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Towards Fewer Handicapped ChildrenAuthor(s): John H. SmithSource: The British Medical Journal, Vol. 280, No. 6209 (Jan. 26, 1980), pp. 252-253Published by: BMJStable URL: http://www.jstor.org/stable/25438611 .
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252 BRITISH MEDICAL JOURNAL 26 JANUARY 1980
(caused by anxiety, inappropriate, or paroxys
mal) but even more so if it is of ventricular
origin. The commonest cause of ventricular
tachycardia is acute cardiac infarction, and
the differentiation at the bedside between a
paroxysm of ventricular tachycardia and one
of supraventricular origin is by no means
easy. Both usually give a heart rate of 160 or
more beats a minute and one of the few
differences is that in ventricular tachycardia
spacing of the beats may be irregular and this
may be clinically perceptible. Your expert, who recommends intravenous digoxin for a
heart rate that "becomes fast and irregular," could easily convert what might be a ventricu
lar tachycardia into ventricular fibrillation.
Nor am I happy with the routine use of
lignocaine to prevent primary ventricular
fibrillation. This is a longstanding controversy but there is increasing opinion today not
only that it may be of no use but that it may
actually be harmful. Pantridge1 in 1970
found lignocaine to be ineffective against ventricular ectopic beats occurring in the
first hour of the clinical onset of acute myo cardial infarction. In 1971 Chopra et al2
showed that both ectopics of R on T type and multifocal ectopics were resistant to
lignocaine, and that the only ectopics which
were easily abolished were those occurring in
diastole?and these in any case are considered
relatively benign and unlikely to produce
primary ventricular fibrillation. Darby et al3
in 1972 found that ventricular tachycardia and fibrillation occurred no less frequently in the group treated with lignocaine than in
the control group. Lie et al* in 1974 in
400 successive patients with acute cardiac
infarction found that 5% developed primary ventricular fibrillation in the lignocaine treated group as opposed to 4-3% in the
control group. Moreover, Bleifeld5 showed
that ectopic beats, sinus bradycardia, and
second-degree atrioventricular block were
more common in the lignocaine-treated group than in the control group; and concluded
that lignocaine should not be used routinely in acute cardiac infarction.
Furthermore, your expert does not mention
that it is necessary whenever one gives
lignocaine intravenously to give it very slowly
?taking at least two minutes to administer
100 mg of a 1% solution; otherwise toxic
effects of lignocaine, such as bradycardia and
hypotension, are apt to occur. This is
particularly important in the elderly, where
following its administration many authors6-8 have reported sinus bradycardia, ectopic beats, sinoatrial block, and even cardiac arrest.
Incidentally, I am sure that your expert is
referring to dipyridamole and not disopyra mide in connection with antiplatelet aggre
gation action.
I agree that your expert was attempting to
"oversimplify" the problem, but I hope not
at the expense of creating new problems.
Alan A Morgan Honorary Clinical Assistant
in Chest Diseases
University College Hospital, London WC1E 6AU
1 Pantridge JF. In: Scott DB, Julian DG, eds. Lidocaine
in the treatment of ventricular arrhythmia. Edin burgh: Livingstone, 1971:77-81. 2
Chopra MP, Thadam U, Portal RW, Aber CP. Br MedJ 1971;iii:668-70. 3
Darby S, Cruickshank JC, Bennett MA, Pentecost BL. Lancet 1972 ;i:817-9. 4 Lie KI, Wellens HJ, D?rrer D. Eur J Cardiol 1974;1 : 379-84.
8 Bleifeld W, Merx W, Heinrich KW, Eifert S. Eur J Clin Pharmacol 1973;6:119-26. 6
Lippestad CT, Forfang K. Br MedJ 1971;i:537. 7 Jeresaty RM, Kahn AH, Landey AB. Chest 1972 ;61:
683-5. 8 Cheng TO, Wadhawa J.JAMA 1973;223:790-2.
%*With regard to the first point, we regret that we printed disopyramide rather than
dipyridamole. The similarity between these two names presents a recurring problem. Dr
Morgan points out that intravenous lignocaine must be given slowly. Of course, no drug
should be given fast intravenously, and
lignocaine is no exception. There are indeed
papers suggesting that this drug may not be
useful but at least it rarely seems to do harm.
If the heart is beating very fast and the
patient is hypotensive it must be slowed.
Clearly an electrocardiogram, correctly in
terpreted, is desirable but we live in an im
perfect world. We do not agree that ventricular
tachycardia and rapid atrial fibrillation would
often be confused. The irregularity of ventri
cular tachycardia is obvious on paper but
usually slight compared with that of atrial
fibrillation. The rate of atrial fibrillation can
be slowed by a beta-blocker or by verapamil but we would not regard these as safer than
digoxin in this hypothetical emergency.?
Ed, BMJ.
Effects of naloxone on pethidine-induced neonatal depression
Sir,?We report a follow-up on children included in a neonatal study of the effects
of naloxone on pethidine-induced depression of respiration, feeding, and measures of
behaviour.1
Nineteen of 29 infants included in the origi nal trial attended for examination when aged 10-16 months. At birth nine of the infants had
received placebo (normal saline) and 10
naloxone hydrochloride 200 /xg intramuscu
larly. At follow-up all were rated on the Cardiff
standardisation of the Denver developmental
screening test2 and were neurologically examined. No differences were found between
the placebo and naloxone groups of children.
Of the nine children in the placebo group one
had delayed gross motor and two had delayed fine motor development. Two of the children
in the naloxone group had delayed gross motor achievements.
These findings complement the results of the
original trial, which indicated that 200 /?g intramuscular naloxone at birth seemed to reverse the undesirable effects of pethidine up to 48 hours after birth. We conclude that
naloxone did not disproportionately affect
development. P C Wiener
Sheila Wallace Department of Anaesthetics, University Hospital of Wales, Cardiff CF4 4XW
1 Wiener PC, Hogg MPJ, Rosen M. Br MedJ 1977; ii:228-31. 2
Bryant GM, Davies KJ, Newcombe RG. Develop Med Child Neurol 1979;21:353-64.
Resuscitation of the newborn
Sir,?Dr A R J Bosley (15 December, p 1590) is incorrect in stating that the Penlon bag was
not designed for use with an endotracheal
tube. Mushin and Hillard mentioned such an
application in their original description.1 The
ability of the device to create airway pressures
up to 80 cm H20 was also noted. In using a
leak hole in the inflating valve (instead of an
ordinary blow-off valve with a preset pressure
limit) the authors found that as pulmonary
compliance increased (with inflation of the
lungs) the maximum pressure obtainable would
fall. This variable blow-off effect was justified
by pointing out that the inflation pressure needed for totally airless lungs2 may often be
80 cm H20, so it was illogical to use a blow-off valve preset at a lower figure. Nevertheless, in
another study, which compared the Penlon
bag with the Ambu neonatal bag, which uses
an equally novel mechanism, again not depen dent on a blow-off valve, it was found3 that
both gave maximum pressures of about 85 cm
H20 with either a high or a low resistance.
However, the Penlon created a maximum
pressure of 175 cm H20 in a closed system
compared with only 85 cm H20 with the Ambu bag.
Despite these comments, these "flat" babies will not survive without someone inflating the
lungs with one of a multitude of devices at his
disposal. The fact that they all carry risks of
pneumothorax, which may prove fatal, does not alter the situation. Endotracheal intubation
of the neonate is often difficult to perform and to teach4 but may be life saving. With the
appalling UK perinatal mortality statistics, can we afford to limit the resuscitation abilities
of the obstetric team ?
M J Boscoe
Department of Anaesthetics, University Hospital of Leiden, Leiden, The Netherlands
1 Mushin WW, Hillard EK. Br MedJ 1967;i:416-7. 2 Rosen M, Laurence KM. Lancet 1965;ii:721-2. 3 Rondio Z, Rawicz M. Anaesth Resus Intensive Therap 1976;4:273-9. 4 Rosen M, Mushin WW. Lancet 1968 ;i: 1307.
Towards fewer handicapped children
Sir,?Your recent leading article "Towards
fewer handicapped children" (8 December,
p 1458) mentions the relation between severe
handicap, low birth weight (<2500 g), and
low socioeconomic group and suggests that
researchers might best employ themselves by
identifying which particular components of
socioeconomic deprivation result in an in
creased incidence of handicap. Surely part of
this research has already been done.
Improved maternal nutrition during preg
nancy in low socioeconomic groups is known
to increase average birth weight, reduce the
incidence of low-birth-weight babies ( < 2500
g), and reduce perinatal mortality. Thus in
Guatemala1 adequate maternal dietary supple mentation during pregnancy in village dwellers
resulted in an average fall from 30% to 9% in the incidence of low-birth-weight babies.
Similar findings are demonstrated in developed countries. In Montreal2 reduction in the
incidence of low-birth-weight babies ( < 2500 g) and a decrease in both perinatal and neonatal
mortality was shown in a high-risk, low
socioeconomic study group subjected to
"intensive nutritional care" (counselling and
dietary supplementation) throughout preg
nancy. With such improvements in birth weight and
reduction in perinatal and neonatal mortality can one not expect an attendant reduction in
morbidity, including mental and physical
handicap ? While attention is focused sharply on perinatal intensive care, could we not
reduce perhaps the size of the perinatal
problem by instituting "intensive nutritional
care," including dietary supplementation
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BRITISH MEDICAL JOURNAL 26 JANUARY 1980 253
where necessary, throughout the antenatal
period, especially in low socioeconomic
groups ?
John H Smith
Rotunda Hospital, Dublin, Eire
1 Lechtig A, Habicht JP, Delgado H, Klein RE,
Yarbrough C, Martorell R. Pediatrics 1975 ;56: 508-20.
2 Primrose T, Higgins A. J Reprod Med 1971 ;7: 257-64.
Monitoring blood glucose
Sir,?Mary Warner (15 December, p 1581) and Dr R D Eastham (12 January, p 116) have
both quite rightly cautioned us on the indis
criminate and unsupervised use of blood
glucose meters and one has to agree with many of the points made. The biochemistry labora
tory should indeed be able to produce the more
accurate results, and results from meters in
some clinical situations, operated by a variety of personnel, may at times be suspect. How
ever, even with all the limitations of interpre tation of the single clinic blood glucose estima
tion, it is far more valuable if the result is
available at the time of the consultation; and
this in many hospitals and outlying clinics
can be provided only by a meter and strip
system. The responsibility for such a system must lie with the clinician, who should be
constantly checking quality control with the
assistance of his biochemical colleagues. With regard to self-monitoring by the
patient, one fundamental question is in danger of being overlooked?who needs to know the
blood glucose results ? The answer is that it is
the patient who needs the result and he or she
needs it at the time of the test, not two or three
days later. The patient must be trained to react
to abnormal patterns of results by making sen
sible changes of treatment. If this is not done
then the full potential of self-monitoring is not
being realised. Thus filter paper strips sent to
the laboratory, as described by Dr R Paisey and others (8 December, p 1509), provide only a
partial self-monitoring system. A coefficient
of variation of less than 10% is adequate for
day-to-day diabetic management and may be
achieved by suitably trained patients using meters and strip tests at home.1 Quality control
is important with self-monitoring even if more
difficult to organise than in the hospital. The
clinician must be satisfied that the patient is
well trained, maintains good technique, and
responds appropriately to the results. The
blood glucose meters and strip systems must
be kept under critical review and must be
shown to live up to the manufacturers' speci fications when put into the hands of the
trained patient.
Self-monitoring of blood glucose may be a
real advance for many patients. Producing inaccurate results will give it a bad name but so
will limiting its potential by giving the result
to the doctor in preference to the patient.
A H Knight
Stoke Mandeville Hospital, Aylesbury, Bucks HP21 8AL
1 Webb DJ, Lovesay JM, Ellis A, Knight AH. Br MedJ In press.
Sir,?We read with interest the paper by Dr I Peacock and others on self-monitoring of blood glucose during diabetic pregnancy
(24 November, p 1333).
Our own experience using the Ames
Dextrostix-Eyetone reflectance meter system is very similar in a series of 24 un
selected consecutive patients (21 established
diabetics ? duration of insulin therapy nine
years, range 0-5 to 26 years ? and three
gestational diabetics on insulin). However, our
patients made three to four measurements of
preprandial blood glucose daily and were
taught and encouraged to modify their own
insulin doses to achieve optimal diabetic
control. We have found that in many patients there are abrupt changes in insulin dose
requirements, particularly towards the end of
the second trimester. Weekly profiles, no
matter how detailed, do not yield enough information in such patients. Furthermore,
postprandial measurements of blood glucose do not appear to be particularly helpful in that
high concentrations after breakfast seem to be
predictable from the value before breakfast.
We are, however, in agreement with the
authors' comments about the dangers of
nocturnal hypoglycaemia, although we have
not found it necessary to advise a third injec tion for this reason.
Collection of blood samples at home for
processing in the laboratory (Dr R B Paisey and others, 8 December, p 1509) may be a
useful method of checking on the correctness
of patients' measurements but does not have
the same educational value as true self
monitoring of blood glucose. In addition, surveillance can be improved by unheralded
visits from a health visitor or specialist nurse.
Measurement of glycosylated haemoglobin concentrations in the pregnant diabetic is too
insensitive a method to detect any but the
more gross forms of aberration in diabetic
control. In our hands normal haemoglobin
Ai concentrations (measured by the micro
column method) can be achieved even when
blood glucose is normal. Hb A1 estimations
give no clue about the swings of blood glucose
(either hyperglycaemia or hypoglycaemia).
By involving the patients in their own dia
betic control motivation and understanding of
the aims of diabetic treatment are greatly enhanced. Although shortening of the period of
hospitalisation was not our prime aim, we
found this easy to achieve save in women with
established diabetes of 10 years or more. In
this group the maternal course during preg
nancy was frequently complicated despite
good control of blood glucose, although the
fetal outcome was as good as in the group with
duration of maternal diabetes of less than 10
years. This method of blood glucose surveil
lance and diabetic control was acceptable to all
our patients and no problems arose as a result
of the frequent capillary blood sampling.
TET West E E Edwards
Royal Shrewsbury Hospital, Shrewsbury, Shropshire
Clara Lowy
S L Judd St Thomas's Hospital, London SEI 7EH
Sir,?As Dr R D Eastham states (12 January,
p 116), the days of the single clinic blood
glucose estimation for assessment of treatment
of diabetes mellitus are numbered. Glyco
sylated haemoglobin may become a better
measure of general diabetic control at inter
mittent clinic visits. However, frequent blood
glucose estimations are required to provide
the up-to-date information necessary for rational adjustment of insulin dosage.
Home monitoring of blood glucose levels is a practical procedure1 and, given the current
mode of insulin administration, exact glucose levels as provided by a clinical chemistry laboratory are unnecessary for this purpose.
Blood glucose levels may be estimated with
glucose oxidase-peroxidase test strips using a
colour comparison scale without the need to
purchase a reflectance meter.2 We have not
found these newer test strips liable to varia tion. Clearly the laboratory estimation of
plasma glucose remains essential for glucose tolerance tests and for management of patients during intercurrent illness and in diabetic
emergencies (and for the calibration of blood
glucose meters). But diabetic patients who have achieved better diabetic control through home monitoring3 should not abandon the
method because it has not yet reached the
precision expected of laboratories.
C M Kesson
Paul Lawson
John T Ireland
Department of Medicine, Southern General Hospital,
Glasgow G51 4TF
1 S?nksen PH, Judd SL, Lowy C. Lancet 1978;i:729-32. 2 Lawson PM, Kesson CM, Ireland JT. Lancet 1979; ii:742.
3 Tattersall RB. Diabetologia 1979;16:71-4.
Postoperative analgesia
Sir,?Dr P C Rutter and others (5 January, p 12) have clearly shown that continuous
intravenous opiate analgesia following abdo
minal surgery produces better analgesia for
less opiate. Vital capacity and peak expiratory flow rate are improved and pulmonary com
plications are fewer with this regimen than
with the two more commonly employed alternatives.
It would be interesting to know the arterial
blood oxygen and carbon dioxide tensions and
pH in the three patient groups during treat
ment, for these findings would have implica tions for the postoperative management of
patients who have preoperative impairment of
pulmonary function. Analgesia is often given
reluctantly to such patients on the grounds that it may cause or exacerbate respiratory failure. If the patients in groups B and C
were more hypoxic and hypercapnic than those
in group A this might suggest that adequate
analgesia by infusion of opiates is more likely to secure optimal pulmonary function even
in patients at risk of respiratory failure because
of lung disease. Postoperative pain resulting from a reluctance to prescribe opiates for these
patients may be more likely to cause respiratory failure than adequate opiate analgesia.
A G Leitch
Department of Respiratory Medicine, City Hospital, Edinburgh EH10 5SB
***We sent a copy of this letter to the authors,
and Professor H A F Dudley's reply on behalf
of his colleagues is printed below.?Ed, BMJ.
Sir,?Dr Leitch is quite right in saying that
the reluctance to give opiates to patients with
borderline respiratory function when they suffer the additional embarrassment of pain
may not be soundly based. However, we cannot
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