to me about my paper on obstetrics in general ... trars, and senior house officers for their care of the ..... 2 Porter M, Gorman D. Approaches to somatisation.
health district invests in dedicated preventive health visiting care for elderly people over the age of 70. The cost of one or two preventable admissions to hospital a week must more than pay for a compact team covering a defined locality such as Malvern, where I work. Community workers know that we can respond quickly to a request to meet personal hygiene needs if required. We are at present proactively visiting people over 80 in Malvern and have found little unmet hygiene needs in those unknown to us so conclude that our service does work. I think that perhaps all health districts should consider in their performance indicators for the elderly how many baths and simple toenail cutting services they provide and whether a service provided under health visiting management would not answer any unmet need cost effectively. KATHLEEN STEEL Malsern Health Centre, Malvern WR14 2J Y I Penn NI), Belfield PWV, Mascie-Tralor BH, Mullev GP. Old and unwashed: bathing problems in the oser 70s. Br Med J7 1989;298: 1 158-9. ('29 April.)
Audit of 26 years of obstetrics in general practice SIR,-While thanking those who have written to me about my paper on obstetrics in general practice' I should like to reply to a critical letter in your columns from associates of the consultant unit used by my practice.2 Mr A Prentice and others question the relevance of data from previous decades to current practice. I believe that in many aspects of human endeavour, not least in medicine, an appreciation of what has happened in the recent past is essential to an adequate understanding and critical appraisal of the present. Surely all concerned with obstetrics in this country will look back with pride and pleasure at the great reduction in national perinatal mortality in the past three decades? The writers say "we have recently completed an audit of all patients referred for booking in the general practitioner unit at North Tees and there are differences between our findings and his." Comment on this is difficult when they give no details of their findings; however, my results relate entirely to my own practice and bookings, which I do not claim are typical-only that they could be if there were more enthusiasm for obstetrics within general practice. Having stated that patients delivered in the general practitioner unit are not comparable with those delivered in the consultant unit, Mr Prentice and others then proceed to compare them. They point out that those delivered in the consultant unit are by definition a high risk group, a matter that I supposedly ignored. On the contrary, I made a point of thanking the consultants, registrars, and senior house officers for their care of the abnormal patients in my audit, and I argued that because I undertake delivery of a substantially higher proportion of my patients (54%) than general practitioners do nationally (10%), this inevitably results in a higher proportion of abnormal deliveries among patients who are booked for or transferred to the consultant unit. My plea was that greater involvement by general practitioners in normal obstetrics would leave the specialists freer to concentrate on their specialty. In other words, the "high risk" group delivered in consultant units currently contains many patients who are not high risk at all. Mr Walton will be well aware that after our many years of working amicably together on the booking committee we are relaxing even further the now antiquated recommendations of the Cranbrook committee' so
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that more women can be offered care by their own general practitioner. Mr Prentice and others deny that their consultant unit is associated with higher intervention rates. In that case it is very odd that the increase in deliveries in the unit from 20% to 45% between the first six and last 11 years of my audit should have been associated with a threefold increase in caesarean sections and an even greater increase in forceps deliveries. Arguably, this increased intervention might have been justified as it has been accompanied nationally by improved perinatal mortality rates. Although intervention was for a time very fashionable,4 I do not believe that it is always in the best interests of mother and baby and I welcome its current decline. Far from seeking to perpetuate divisions between specialists and general practitioners, I simply reaffirmed my unchanging belief that it is optimal for the normal mother to have her normal baby in congenial surroundings, in the presence of her husband or some other familiar relative or friend, and attended by her own familiar general practitioner who has supported her throughout antenatal care and often for many years. Should difficulties be foreseen or occur, then of course specialists must be involved, and I am the first to welcome their expertise and to congratulate them on their good results. G N MARSH Norton Medical Centre, Stockton on Tees, Cleveland TS20 lAN 1 Marsh GN, Channing DM. Audit of 26 years of obstetrics in general practice. BrMedJ 1989;298:1077-80. (22 April.) 2 Prentice A, Perles N, Walton SM. Audit of 26 years of obstetrics in general practice. Br MedJ 1989;298:1313. (13 May.) 3 Ministry of Health. Report of the Maternity Services Committee. London: HMSO, 1959. (Cranbrook committee report.) 4 Macfarlane AJ, Mugford M. Birth counts: statistics of pregnancy and childbirth. London: HMSO, 1984.
Tetrahydroaminoacridine in Alzheimer's disease SIR,-The report by Drs J Byrne and T Arie on the effects of tetrahydroaminoacridine on Alzheimer's disease' and the more recent letter by Scott and de Jong on ataxic (Cheyne-Stokes) breathing remarkably relieved in an apparently moribund patient by 2 0 mg physostigmine intravenously reminded me of a patient we treated with anticoagulant drugs to improve the circulation to his brain.3 He was treated for dementia on the basis that he had cerebrovascular insufficiency,4 and each time we gave him the anticoagulant there was great improvement in his mental state with reduction in confusion and combativeness, but he regressed each time it was stopped. This happened three times and each mental regression was accompanied by a physical deterioration manifested by unsteadiness on his feet and a tendency to fall plus ataxic breathing and stupor to the point where we were afraid he might die. These physical signs, including his abnormal breathing, also disappeared when the anticoagulant was resumed. This patient eventually died when the anticoagulant was stopped permanently after his transfer to another hospital, and necropsy proved he had Alzheimer's disease. It would thus seem not unreasonable to assume that the increased blood flow to the brain allowed the neurones to resume their production of acetylcholine, which helped not only the mental function but also the breathing mechanism in a manner similar to the response of the patient of Scott and de Jong. The mental response suggests that Alzheimer's disease may be related to vascular insufficiency of the brain as suggested by AskUpmark and Fajers in their study of Takayashu's syndrome, in which they found changes in the
brain resembling Alzheimer's disease and suggested this finding be studied further. ARTHUR C WALSH
Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, United States 1 Byrne J, Arie T. Tetrahydroaminoacridine (THA) in Alzheimer's disease. BrMedJ 1989;298:845-6. (1 April.) 2 Scott PV, de Jong M. Tetrahydroaminoacridine in Alzheimer's disease. BrMedJ 1989;298:1250-1. (6 May.) 3 Walsh AC. Anticoagulant therapy as a potentially effective method for the prevention of presenile dementia: two case reports. Am Geriatr Soc 1968;16:472-7. 4 Walsh AC. Senile dementia-a re-evaluation of its cause and a possible method of prevention. Pennsylvania Medical ournal 1967;:55-9. 5 Ask-Upmark E, Fajers CM. Further observations on Takayashu's syndrome. Acta Med Scand 1956;159:155-275.
Pitfalls in voting for GMC SIR,-The voting papers for the General Medical Council election have now been distributed. A study of the list of candidates in 1984 discloses some peculiarities which will be repeated in the 1989 list. In 1984 there were 169 listed candidates in the English constituency, of whom 39 were elected (23%). The list is in alphabetical order. Names beginning with A number 15 and, of these, eight were elected (53%). If the 169 names are divided into 13 consecutive groups of 13 names, then the numbers elected in each group are seven, four, two, two, four, three, none, three, two, three, two, two, and five. This distribution suggests a bias towards the first page and perhaps a smaller bias towards the last page. It is easy to see how this could arise. Candidates are requested to state their main field of medical activity. Statements like "General practice" (62 entries) convey nothing to the voter as to the candidate's suitability. The same paucity of information applies to the other entries in that column in the list, with the exception, of course, of the handful of well known names, who were too few to fill all 39 vacancies. The voter, having ticked off the eminent minority and wishing to complete the remaining vacancies, may yield to the temptation to tick off those names nearest at hand, which are mostly ergonomically convenient on the first page and to a smaller extent on the last.
In future candidates should be invited to state why they consider themselves suitable to serve on the GMC, and these expressions of opinion should be printed in an additional column. I am by no means the first to point out the bias created by lists drawn up in alphabetical order. The remedy here is to randomise the order. I urge voters to resist the influence of alphabetical order and, where necessary, to cop tact candidates to find out what special qualifications they may have. B J FREEDMAN London N 19 3TR
Dental health and acute myocardial infarction SIR, - Dr Kimmo J Mattila and colleagues suggested an association between dental health and acute myocardial infarction,' but their case-control study has several methodological flaws. The rather odd design of the study, with two separate series of cases and controls each with different inclusion criteria, is unexplained and suggests that their results may have been chance findings rather than the primary purpose of the study. The low response rate among controls in the first series (65%) leaves considerable scope for response bias. Furthermore, it is well known that both dental health and
incidence of myocardial infarction are related to social class. It would have been sensible to match cases and controls for social class as well as for age and sex. Dr Mattila and colleagues went to great lengths to discount social class as a confounding variable, including the use of logistic regression, but they did not include a table to compare the dental indexes for cases and controls within each social class, which would have been very informative. The two methods of assessing dental health are innovative, to say the least, and neither is referenced. The total dental index and the pantomography index included measurements of both caries and periodontal disease. It is more appropriate and more usual to examine for factors associated with caries, a disease predominantly related to diet, with the DMF (delayed, missing, and filled teeth) index,2 and to measure periodontal disease, traditionally related to oral hygiene and age, with the community periodontal index of treatment need (CPITN index).' Whatever index of dental health is used, it should have been applied by. a single, blinded observer. There are also several misuses of statistics in the paper. Dr Mattila and colleagues claimed that the "high correlation" (r=069) between the pantomography index (which was assessed blind) and the total dental index (which was not) suggests that the total dental index assessment was not biased. The use of correlation is not appropriate in this context,4 nor in assessing the strength of the association between the total dental index and a discrete variable such as social class. In view of these. design flaws, we remain unconvinced of the clinical relevance of the observed association between poor dental health and myocardial infarction, which can probably be explained by study bias or, more possibly, by the known association of low social class with both disorders.
slightly better than that among the controls who did respond (1-5 v 2-0, respectively). The nonresponders were not of lower social class than the responders. Instead of comparing the dental indexes within each social class (making eight pairwise post hoc comparisons, as proposed by Dr Gilmour and colleagues) we used logistic regression analysis. This method examines whether the association between dental infections and acute myocardial infarction is independent of other risk factors. We tried to measure active lesions caused by caries and periodontal disease. Although many indexes for measuring dental state exist, we were unaware of any generally accepted scale suitable for our purposes. We do not believe that the DMF (decayed, missing, and filled teeth) index is a sensitive scale for measuring active carious lesions, and nor do we think that various indexes developed for assessing the need for treatment would have given more reliable information. We used Spearman's rank correlation to examine whether the two indexes ranked the subjects in a reasonably similar order. As both indexes are ordered variables this correlation should give useful information. There was a monotonous increase in both dental indexes from social class I to social class IV. As social class and dental indexes can both be considered as ordered variables, we do not think that use of Spearman's rank correlation is erroneous. We believe that our results strongly suggest that patients with acute myocardial infarction have more dental infections than random community controls. The association, whether direct or indirect, deserves further study. KIMMO J MATTILA First and Second Departments of Medicine,
Helsinki University Central Hospital, 00290 Helsinki, Finland
Department of Communit) Medicine, University of Glasgow, Glasgow G12 8QQ ELIZABETH KAY Department of Oral Medicine and Pathology, University of Glasgow Dental Hospital, Glasgow G2 8QQ D NORTHRIDGE Department of Cardiology, Western Infirmary, Glasgow G 1I 6NT I Miattila KJ, Nieminen MS, Valtonen VV, et al. Association between dental health and acute myocardial infarctioni. Br Medj 1989;298:779-82. (25 March.) 2 Klein H, Palmer CE, Knutson JW. Studies on dental caries I. Public Health Rep 1938;53:751-9. 3 Lindhe J. Textbook of clinical periodontology. Copenhagen: Munksgaard, 1983. 4 Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986;i:307-10.
AUTHOR'S REPLY, -We investigated the hypothesis that chronic lowgrade infection is concerned in the pathogenesis of coronary heart disease and used a case-control design as a prospective cohort study was not possible. Two separate series of patients were collected, mainly because the response rate among the controls in the first series was not entirely satisfactory. We believe that the similar strong association between poor dental health and acute myocardial infarction that we found in two separate series speaks against (and not for) chance as the explanation. Likewise, we do not think that using different dentists in the two series diminishes the reliability of our results. The low rate of participation in the first series was largely due to out of date addresses for patients. After the first series had been completed we invited 10 (roughtly half) of the controls who had not responded to have a dental examination. The median total dental index among them was
Twenty one years of legal abortion SIR,-I was not unduly surprised to find no mention of the complications resulting from the three million abortions carried out since the 1967 Abortion Act in the article by Ms Diane Munday and others.' I certainly question the statement that early abortion has no adverse mental or physical sequelae. I can assure colleagues that women are regularly admitted to my gynaecology ward with secondary haemorrhage, pelvic sepsis, retained products, and cervical or uterine damage resulting from abortions carried out elsewhere. The latest confidential inquiry into maternal deaths reminds us that death still occurs too. Unfortunately, most of these complications occur after the seven day limit for recording on the abortion return form sent to the Department of Health. In my infertility practice I am encountering increasing numbers of women with tubal occlusion after abortion for which no other cause can be found. Similarly the long term symptoms of grief and guilt, far from being confined to women in Northern Ireland, are widely manifest in the whole of the United Kingdom. Postabortion counsellors are as necessary today as other grief counsellors. Ask any priest or minister and you will be told of countless numbers of women, and sometimes men, who need ministry and comfort for the resulting inner hurts, pain, and depression for which medicine has little answer. Such is the need that there are now books published on the subject of
postabortion grief. There are still long term medical sequelae; I am still seeing occasional cases of abdominal wall endometriosis after abortion by hysterotomy carried out in the early 1970s. In medical terms the authors claim 21 years
of success. In human terms, to quote Samuel Johnson, "success and miscarriage are empty sounds." ROBERT BALFOUR Bridgend CF32 OPQ I Munday D, Francome C, Savage W. rwenty one years of legal abortion. BrMedJ 1989;298:1231-4. (6 May.)
Somatisation SIR,-Somatisation' 2 is more common than is recognised and occurs in patients with no obvious psychiatric illness. It is well known that mildly depressed patients can present with a symptom of pain that is relieved by a small dose of a drug such as amitriptyline, but it is less well known that pain can present as part of an anxiety-stress condition. The diagnosis is not always obvious but is suggested by pain with no obvious organic basis, usually musculoskeletal in pattern but with inappropriate anatomical presentation. In addition, these patients will readily admit to being under stress or having social or economic problems that are nearly out of their control. They seldom have a history of emotional instability and often have responsible jobs and good personalities. Previous treatments such as physiotherapy, osteopathy, and non-steroidal anti-inflammatory drugs have been tried and failed. They have often had multiple investigations. When the diagnosis is of a stress related condition the treatment may be difficult, paradoxically because patients respond so well to being taught techniques similar to self hypnosis. There is, however, a shortage of doctors or psychologists trained and able to use this simple treatment. I have been using this technique of emotive training in the pain relief clinic with good results: of 40 patients given this form of training, 35 obtained good relief from pain and anxiety (report to Royal Society of Medicine, 1988). The technique has been developed and is used increasingly. It is also helpful in the irritable bowel syndrome and migraine. The great advantage to the patient is that the technique is lasting, has no side effects, and is under the patient's own control. CLIVE JOLLY Pain Relief Clinic, Ipswich Hospital, Ipswich IN'4 5PD 1 Murphy M. Somatisation: embodying the problem. Br Med j 1989;298:1331-2. (20 May.) 2 Porter M, Gorman D. Approaches to somatisation. Br Med J 1989;298:1332-3. (20 May.)
SIR,-I cannot agree with Drs M Porter and D Gorman, who conclude that general practice will be unable to deal adequately with somatising patients until special time is created to do so.t Patients who somatise their psychological problems and are not managed adequately will seek medical attention repeatedly and become the "heartsink patients" of general practice. Gask et al have developed a model for the management of these patients in general practice, taking cognisance of the consultation time available, and have shown that doctors can be taught the skills necessary to identify and manage these patients appropriately.2 Though this approach may require more time initially, it should benefit the patient3 and save time in the long run. The question therefore is not whether general practice can afford the time to come to terms with somatisation but whether it can afford to ignore it. KIERAN HARKIN
Ferryhill, County Durham DL 17 OEN 1 Porter M, Gorman P. Approaches to somatisation. Br Med 7 1989;298:1332-3. (20 May.) 2 Gask L, Goldberg D, Lesser AL, Millar T. Improving the
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