peroxidase (GPX)5, and this enzyme together with catalase, superoxide dismutase, and vitamin E provides a line of defence against pro-oxidant molecules.
LETTERS TO THE EDITOR
JOURNAL
OF
THE ROYAL
SOCIETY OF
MEDICINE
Preference is given to letters commenting on contributions published recently in the JRSM. They should not exceed 300 words and should be typed double spaced
Priorities for research in complementary medicine
The House of Lords' report on complementary and alternative medicine (CAM) recommends that adequate research funds for CAM should be created in the UK. This raises the question about research priorities in this area. In 1996, we reported a (1995) survey of CAM researchers' views on this matter1. The same survey instrument was used again in 2000, at another international conference on CAM research (Evidence-based Complementary MedicineÐState of the Evidence, Methodological Challenges, Technische UniversitaÈt, Munich, April 2000). Table 1 shows the three answers with the highest level of priority in both years. The remarkable stability of these results over 5 years suggests that assessment of ef®cacy and safety as well as development of research tools are true priorities for CAM research of the future. D Melchart Centre for Complementary Medicine Research, II, Department of Internal Medicine, Technical University of Munich, Kaisterstr. 9, D-80801 MuÈ nchen, Germany
E Ernst Department of Complementary Medicine, School of Postgraduate Medicine and Health Sciences, University of Exeter, 25 Victoria Park Road, Exeter, Devon EX2 4NT, UK
Volume
94
November 2001
There is a saying, `The doctor who treats himself is dealing with two stupid people'. In clinical practice we take a history, conduct an examination and then request special investigations when indicated. This enables us to advise patients about the diagnosis and treatment. Such advice is based on current knowledgeÐoften limitedÐwhich needs to be expressed in words that the individual patient can understand, not easy when we are steeped in medical terms. The advice we give is occasionally wrong; only the insightless are invariably right. The patient has to decide whether to take the adviceÐin total, in part or not at all. Some years ago a patient with cluster headache, having been given the correct diagnosis by three consultants told me that they had not convinced him. I had not previously considered this aspect of a consultation and remain puzzled by the means with which we convince patients. Any ideas? J N Blau St John & Elizabeth Hospital, 60 Grove End Road, London NW8 9NH, UK
Professor Chambers says that a survey of 250 people might cost £2000. I calculate 2 second class stamps=38p, 2 envelopes 2p, survey document A4 photocopy6265p=10p, total 50p6250=£125. That leaves a healthy £1875 for management and overheads. In a nutshell, it indicates that though possibly worth the effort it is not worth the cost. P L Jenkins St Joseph's Hospital, Newport NP9 6EZ, Wales, UK
REFERENCE
1 Ernst E, Abbot NC. Research priorities in complementary medicine. BMJ 1996;312:1481±2
Table 1 Survey responses Research question*
1995 (N=50)
2000 (N=49)
How can we improve research methodologies?
1
2
Is a given therapy more effective than placebo, sham or gold standard treatment?
2
1
Is a given therapy safe?
3
3
* 22 different topics were provided in alphabetical order (complete ranking available from ®rst author on request) N=evaluable responses
Involving patients and the publicÐis it worth the effort?
608
Professor Ruth Chambers (August 2001 JRSM, pp. 375± 377) says that many people use the word `involve' as an umbrella term. My interpretation is cover-up.
Anticoagulants for deep venous thrombosis
In their case report of super®cial thrombophlebitis followed by pulmonary embolism (April 2001 JRSM, pp. 186±187) Dr Kesteven and Mr Robinson raise the question whether anticoagulants should be used to treat super®cial venous thrombosis. This might be a good subject for a clinical trial; however, even the use of anticoagulants in venous thromboembolismÐi.e. deep venous thrombosis (DVT) and pulmonary embolism (PE)Ðis open to doubt. No randomized placebo-controlled trial has ever been published supporting the ef®cacy or safety of anticoagulants in DVT. To justify anticoagulant treatment of DVT patients, textbooks and review articles generally lump DVT with PE and cite a placebo-controlled randomized trial of patients with PE by Barritt and Jordan1. The authors of this old and small study (n=35) used clinical signs and symptoms without lung scans or angiograms to diagnose PE. We now know that clinical suspicion of PE is con®rmed by angiograms in only about 25% of cases2. Also, assignment of fatal PE as the cause of death was questionable in at least three of the ®ve placebo group patients with severe underlying co-morbidity. In short, Barritt and Jordan's
JOURNAL
OF
THE
ROYAL
study does not qualify as scienti®c evidence supporting anticoagulant treatment to reduce the morbidity and/or mortality of patients with PE. Therefore, we cannot extrapolate the conclusion of Barritt and Jordan's trial to DVT patients or further extrapolate it to super®cial venous thrombosis patients. More recently in patients with DVT, Nielsen et al. compared heparin plus phenprocoumon anticoagulation with phenylbutazone in the only published randomized controlled trial3,4. It was a negative study with 1/48 anticoagulated patients and 0/42 phenylbutazone patients dying of pulmonary embolism. For the articles and FDA correspondence detailing the case for withdrawing the indications for anticoagulants (heparins and vitamin K antagonists) in prophylaxis and treatment of venous thromboembolism, see my website: [http://hometown. aol.com/~dkcundiff/home.htm]. David K Cundiff 319 Grand Avenue, Long Beach, LA 90814, USA
REFERENCES
1 Barritt DW, Jordan SC. Anticoagulant drugs in the treatment of pulmonary embolism ± A controlled trial. Lancet 1960;1:1309±12 2 Carson JL, Kelley MA, Duff A, et al. The clinical course of pulmonary embolism. N Engl J Med 1992;326:1240±5 3 Nielsen HK, Husted SE, Krusell LR, Fasting H, Charles P, Hansen HH. Silent pulmonary embolism in patients with deep venous thrombosis. Incidence and fate in a randomized, controlled trial of anticoagulation versus no anticoagulation. J Intern Med 1994;235:457±61 4 Nielsen HK, Husted SE, Krusell LR, et al. Anticoagulant therapy in deep venous thrombosis. A randomized controlled study. Thrombosis Res 1994;73:215±26
Cardiovascular manifestations of HIV infection
Dr Barbaro (August 2001, JRSM, pp. 384±390) brie¯y mentions selenium de®ciency as a contributing factor in the development of cardiomyopathy in patients infected with human immunode®ciency virus (HIV). Cardiomyopathy similar to Keshan disease has been well documented in HIV patients1 and those on total parenteral nutrition (TPN)2. TPN is de®cient not only in selenium but also in other micronutrients including vitamin E3, and this may contribute to the development of cardiomyopathy. In animals, combined vitamin E and selenium de®ciency can impair cardiac conduction4 and hence facilitate the development of disease. Selenium is an essential component of glutathione peroxidase (GPX)5, and this enzyme together with catalase, superoxide dismutase, and vitamin E provides a line of defence against pro-oxidant molecules. In the absence of selenium, GPX is inactive and low GPX is found in HIV disease5. GPX activity increases after selenium supplementation5. Also the oxidative muscle
SOCIETY
OF MEDICINE
Volume
94
November 2001
damage produced by zidovudine treatment can be prevented with anti-oxidants6. TPN is increasingly being used in HIV and other chronic illness. Adequate supplementation of selenium in TPN and in malnourished patients might protect against the development of cardiomyopathy in these patients. To date, there are no of®cial guidelines regarding the use of selenium in TPN. Syed Wamique Yusuf Division of Cardiology, University of Texas, Houston, USA
REFERENCES
1 Dworkin BM, Antonecchia PP, Smith F, et al. Reduced cardiac selenium contents in acquired immunode®ciency syndrome. J Parenter Enteral Nutr 1989;13:644±7 2 Johnson RA, Baker SS, Fallon JT, et al. An occidental case of fatal cardiomyopathy and selenium de®ciency. N Engl J Med 1981;304: 1201±2 3 Forbes GM, Forbes A. Micronutrient status in patients receiving home parenteral nutrition. Nutrition 1997;13:941±44 4 Kennedy S, Rice BA. Selective morphological alteration of the cardiac conduction system in calves de®cient in vitamin E and selenium. Am J Pathol 1988;130:315±25 5 Delams-Beauneux MC, Peuchant E, Conchouran A, et al. The enzymatic anti-oxidant system in blood and glutathione status in human HIV infected patients: effect of supplementation with selenium and betacarotene. Am J Clin Nutr 1996;64:101±7 6 de La Asuncion JG, del Olmo ML, Sastre J, et al. AZT treatment induces molecular and ultrastructural oxidative damage to muscle mitochondria. Prevention by anti-oxidant vitamins. J Clin Invest 1998;102:4±9
Ocular airgun injuryÐan ENT perspective
Mr Shuttleworth and Mr Galloway (August 2001 JRSM, pp.396±399) record the devastating effects of airgun injuries to the eye. Otorhinolaryngologists also encounter such injuries. We presented a series of three cases previously1; since then two more have been seen. Included in the series was a 14-year-old boy who, whilst walking with a friend along one of the canals in West Bromwich, Birmingham, felt a sudden sharp pain in the left eye. At the time, he was unaware that he had been shot. On arrival at home his father noticed bleeding from his left eye. He was taken to Sandwell District Hospital and a pellet was shown lodged in the right sphenoid sinus. The eye was damaged and had to be removed. The pellet was extracted from the sphenoid sinus. The path of the pellet was through the left eye, left ethmoid sinuses, through the cartilagenous nasal septum (creating a permanent hole) and nose. The pellet ricocheted off the right lateral wall of the nose and lodged in the right sphenoid sinus having entered the sinus through its anterior wall. The perpetrator of this injury was found to be a 9-yearold boy playing unsupervised with an airgun. We agree with Shuttleworth and Galloway that more measures need to be
609
JOURNAL
OF
THE ROYAL
SOCIETY OF
MEDICINE
taken to avoid such injuries, but we think the best way is through raising public awareness. Another important point to discuss is: remove or leave the pellet? A further case dealt with since this report was of a patient who had had a pellet lodged in her face (on the anterior surface of the maxillary sinus) for well over 30 years. When she was a child whilst walking with her elder sister in a park in West Bromwich, she felt a sudden sharp pain in her cheek. Blood was found tracking from a small wound on the cheek and nothing much was done about this at the time. After more than 30 years there was a reunion between the two sisters attending their mum's funeral, and the younger sister was prompted to seek advice. An X-ray showed a pellet lying on the anterior surface of the maxillary sinus. Blood lead concentration was not raised. Personally, I favour removal of lodged pellets, and this was done. Ahmes L Pahor City Hospital NHS Trust, Department of Otorhinolaryngology, Dudley Road, Birmingham B18 7QH, UK
REFERENCE
1 O'Connell J, Turner N, Pahor AL. Airgun pellets in the sinuses. J Laryngol Otol 1995;109:1097±100
Volume
94
November 2001
Fair shares
Imre Loe¯er's ideas (August 2001 JRSM, pp. 418±419) about redistributing the wealth have been around a very long time. Before he was assassinated, Huey Long, the colourful Louisiana governor and presidential hopeful (he even wrote a book entitled My First Days in the White House), called for the very same thing. James Kalivas Phoenix, Arizona 00133904, USA
Correction Book review: Iatrogenic Multiple Pregnancy
We regret that the address of Alyson Hunter and Peter Soothill, reviewers of the above book (October 2001 JRSM, p. 546), became detached. It is: Fetal Medicine Research Unit, University of Bristol, St Michael's Hospital, Bristol BS2 8EG. This address was erroneously credited to Adrian Marston, reviewer of An Intelligent Person's Guide to Medicine (p. 547).
John Worley
John Worley (1624±1721) was one of the ®rst pensioners at the Royal Hospital for Seamen, Greenwich, established in 1696 by King William III and Queen Mary as a naval equivalent of the Royal Hospital, Chelsea. The portrait is thought to have been painted by Sir James Thornhill (see Seamen's Hospital Society quarterly magazine, March, 1935) when Worley was admitted as a pensioner at about 80 years old. In 1873 the Royal Hospital became the headquarters of the Royal Naval College (the last of the pensioners had left in 1870), and it has now taken on yet another role, as part of Greenwich University. [Photograph from the Seamen's Hospital Society archive, reproduced with permission.]
G C Cook
610
