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SATURDAY 26 JULY 19860
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F
LEADING ARTICLES
Didthe drugdo it? M SLANGMAN ..................................................219.....................2
M
B. H COLMAN.............. ........................ 220
The lealabyrinth GM O'DONOGH,
AIDS and swimmingpools ARIE J ZUCKERMAN ................................................................. 221
Child health servces in the community: makigthem work AIDAN MACFARLANE .222
223
Bladderdysfunctionin progresseautonomic failure RSKIRBY, RBANNISTER .,
Graduated elastic stockings KG BURNANDGGTLAYER ........................................................... 224
Mrs Short'srecipe for betterprsonhealth RICHARDSMITH ................. 226
CLINICAL RESEARCH * PAPERS AND SHORT REPORTS * PRACTICE OBSERVED
Angina pectoris-like pain provoked by intravenous adenosine in healthy volunteers
CHRISTER SYLV9N, BJORN BEERMANN, BROR JONZON, RAGNARBRAMNDT ..............................................
.........
227
Effect of maternal dietary exclusion on breast fed infants with eczema: two controlled studies
AJCANT,JABAILES, RA MARSDEN, D HEWIIT ............................................................................. 231
fiff
atio n rate
Accuracy andreproducbilityofa new contrast clearance method forte deteatioof g l
P J MARTIN, A J POLLARD, N B F
NG C
O'REILLY P J C BROOMAN,
.....................................................BAA C
,
Prevalence of mulpleserosis in a south London borough EDWARDSWILLIAMS, RONALDOMcKERAN. ......,.........237......
Captoprilinelderly patients with heartfailure PATRICKJMURPHY, TISCA VANDERCAMMEN, JAMES MALONE .L................. 239N
nulationofdificult oesophageal strictures with a I c catheters MANDY S SHARPE5, ACHALMERS, RGOUGH .............
Primarybiliay cirrhosis after benoxaprofen cBABBS, TWWARNES .........................................2.....41.i;
se n ological deterioration over 30 years JASNOOK, RVANDSTAR, RO:WELLER .241.... 241
Insulinomaproducingp
Pedicing risk of diabetic itoacidoss in patients
c
subcutaneous insulin infuio
242
CBRADLEYDSGAMSUGKNIGHT,A JMBOULTONJDWARD .....
. . . 243
numin two stowaways SYLVIAMALDRIDGE, SCGLOVER, C JOHNSON ..
Spontaneous pne
Lifetheateningreactiontotubercuintesting MAsPrE, ABOWMAN,ARASSEFI, SWCLARKE .................................... 243
R G WILSON, J ANDERSON, B K SHENTON, M D WHIlE, RM R TAYLOR, G PROUD . . . . 244
Natural killer cells in insulin dependent diabetes mel
Correction:Selfpoisoningwitlhoracadlmiumchloride BUCKLER .236
Diagnosing cancerin general practice: when is cancer suspected? MAGNENYLENNA ........................................... 245
.
MEDICAL PRACTICE
on's chorea: the needformore informatio DIOCRAUFURD, RARRIS .249
Ethics ofpredicive testingfor Hun
..252
Pharmacology:analysis and exploration sI JAMES BLACK
Slipped capitalfemoralepiphysis: coniuingproble oflate diagnosis I J BRENKEL, AJ PROSSER,M PEARSE
.
.256
on the use ofliving kidney donors i- the United Kingom BRITISH TRANSPLANTATION SOCIETY ...................
Reco
Health surveillance of preschool children AF COLVER, H STEINER............................... ..-.............
The central dilemma: destroy ordevelop T E LANKESTER ..................................................................
251,
AnyQuestions? .............................................251 ,255,26......
.............
MedicineandBooks
.
..........
Personal View JDHELL
.....
..
257
258.
260
261
262
.........264
................
...................
........................~~~~~~~~~~~~~~~~~~~~~~~~~~~~.
CORRESPONDENCE-ListofContents................... 265
NEWS AND NOTES
275
Views ...............................
MedicalNews ..............
................. 276
277
BMA Notces ...............................
........... 278
Sclntifically Speaking BERNARDIXON .......
NO 6541 BRITISH-MIAL JOURNAL 1986. VOLUME 293 219-284
BRITISH MEDICALASSOCATION TAVISTXXO SQUARE LONDON WC1H 9JR.
OBITU
..ARY
....... 272
SUPPLEMENT
^TheWeek .................2...........................
279
-FIrm reply to a weak agenda: GMSC's reponseto the
s "aNo"AN EIS.... 280
govesrnment's"agendafor
. salaies 284
rBMA writestoSecretaryofStateonclaina
GMSC appro ie repot on agenda ter pi
are 284
WEEKLY;
SN0267-0623
ASTM COEN: BMJOAE 293(6541)219-284(196 )
BRITISH MEDICAL JOURNAL
VOLUME 293
26 JULY 1986
265
CORRESPONDENCE
List size and quality of practice
B Lee,MRCGP ........
..................
265
Steroids, the eye, and general practitioners
T C O'Dowd, MD, and L Beck, FRcs ......... 265
Nursing dependency in registered nursing
homes and long term geriatric wards
D G MacMahon, MRcp, and others ...... 2....65
Psorasis
C E M Griffiths, MRcP, and others; R A
Wakeel, MRCP,and D C Dick, MRCP ........ 266
Does sodium restriction lower blood
pressure?
266
M R Lee, FRCPED, and others
.............
Leucocyte sodium pumps in patients with
essential hypertension
V Oh, MRcp, and Elizabeth Taylor, PHD ..... 267
Treatment of the premenstrual syndrome by
subcutaneous oestradiol implants and
cyclical oral norethisterone
L O Simpson, PHD ..........
267
............
Sodium excretion in young children
Valerie Walker, MRCPATH, and M E Allison,
Ms .............. ;
0 tempora, 0 Mary's
P Richards, FRcp . .............
Clinical competence and curiosity
W D Dauphinee, FRcPc, and others .
The doctor, the patient, and their contract
M G Jacoby,Ms ........................
What price academic general practice?
R j Taylor, FRCGP; R J Wolstenholme, FRcP
Gastrointestinal investigation of iron
deficiency anaemna
C J Cahill, FRCS, and others .269
Severity scoring in intensive care
PO Collinson, ms, andothers .269
Reye's syndrome, aspirin, and juvenile
chronic arthritis
Ann Hall, MRcP, and Barbara Ansell, FRcp...
A comprehensive bibliography database using
a microcomputer
DW Bullimore, mD; D P Sellu, FRcs .
267
268
268
268
269
270
270
Efficacy of a new nystatin formulation in oral
candidiasis
G K Crompton, FRCPED; P-J Lamey, mB, and
L P Samaranayake, MRCPATH ......
270
.......
Drug points Complete heart block induced by
hyperkalaemia associated with treatment with
a combination of captopril and spironolactone
(MLakhani) ........................... 271
Points Diffuse peritonitis and chronic ascites
due to infection with Chlamydia trachomatis
(Caroline Bradbeer and Jan Welch); Nonsteroidal anti-inflammatory drugs and the
kidney (J C Davidson); Transcutaneous
oxygen tension during exercise in patients
with claudication (C P Shearman and others);
Sweet tooth maketh a sour disposition (A
Comfort; J Yudkin); The doctor, the patient,
and their contract (S J Watkins) ...... ..... 271
Correction: Asystole and electromechanical dissociation (Hopkins) .........
............
271
Because we receive many more letters than we have room to publish we may shorten those that we do publish to allow
readers as wide a selection as possible. In particular, when we receive several letters on the same topic we reserve the
right to abridge individual letters. Our usual policy is to reserve our correspondence columns for letters commenting on
issues discussed recently (within six weeks) in the BMJ.
Letters critical of a paper may be sent to the authors of the paper so that theirreply may appear in the same issue.
We may also fonvard letters that we decide not to publish to the authors ofthe paper on which they comment.
Letters should not exceed 400 words and should be typed doubk spaced and signed by all authors, who
should include their main degree.
List size and quality of practice
SIR,-In discussions about optimum list size
in general practice attempts at assessing clinical
quality have, inevitably, to use factors that are
measurable, such as extent of record keeping, time
spent with patients, and consultation rates (Dr
Martin Lawrence, 12 July, p 135).
It is harder to take account of a more nebulous,
but fundamental, aspect: the need for the list to be
big enough to supply an adequate mass of clinical
material of wide range. If the mass is not large
enough to keep the GP's diagnostic skills constantly engaged and stimulated his clinical acumen
and intuition are bound to get rusty. For this
reason there is a strong, though unfashionable,
case for encouraging the GP to take on the
maximum number of patients he can cope with.
This applies especially where there is, effectively,
competition between local hospitals and GPs for
the "clinical material" available.
With its direct, bearing on medical employment
and unemployment in the NHS, list size is, of
Steroids, the eye, and general practitioners
SIR,-The debate on steroids and the eye has
become predictably adversarial (31 May, p 1448,
28 June, p 1737). By its very nature consultant
experience is distiled from the (apparently very
few) general practice cases that go wrong. Too
much consultant admonishing means that GPs
who prescribe steroids will do so without declaring
this in their referrals. In this practice we recently
had an audit of our use of steroids in the eye and
found it difficult to find cases, though we do
prescribe such steroids.
We would like to compliment Mr Patrick Trevor-
(4) Avoid steroids on a repeat prescription
without expert opinion: patient may be a "steroid
reactor."
(5) Avoid if there is a history of dendritic ulcer.
(6) Be more wary if problem is unilateral.
(7) Check cornea first with fluorescein.
We- hope that the many GPs who prescribe
steroids will find these guidelines helpful.
course, a medicopolitical and economic hot potato.
But it would be unfortunate for the patients and
demoralising for those doctors who have jobs if a
smaller maximum list, while leading to an overt fall
in unemployment, brought with it a hidden rise in
clinical underemployment of a degree that reduced
quality.
It is probably a fallacy that the longer a doctor
THOMAS C O'DOWD
spends with the patient the better must be the University Department ofGeneral Practice,
quality of the clinical transaction. It may simply be Llanedeyrn, Cardiff CF3 7PN
that the doctor with even a medium size list is at his
LYN BECK
wits' end to know how otherwise to fill up his day,
Ophthalmology,
Department
of
unless he also does a job outside his practice.
University Hospital of Wales,
It may be that the problem of medical unem- Heath Park, Cardiff
ployment will have to be solved by work sharing,
but we should not disguise from ourselves that that
is what is happening, or try to ignore its effects on
Nursing4ependency in registered nursing
clinical competence.
BENJAMIN LEE homes and long term geriatric wards
Richmond,
SIR,-We were interested in the contrasting levels
Surrey
of dependency found by Dr Anne E Capewell and
colleagues between patients in nursing homes and
those in geriatric wards in Edinburgh (28 June, p
1719). We recently surveyed the total provision for
Roper (p 1738) on his pragmatic approach and continuing care in one district of Cornwall, includamplify some of the indications he has listed. The ing public, private, and voluntary sectors, and
following guidelines for steroid use in general confirm many of their findings.
The Edinburgh team allude to a smaller contripractice have emerged as a result of discussion
between the GPs in this practice and a consultant bution by NHS hospitals to total long term bed
ophthalmologist.
provision in Britain than may have been hitherto
(1) Never give steroids for an undiagnosed red assumed, and this was confirmed in our survey,
which showed more than three beds in private
eye.
(2) Never prescribe if visual acuity is impaired. nursing homes to each continuing care bed in
(3) Refer if condition is getting worse rather hospital (151 v 44) and more less dependent
than better after 24 hours; review patient next day patients in nursing homes than in hospital wards.
However, given the greater numbers of nursing
after starting steroids.