 patients, abrupt occlusion occurred in only 0.7% of patients having coronary stent placements2. Stenting may also be used as a treatment of acute occlusion following PTCA with the stent being placed as a secondary procedure. In a series of 11 patients
509
510
Journal of the Royal Society of Medicine Volume 84 August 1991
being treated for acute occlusion following PTCA, by stenting, no deaths or myocardial infarctions ocurred in the patients satisfying the inclusion criteria. One of these patients experienced reocclusion 3 months after the procedure3. None of the patients required bypass surgery. Stents may also be used to prevent or treat, restenosis following PTCA. These usually occur within 6 months of the procedure. In a study of 42 patients who underwent arteriography 7 months after placement of a coronary stent only -three (7%) were shown to have developed arteriographic restenosis4 compared to reported incidence of up to 40% for PTCA. Stents have been shown experimentally to become incorporated into the wall of the artery and be covered by an endothelial lining within 2 weeks5. Finally the role of stenting as a primary procedure in coronary disease is promising6 and is currently under evaluation. One of the disadvantages of stenting is that all patients receiving stents need to be aggressively anticoagulated and receive antiplatelet agents for a period of up to -6 months depending on the type of stent. Controlled randomized clinical trials are currently under, way to clarify fully the role and indications of stenting in coronary arterial disease. S K SHAMi Department of Surgery University College and Middlesex School D A SHIELDS of Medicine S SARIN The Middlesex Hospital, Mortimer Street,' London WlN 8AA References 1 Dotter CT. Transluminally placed coilspring endarterial tube grafts: long term patency in canine popliteal artery. Invest Radiol 1969;4:329-31 2 Pompa JJ, Ellis SG. Intracoronary stents: clinical and angiographic results. Hertz 1990;15:307-18 3 Sigwart U, Urban P, Golf S, et al Emergency stenting for acute occlusion after coronary balloon angioplasty. Circulation 1988;78:1121-7 4 Sigwart U. The self-expanding mesh stent. In: Topol EJ, ed. Textbook of interventional car#diology. Philadelphia: W B Saunders, 1990:605-22 5 Roubin GS, Robinson KA, King SB, et at Early and late results of intracoronary arterial stenting after coronary angioplasty in dogs. Circulation 1987;76:891-7 6 Ellis SG, Roubin GS, King SB, et al. Intracoronary stenting to prevent restenosis: preliminary results of a multicenter study using the Palmaz-Schatz stent suggest benefit in selected high risk patients (abstract). JAm Coll Cardiol 1990;15:118A
Accident flying squads and emergencies The paper by Cope et al (March 1991 JRSM, p 144) argues that 'accident flying, squads are cleared for take off'. However, their evidence does not appear to support this. They were unable to demonstrate a significant benefit in terms of survivals and we are given insufficient information to know whether those patients who did respond to life-saving treatment might not also have done so if treated by suitablytrained ambulance staff. The training value whic they sugs - experiencing how to intubate in the-dark- under an ovrerturned lorry - seems far removed from wShat is required in everyday clinical practice, and there is good evidence that resuscitation skills require regular updating. While it is indicated that the vehicle is provided for by voluntary donationls, it is not clear that all of the
other costs are covered, including perhaps higher staffing levels. Is it really true that there is no cost to the health authority? Finally at a time when there is increasing concern about the hours of work of junior doctors, and the consequences of 'Achieving a Balance', is it really sensible to have highly trained and expensive staff spending time driving around the countryside? One hope that air trafflc control will seek a further evaluation before giving the final clearance for take-off. MARTIN MCKEE
Department of Public Health and Policy Health Services Research Unit London School of Hygiene and Tropical Medicine Keppel Street, London WC1E 7HT
Accident proneness Surely in embracing the, I had thought discredited, concept of accident proneness, Engel (March 1991 JRSM, p 163) is indulging in the practice that we are all now encouraged to eschew, that of blaming the patient for the disease. Accidents occur to people a4d objects because the organizat4onal structure around them has not done both of two things, anticipated the possibility of accidents and taken suitable preventive action. Suitable preventive action includes matching ability to the task. The report of a recent investigation of injuries in a Dutch shipyard concluded that hearing loss and alcohol consumption were safety hazards1. It is up to whover is in authority in the enterprise to ensure that workpeople with less than normal, hearing or under the -influence of alcohol do not get into situations where their disabilities present a risk to themselves or anyone else. Accidents represent a failure in the managerial system of the organization in which the accident occurs. Whether those charged with the management of the organization are deemed culpable can only be a matter ofjudgement of whether it could be reasonably expected that the conditions which gave rise to the accident could have been foreseen. There could be a strong case for not giving the directors of London Underground the benefit of the doubt over King's Cross nor, now the late, Arnold Hammer for Piper Alpha. If, as suggested by Vickers and Reeve in the same issue (p 180), 35% of doctors are in the wrong niche in terms of personality does that not represent a possible explanation for the other phenomenon Engel refers to, the returning patient? Perhaps the patients .wopl4dn't be returning if the physicians were, in the organizational rather than the therapeutic sense, competent to manage them in the first place. 3 Crossfell Road JOHN GREEN Hemel Hempstead HertA HP3 8RB
Reference
1 Moll van Charante AW, Mulder PGIL Perceptual acuity
and the risk of industrial accidents. Am J Epidemiol 1990;131:652-63
-Long-ter benzodiazepine use and painl We were very pleased to see the paper by Hardo and Kennedy (;February 1991, JRSM, p 73) conerning the problem of long-term benzodiazepiBe use by patients
see the real consequence of increase in poverty and cuts in the benefits on children. There is no annual Government report about children. The only Quango set up for this purpose (the Children's Committee) was abolished in 1982 and most of the data which now exists comes from academic bodies. The Children's Act 1989 will attempt to start data collection and gave a chance to rethink practices. Generally the policies for children suffer from Departmental isolationism in Whitehall. We need to direct a lot of time and money at this problem, if not just for simple humanity but for self-interest, for the future of the country lies with these children.
The second speaker at this meeting was the President of the Open Section, Dr Zarrina Kurtz, from the Institute of Child Health of the University of London. She traced the history of ill health in infants and childhood from the 16th century. Survival was the key concern and she showed that by the middle of the 19th century, a third ofthe children still died before the end of childhood. In the current century, death rates have fallen considerably, probably due to better social environmental conditions and the reduction in the incidence and sequelae of infectious diseases. Dr Kurtz drew attention to the disadvantaged in social classes IV and V; some of the improvements were due to the shift in maternal age, parity and social class rather than any medical or social improvement. Early deaths before 28 days are recorded as neonatal mortality and these were largely caused by low birthweight; this situation has improved in all developed countries. Subsequently, for the next 11 months after birth there is less improvement in infant mortality. The neonatal improvement may be because society has put a lot of effort and resources into the intensive care of the low birthweight baby. Later in the first year of life, the single most important cause of morbidity is the Sudden Infant Death Syndrome (SIDS). There is some evidence that improved socio-economic conditions might reduce the number of SIDS deaths and much research is going to this area.
Letters to the Editor Preference is given to letters commenting on contributions recently published in the JRSM. They should not exceed 300 words and should be typed double-spaced.
Percutaneous transluminal coronary angioplasty in the treatment of patients with multivessel coronary artery disease We enjoyed reading the review on percutaneous transluminal coronary angioplasty (PTCA) by Glazier and Piessens (April 1991 JRSM, p 224). To complete the review, we feel that coronary artery stenting should have been mentioned. The use of stenting in vascular disease has been investigated since the
Children in the UK are generally more healthy but a small proportion still suffer from chronic diseases which have a significant effect on children's activities; about 3.5% of children aged between 5 and 15 years are so affected and two-thirds of these have more than one disability. Dr Kurtz reminded us that the treatments themselves sometimes leave significant problems, both physically and psychologically. Cerebral palsy is still a major problem and its treatment tends to be very patchy. Many children are not receiving basic therapy, for example a weekly visit to the physiotherapist. Children with disability or handicap often come from homeless families with lone parent who may be unemployed or in unskilled occupation. The children with such health problems tend to live in inner city districts. A high proportion of resources are allocated by age group, clustering around the time of birth and the elderly (over 65 years). Data must be collected on childhood and organizations such as the Bristol Child Project and Riverside Project in Newcastle are such initiatives. Dr Kurtz concluded by insisting that in the United Kingdom we must listen carefully to the advice given by the United Nations who calls upon member countries to ensure that the lives and normal development of children should have first call upon society's concerns, that children should be able to depend upon that commitment in good times and bad. Discussion by members of the Open Section was wide. The patchiness of services was commented upon and the lack of data about the needs of children to be planned for are difficult to obtain. Separation of the funding from the delivery service leads to much bureaucratic time wasting and this may be worse under the new Health Service. The need for a Children's Ombudsman was considered and studies were needed on children's rights. The Scottish Child Care Review has already recommended such a step and members of the Open Section considered it was time for the Government to institute one over England and Wales.
Geoffrey Chamberlain Secretary, Open Section
work of Dotter' in 1969, although its application in coronary vessels is a more recent event. In coronary artery disease, stents may be placed primarily at the time of PTCA to avoid short term complications of the procedure including abrupt occlusion which is usually due to dissection with secondary thrombosis and spasm. This complication has an incidence of up to 5% and is usually treated by emergency bypass surgery which is associated with a higher morbidity and mortality than elective procedures. By stenting of the dilated segment, any dissection that occurs cannot cause occlusion as it is firmly held in place by the stent. In a series of 495 patients, abrupt occlusion occurred in only 0.7% of patients having coronary stent placements2. Stenting may also be used as a treatment of acute occlusion following PTCA with the stent being placed as a secondary procedure. In a series of 11 patients
509
510
Journal of the Royal Society of Medicine Volume 84 August 1991
being treated for acute occlusion following PTCA, by stenting, no deaths or myocardial infarctions ocurred in the patients satisfying the inclusion criteria. One of these patients experienced reocclusion 3 months after the procedure3. None of the patients required bypass surgery. Stents may also be used to prevent or treat, restenosis following PTCA. These usually occur within 6 months of the procedure. In a study of 42 patients who underwent arteriography 7 months after placement of a coronary stent only -three (7%) were shown to have developed arteriographic restenosis4 compared to reported incidence of up to 40% for PTCA. Stents have been shown experimentally to become incorporated into the wall of the artery and be covered by an endothelial lining within 2 weeks5. Finally the role of stenting as a primary procedure in coronary disease is promising6 and is currently under evaluation. One of the disadvantages of stenting is that all patients receiving stents need to be aggressively anticoagulated and receive antiplatelet agents for a period of up to -6 months depending on the type of stent. Controlled randomized clinical trials are currently under, way to clarify fully the role and indications of stenting in coronary arterial disease. S K SHAMi Department of Surgery University College and Middlesex School D A SHIELDS of Medicine S SARIN The Middlesex Hospital, Mortimer Street,' London WlN 8AA References 1 Dotter CT. Transluminally placed coilspring endarterial tube grafts: long term patency in canine popliteal artery. Invest Radiol 1969;4:329-31 2 Pompa JJ, Ellis SG. Intracoronary stents: clinical and angiographic results. Hertz 1990;15:307-18 3 Sigwart U, Urban P, Golf S, et al Emergency stenting for acute occlusion after coronary balloon angioplasty. Circulation 1988;78:1121-7 4 Sigwart U. The self-expanding mesh stent. In: Topol EJ, ed. Textbook of interventional car#diology. Philadelphia: W B Saunders, 1990:605-22 5 Roubin GS, Robinson KA, King SB, et at Early and late results of intracoronary arterial stenting after coronary angioplasty in dogs. Circulation 1987;76:891-7 6 Ellis SG, Roubin GS, King SB, et al. Intracoronary stenting to prevent restenosis: preliminary results of a multicenter study using the Palmaz-Schatz stent suggest benefit in selected high risk patients (abstract). JAm Coll Cardiol 1990;15:118A
Accident flying squads and emergencies The paper by Cope et al (March 1991 JRSM, p 144) argues that 'accident flying, squads are cleared for take off'. However, their evidence does not appear to support this. They were unable to demonstrate a significant benefit in terms of survivals and we are given insufficient information to know whether those patients who did respond to life-saving treatment might not also have done so if treated by suitablytrained ambulance staff. The training value whic they sugs - experiencing how to intubate in the-dark- under an ovrerturned lorry - seems far removed from wShat is required in everyday clinical practice, and there is good evidence that resuscitation skills require regular updating. While it is indicated that the vehicle is provided for by voluntary donationls, it is not clear that all of the
other costs are covered, including perhaps higher staffing levels. Is it really true that there is no cost to the health authority? Finally at a time when there is increasing concern about the hours of work of junior doctors, and the consequences of 'Achieving a Balance', is it really sensible to have highly trained and expensive staff spending time driving around the countryside? One hope that air trafflc control will seek a further evaluation before giving the final clearance for take-off. MARTIN MCKEE
Department of Public Health and Policy Health Services Research Unit London School of Hygiene and Tropical Medicine Keppel Street, London WC1E 7HT
Accident proneness Surely in embracing the, I had thought discredited, concept of accident proneness, Engel (March 1991 JRSM, p 163) is indulging in the practice that we are all now encouraged to eschew, that of blaming the patient for the disease. Accidents occur to people a4d objects because the organizat4onal structure around them has not done both of two things, anticipated the possibility of accidents and taken suitable preventive action. Suitable preventive action includes matching ability to the task. The report of a recent investigation of injuries in a Dutch shipyard concluded that hearing loss and alcohol consumption were safety hazards1. It is up to whover is in authority in the enterprise to ensure that workpeople with less than normal, hearing or under the -influence of alcohol do not get into situations where their disabilities present a risk to themselves or anyone else. Accidents represent a failure in the managerial system of the organization in which the accident occurs. Whether those charged with the management of the organization are deemed culpable can only be a matter ofjudgement of whether it could be reasonably expected that the conditions which gave rise to the accident could have been foreseen. There could be a strong case for not giving the directors of London Underground the benefit of the doubt over King's Cross nor, now the late, Arnold Hammer for Piper Alpha. If, as suggested by Vickers and Reeve in the same issue (p 180), 35% of doctors are in the wrong niche in terms of personality does that not represent a possible explanation for the other phenomenon Engel refers to, the returning patient? Perhaps the patients .wopl4dn't be returning if the physicians were, in the organizational rather than the therapeutic sense, competent to manage them in the first place. 3 Crossfell Road JOHN GREEN Hemel Hempstead HertA HP3 8RB
Reference
1 Moll van Charante AW, Mulder PGIL Perceptual acuity
and the risk of industrial accidents. Am J Epidemiol 1990;131:652-63
-Long-ter benzodiazepine use and painl We were very pleased to see the paper by Hardo and Kennedy (;February 1991, JRSM, p 73) conerning the problem of long-term benzodiazepiBe use by patients
