Iron deficiency is neglected in women's health [5]

Abstract

Editor—The data by Waalen et al show that 38% of menstruating women living in San Diego are iron deficient using the accepted cut-off point of <20% for transferrin saturation as an indicator of deficiency. These data support our hypothesis that haematological distributions contain a large proportion of iron deficient women.1

By focusing on the mean haemoglobin distribution, Waalen et al lose sight of a fundamental part of our work: why should women have lower reference limits for haemoglobin and serum ferritin concentrations than men?2 Our hypothesis for this was that a significant number of women are iron deficient. Mean values mask anomalies in distribution and are inappropriate to evaluate the issues we have raised. Since women menstruate, men would be expected to have higher mean haemoglobin concentrations because they can attain higher upper limits, so the 10g/l difference found by Waalen et al was not unexpected.

A similar situation occurs in menstruating but not in non-menstruating non-human primates.3 To support their case Waalen et al cite one menstruating non-human primate example—unfortunately this paper included data from infants, adolescents, and female animals half the age of the males, and it is therefore unreliable.4 Data analysis of a sex difference with age is more complex than simply presenting mean values from uncontrolled populations.

Close inspection of the ferritin data in part C of Waalen et al's study shows a large number of women “falling off” the lower end of the distribution. The haemoglobin difference between the sexes was of the range 15-20 g/l, which represents a significant proportion (39%) of the female distribution having a serum ferritin concentration below the lowest male value. In part B, the transferrin saturation data for 26-55 year old menstruating women show a significant difference in haemoglobin concentration of 15-25 g/l with a transferrin saturation below 20%, the accepted cut-off point for iron deficiency. In postmenopausal women (part D) 29% were affected. Ten per cent were classified as normal (haemoglobin concentration >120g/l) but were clearly iron deficient on the basis of having transferrin saturations <10%.

Iron deficiency is a significant and seemingly neglected factor in women's health. Why should the lower reference level be sex dependent? What compelling evidence is there to support this apparent anomaly? In this context men are non-menstruating women, haematologically speaking.

Full text

Undisclosed payments in research
Patients have the right to know
motivations of researchers
Editor
—
Rao and Sant Cassia discussed the
ethics of undisclosed payments to doctors
recruiting patients in clinical trials.1For
many years now the greater Glasgow
community and primary care local research
ethics committee has insisted that reference
to doctors’ payment is included in the
patient information sheet that goes to all
potential participants. I object to the
payment being hidden behind such phrases
as “your doctor’s research fund will be paid,”
which a number of medical research ethics
committees allow,and I note that the phrase
“for the additional work involved” often
appears.
Although the NHS and NHS Scotland
are the remit of two different parliaments,
cross border acceptance of approval by
medical research ethics committees exists.
Patients are also likely to see the NHS as a
whole and the ethical principles of doctors
and other healthcare professionals as not
having regional variations. In the interests of
equality (as well as informed consent) British
guidelines need to be developed on this and
other minimum requirements of infor-
mation to be given to patients. This could
include the amount of payment. My quick,
non-random survey of my non-medical
family and friends shows that the size of the
payment and the potential overall income
are underestimated.
Other types of personal gain exist for
researchers that I also believe potential par-
ticipants should know about
—
when the
work forms part of the requirements for a
degree. Some people who already have a
professional qualification and who are using
“their” patients in research do not always
believe that it is necessary to inform patients
that they are registered for a degree for
which this research is necessary. Such
research may not always reach publication
and may be designed as a learning
experience rather than a complete piece of
research. If patients are to be expected to
take part in research for altruistic reasons
they have a right to know what reasons
motivate the people carrying out the
research.
Jacqueline M Atkinson senior lecturer
Department of Public Health, University of
Glasgow,Glasgow G12 8RZ
j.m.atkinson@clinmed.gla.ac.uk
1 Rao JN, Sant Cassia LJ. Ethics of undisclosed payments to
doctors recruiting patients in clinical trials. BMJ
2002;325:36-7. (6 July.)
Guidelines already exist
Editor
—
I write as a member and former
chairman of the ethical issues committee of
the Faculty of Pharmaceutical Medicine, a
former medical director of the Association
of the British Pharmaceutical Industry, and a
member of two research ethics committees.
Rao and Sant Cassia make several points
that disregard the truth about phase IV
clinical trials and do not differentiate
between phase IV clinical trials and the
safety assessment of marketed medicines,
both of which are subject to strict guide-
lines.1These should be familiar to members
of research ethics committees but are clearly
unfamiliar to the authors of this paper.
Phase IV clinical trials, soon to be
covered by the national legislation that
follows the adoption of the European direc-
tive on clinical trials, are scientific projects
already subject to ethical review. They are
conducted in accordance with protocols
submitted to medical and local research eth-
ics committees as appropriate, and pay-
ments to be made are clearly included in the
application for ethical review. Neither they
nor safety assessment studies are designed
solely to familiarise doctors with new and
recently licensed medicines. They may well
be required by the licensing authority to be
conducted to establish a more robust safety
database for a new medicine.
Rao and Sant Cassia seem to be
ignorant of what they can already do about
the concerns they express. This year’s BMA
annual meeting endorsed the need for the
suggested fee for clinical research to be
widely published so that research ethics
committees, among others, can have up to
date independent advice on an agreed
benchmark for payment to doctors taking
part. Every phase IV study sponsored by a
pharmaceutical company must be submitted
to the appropriate research ethics commit-
tee(s), which can turn down an application if
the payment is thought to be coercive. Stud-
ies into the safety assessment of marketed
medicines do not need review by research
ethics committees, but a BMA suggested
payment exists for these, too. If a third party
believes that a study is a marketing exercise
masquerading as a research project or a
safety assessment study, a complaint can be
referred to the Prescription Medicine Code
of Practice Authority and the company
sanctioned if the complaint is upheld.
I agree that undisclosed payments to
doctors recruiting patients in clinical trials
would be unethical. However, payments
must be disclosed to research ethics
committees, which must therefore ensure
that disclosure is complete and what is
disclosed is acceptable.
Frank O Wells non-executive chairman
Marix Drug Development Limited, Marix, Cardiff
CF11 9UY
FOW5851@aol.com
1 Rao JN, Sant Cassia LJ. Ethics of undisclosed payments to
doctors recruiting patients in clinical trials. BMJ
2002;325:36-7. (6 July.)
Sildenafil for “blue babies”
Such unlicensed drug use might be
justified as last resort
Editor
—
We were disappointed to hear that
a doctor in India has been criticised for
treating pulmonary hypertension in three
neonates (so called blue babies) with the
phosphodiesterase type 5 inhibitor sildenafil
(Viagra), a drug not licensed for this
purpose.1
Many drugs are widely and appropriately
used outside their product licence.2Such pre-
scribing practice is common in adult medi-
cine, but is particularly prevalent in paediat-
rics because companies rarely undertake the
work necessary to gain a licence for children.
The decision to prescribe outwith a drug’s
licence should be supported by evidence of
safety and potential benefit and, when
possible, by a reasonable body of supporting
professional opinion.
Of course, controlled clinical trials
should be performed when possible to
evaluate new treatments for specific indica-
tions. But these data are not always available,
and then clinicians must make difficult deci-
sions as to whether other information, such
as efficacy and safety in other groups of
Advice to authors
We would like to receive all responses
electronically at our website. Please send your
letter directly to bmj.com as a rapid response to a
published article.
All rapid responses will be considered for
publication in the paper journal; authors will be
notified by email if their rapid response has been
accepted, but not otherwise.
For more detailed advice please see
bmj.com/advice/sections.shtm#letters
bmj.com
Letters
Website: bmj.com
1174 BMJ VOLUME 325 16 NOVEMBER 2002 bmj.com

patients, justifies unlicensed drug use.
Subsequently, case reports should be pub-
lished, facilitating scientific debate and
informing the design of clinical trials.
Evidence is growing that sildenafil acts
as a vasodilator in the pulmonary circulation
and is effective in lowering pulmonary
artery pressure in pulmonary arterial hyper-
tension. This effect has been shown in adults
with pulmonary hypertension and healthy
volunteers with pulmonary hypertension
induced by hypoxia.34Intravenous sildenafil
also normalised pulmonary artery pressure
in an animal model of neonatal pulmonary
hypertension.5
The evidence currently available is not
sufficient generally to recommend the use of
sildenafil in neonates with pulmonary
hypertension. Assuming, however, that silde-
nafil was used as a last resort, after standard
treatment, we believe that there are sufficient
data to support the actions of this doctor.
Perhaps the publicity that has arisen about
this action will encourage further clinical
research into the potential of inhibiting
phosphodiesterase type 5 as a treatment for
neonatal pulmonary hypertension, which
may ultimately result in wider benefit to
patients.
James Oliver lecturer in clinical pharmacology
James.Oliver@ed.ac.uk
David J Webb professor in clinical pharmacology
Clinical Pharmacology Unit and Research Centre,
University of Edinburgh, Western General Hospital,
Edinburgh EH4 2XU
1 Kumar S. Indian doctor in protest after using Viagra to
save “blue babies.” BMJ 2002;325:181. (27 July.)
2 Prescribing unlicensed drugs or using drugs for unli-
censed indications. Drug Ther Bull 1992;30:97-9.
3 Michelakis E, Tymchak W, Lien D, Webster L, Hashimoto
K, Archer S. Oral sildenafil is an effective and specific pul-
monary vasodilator in patients with pulmonary arterial
hypertension: comparison with inhaled nitric oxide. Circu-
lation 2002;105:2398-403.
4 Zhao L, Mason NA, Morrell NW, Kojonazarov B, Sadykov
A, Maripov A, et al. Sildenafil inhibits hypoxia-induced
pulmonary hypertension. Circulation 2001;104:424-8.
5 Shekerdemian LS, Ravn HB, Penny DJ. Intravenous silde-
nafil lowers pulmonary vascular resistance in a model of
neonatal pulmonary hypertension. Am J Respir Crit Care
Med 2002;165:1098-102.
Ethics, conscience, and science have to be
balanced against limited resources
Editor
—
The unlicensed use of sildenafil
(Viagra) by an Indian doctor to save “blue
babies” has recently been the topic of a
heated debate.1Before passing any judg-
ment it is important to note that most
neonatal nurseries in the developing coun-
tries cannot afford either to document or to
treat persistent pulmonary hypertension in
newborn infants by the currently accepted
standards. Access to pulse oximetry and car-
diac echocardiography is difficult, and very
few units are equipped for ventilation and
surfactant therapy.2Transfer to regional
centres is almost impossible given the lack of
neonatal transport services.
Advocating a theory of failure of
conventional management before resorting
to experimental treatments after informed
consent is easy. It must, however, not be for-
gotten that the worldwide use of hyperventi-
lation, muscle paralysis, bicarbonate infu-
sion, and non-specific vasodilators such as
magnesium sulphate, prostacycline, glyceryl
trinitrate, and sodium nitroprusside in the
conventional management of persistent pul-
monary hypertension in newborn infants is
not based on evidence from any randomised
controlled trials.3The use of the most popu-
lar non-specific pulmonary vasodilator tola-
zoline has also been serendipitous, stem-
ming from the original case report of
persistence of the fetal circulation in 1969
rather than from controlled studies of its
efficacy, kinetics, or safety.
The current expensive gold standard
—
using specific pulmonary vasodilator treat-
ment and inhaled nitric oxide
—
is unlikely to
be available or affordable in developing
countries in the near future.3Moreover,
nitric oxide has also not proved to be the
single magic bullet for persistent pulmonary
hypertension in newborn infants. Nearly
20-30% of cases do not respond to nitric
oxide, especially those with severe parenchy-
mal lung disease (as in meconium aspiration
and pneumonia) or pulmonary hypoplasia
(as in congenital diaphragmatic hernia).3
The recent addition of adenosine, pentoxi-
fylline, and dipyridamole as possible thera-
peutic options for persistent pulmonary
hypertension in newborn infants is also
based on case reports or series rather than
randomised controlled trials.
Given the lack of resources, a conscien-
tious doctor in a developing country may
unsurprisingly resort to an experimental but
potentially promising treatment in a desper-
ate attempt to save a blue baby with possible
persistent pulmonary hypertension when
conventional treatments have failed.45 The
issue of defining appropriate conventional
treatments for persistent pulmonary hyper-
tension in newborn infants in developing
countries is extremely complex.
Sanjay Patole locum neonatologist
skpatole@hotmail.com
Javeed Travadi senior registrar
Department of Neonatal Pediatrics, King Edward
Memorial Hospital for Women,Bagot Road,
Subiaco, Western Australia 6008, Australia
1 Kumar S. Indian doctor in protest after using Viagra to
save “blue babies.” BMJ 2002;325:181. (27 July.)
2 Paul VK, Newborn care in India: a promising beginning
butalongwaytogo.Semin Neonatol 1999;4:141-9.
3 Macrae DJ. Drug therapy in PPHN. Semin Neonatol
1997;2:49-58.
4 Atz AM, Wessel DL. Sildenafil ameliorates effects of
inhaled nitric oxide withdrawal. Anesthesiology
1999;91:307-10.
5 Erickson S, Reyes J, Bohn D,Adatia I. Sildenafil (Viagra) in
childhood and neonatal pulmonary hypertension. JAm
Coll Cardiol (in press).
Making the best of health
advocates and interpreters
Telephone interpreting is not an
acceptable solution
Editor
—
I agree with Adams’s assertion that
it is unacceptable to neglect to use interpret-
ers with non-English speaking patients.1As
she acknowledges, telephone interpreting is
not ideal and should be used only if there is
no other solution
—
for example, out of hours
or in an emergency. Telephone interpreting
does not allow any checking on the quality
of the translation unless you are using a tele-
phone with a loudspeaker or two handsets.
In an ideal world interpreters would all
be university trained and completely reli-
able, but good interpreters in most of the
languages used by refugees are few, most
being self taught. So keeping an eye on key
words used, length of delivery, tone of voice,
and other markers is crucially important for
an adequate and complete interpretation.
Telephone interpreting is also impracti-
cal during examinations. It interrupts the
flow and is not conducive to building
rapport between doctor and patient. To
most patients (and doctors) it seems
somewhat artificial.
Since refugees were first assimilated in
Glasgow in April 2000 our practice has pro-
vided medical care to refugees. Currently we
have about 3200 refugees and asylum seek-
ers registered with us. We arrange about
160-200 appointments weekly with (face to
face) interpreters. We now have few (if any)
difficulties in accessing interpreters, maybe
because we refused any and all involvement
with telephone interpreting services.
Peter von Kaehne general practitioner
Fernbank Medical Centre, Glasgow G22 6BD
vkaehne@doctors.org.uk
1 Adams K. Making the best use of health advocates and
interpreters. BMJ 2002;325(suppl):S9. (Career focus.)
(13 July.)
Patient focused approach may help
Editor
—
The debate on making the best use
of health advocates and interpreters can be
broadened by considering the point of view
of non-English speaking patients. In
Adams’s second scenario, in which a
distressed non-English speaker wishes to
terminate her pregnancy, the patient may
prefer her general practitioner to use a tele-
phone interpreter rather than talk face to
face with an interpreter or a health advocate.
Some non-English speakers take great
comfort from the anonymity of a telephone
interpreter, particularly in small or closely
knit ethnic communities. One of the factors
contributing to the patient’s distress in this
scenario could be cultural or social pres-
sures from within her community. If the
patient is forced to talk to her general prac-
titioner with another member of her
community in the room, even if that person
is a professional interpreter, she may feel
unable to speak openly and honestly.
Another key issue is the number of
non-English speakers who have health prob-
lems but never see a healthcare professional.
The main reason is that non-English speakers
are unable to access healthcare services by
themselves. Either they must rely on friends
or family members to help them or they must
simply turn up and hope that a receptionist
can put them in contact with an interpreter,
health advocate, or bilingual member of staff.
At EITI we are talking to a number of
primary care trusts and health authorities
about a new service that allows non-English
speakers far greater access to healthcare
services. A series of telephone hotlines have
Letters
1175BMJ VOLUME 325 16 NOVEMBER 2002 bmj.com

been set up, each with a particular language.
Calls to the hotlines are answered by an
interpreter who speaks the caller’s language
and a “talkback” officer who briefly deter-
mines the caller’s need. The talkback officer
has a conference call with the caller, the
interpreter, and an English speaking mem-
ber of staff at the caller’s local general prac-
tice or hospital. Information can then be
given to the caller over the telephone or an
appointment can be made for a later date.
Graham A Jones company secretary
EITI Limited, EITI House, Bridgegate, Howden
DN14 7AE
graham.jones@eiti.com
1 Adams K. Making the best use of health advocates and
interpreters. BMJ 2002;325(suppl):S9. (Career focus.)
(13 July.)
Homosexual related legislation
does not reduce suicidal intent
in sexual minority groups
Editor
—
Bagley and D’Augelli contend that
suicidal behaviour in bisexual, gay, and
lesbian youth is an international problem
associated with homophobic legislation.1
Heretofore, no data existed to examine this.
I recently found considerable variation in
suicidal behaviour by sexual orientation
cross culturally.2I re-examined the data to
determine whether variations in suicidal
behaviour are associated with national legis-
lation on homosexual (a) adoption, (b) mili-
tary service, (c) employment, and (d)
marriage or domestic partnership.
A more detailed description of partici-
pants and methods can be found else-
where.34 Four English speaking countries
were selected from the intercontinental
study2: Australia (n=185, 17.3% sexual
minority groups), Canada (n=1178, 10.95%
sexual minority groups), United Kingdom
(n=116, 12.9% sexual minority groups), and
United States (n=34 843, 13.41% sexual
minority groups). Only countries with 15 or
more participants in sexual minority groups
were included to detect a proportional
difference of 0.10, assuming a population
proportion of M=0.50 (no difference),
alpha=0.05, and 70% power. National
governments’ positions on issues (a)-(d)
above were scored 0 (no position), 1
(prohibited), and −1 (protected), with a
range of 4 to −4.
The scoring was as follows:
xAustralia −1: adoption 0, marriage or
domestic partnerships 0, employment dis-
crimination 0, military ser vice −1
xCanada −4 (see Canadian Charter of
Rights and Freedoms section 15(1), 1982;
Human Rights Act 1996; judicial decisions):
adoption −1, marriage −1, employment
−1, and military service −1
xUnited Kingdom −2: adoption 0, mar-
riage 0, employment −1, military service
−1
xUnited States 2: adoption 0, marriage 1
(Public Law 104-199), employment 0,
military service 1 (Department of Defense
directive 1332.14, 28 January 1982).
The table shows suicide ideation and
suicide attempts by each sexual orientation
in country, with the odds ratio and 95% con-
fidence interval for risk. The final two
columns reflect the Pearson’s correlation
and its P value for the relation between the
cumulative score for homosexual related
legislation (index) and suicidal behaviour
cross culturally. The percentage of homo-
sexual suicide attempts were strong and sig-
nificant but inversely related to the index
(r=−0.952, P < 0.05). The index was not sig-
nificantly associated with other variables of
suicidal behaviour.
In contrast to Bagley and D’Augelli’s
public policy thesis,1I tested a social
constructivist model that suggests cultural
attitudes towards human sexuality mediate
the relation between suicidal behaviour and
sexual orientation.2The present study
provides empirical evidence to refute the
public policy model. Thus, changing cultural
attitudes towards human sexuality seems to
be a more effective target of intervention for
the suicidal behaviour of bisexual, gay, and
lesbian youth than direct challenges to pub-
lic policy related to homosexuality.
Robin M Mathy clinical research fellow
Department of Psychiatry, University of Minnesota
Medical School, 2450 Riverside Avenue, F282/2A,
Minneapolis, MN 55454, USA
RM346@cam.ac.uk
This work was supported, in part, by an NIMH
supplemental grant for people with a disability,
and a grant from the American Foundation for
Addiction Research.
1 Bagley C, D’Augelli AR. Suicidal behaviour in gay, lesbian,
and bisexual youth. BMJ 2000;320:1617-8.
2 Mathy RM. Suicidality and sexual orientation in five conti-
nents: Australia, Asia, Europe, North America, and South
America. Int J Sex Gender Studies 2002;7:215-25.
3 Cooper A, Scherer C, Mathy RM. Overcoming method-
ological concerns in the investigation of online sexual
activities. Cyberpsychol Behav 2001;4:437-47.
4 Cooper A, Morahan-Martin J, Mathy RM, Maheu M. Toward
an increased understanding of user demographics in online
sexual activities. J Sex Marital Ther 2002;28:105-29.
Iron deficiency is neglected in
women’s health
Editor
—
The data by Waalen et al show that
38% of menstruating women living in San
Diego are iron deficient using the accepted
cut-off point of < 20% for transferrin
saturation as an indicator of deficiency.
These data support our hypothesis that hae-
matological distributions contain a large
proportion of iron deficient women.1
By focusing on the mean haemoglobin
distribution, Waalen et al lose sight of a fun-
damental part of our work: why should
women have lower reference limits for
haemoglobin and serum ferritin concentra-
tions than men?2Our hypothesis for this was
that a significant number of women are iron
deficient. Mean values mask anomalies in
distribution and are inappropriate to evalu-
ate the issues we have raised. Since women
menstruate, men would be expected to have
higher mean haemoglobin concentrations
because they can attain higher upper limits,
so the 10g/l difference found by Waalen
et al was not unexpected.
A similar situation occurs in menstruat-
ing but not in non-menstruating non-
human primates.3To support their case
Waalen et al cite one menstruating non-
human primate example
—
unfortunately
this paper included data from infants,
adolescents, and female animals half the age
of the males, and it is therefore unreliable.4
Data analysis of a sex difference with age is
more complex than simply presenting mean
values from uncontrolled populations.
Close inspection of the ferritin data in
part C of Waalen et al’s study shows a large
number of women “falling off” the lower
end of the distribution. The haemoglobin
difference between the sexes was of the
range 15-20 g/l, which represents a signifi-
cant proportion (39%) of the female
distribution having a serum ferritin concen-
tration below the lowest male value. In part
B, the transferrin saturation data for 26-55
year old menstruating women show a
significant difference in haemoglobin con-
centration of 15-25 g/l with a transferrin
saturation below 20%, the accepted cut-off
point for iron deficiency. In postmenopausal
women (part D) 29% were affected. Ten per
cent were classified as normal (haemoglobin
concentration > 120g/l) but were clearly
iron deficient on the basis of having
transferrin saturations < 10%.
Iron deficiency is a significant and seem-
ingly neglected factor in women’s health.
Why should the lower reference level be sex
dependent? What compelling evidence is
there to support this apparent anomaly? In
Percentage of people with suicidal ideation and who attempted suicide, by sexual orientation and
country, with national index scores for legislative policies on homosexuality, Pearson product moment
correlation across countries, and associated probabilities
Australia Canada United Kingdom United States rP value
Legislation scores −1−4−22——
Suicidal ideation:
Homosexual 28.1 28.5 18.8 25.3 −0.102 0.898
Heterosexual 24.2 14.9 18.0 13.8 −0.096 0.904
OR (95% CI) 1.23
(0.52 to 2.88)
1.05
(0.27 to 4.08)
2.28
(1.50 to 3.45)
2.13
(1.98 to 2.29)
0.564 0.436
Suicide attempts:
Homosexual 12.5 13.1 12.5 10.3 −0.952 0.048*
Heterosexual 7.2 4.8 7.0 4.8 −0.105 0.895
OR (95% CI) 1.84
(0.55 to 6.21)
1.90
(0.36 to 0.07)
3.00
(1.68 to 5.38)
2.28
(2.05 to 2.54)
0.099 0.901
*P<0.05.
Letters
1176 BMJ VOLUME 325 16 NOVEMBER 2002 bmj.com

this context men are non-menstruating
women, haematologically speaking.
D Hugh Rushton honorary senior lecturer
School of Pharmacy and Biomedical Sciences,
University of Portsmouth, Portsmouth PO1 2DT
rushton@btinternet.com
Robin Dover clinical research officer
Cancer Research UK, London WC2A 3PX
Anthony W Sainsbury senior veterinary officer
Institute of Zoology, Zoological Society of London,
London NW1 4RY
Michael J Norris principal lecturer
School of Pharmacy and Biomedical Sciences,
University of Portsmouth
Jeremy J H Gilkes consultant dermatologist
Ian D Ramsay consultant endocrinologist
Lister Hospital, London SW1W 8RH
1 Waalen J, Felitti V, Beutler E. Haemoglobin and ferritin
concentrations in men and women: cross sectional study.
BMJ 2002;325:137. (20 July.)
2 Rushton DH, Dover R, Sainsbury AW, Norris MJ, Gilkes
JJH, Ramsay ID.Why should women have lower reference
limits for haemoglobin and ferritin concentrations than
men? BMJ 2001;322:1355-7.
3 Lynx. Haematological and biochemical data base. London:
Institute of Zoology, Zoological Society,2002.
4 Giulietti M, La Torre R, Pace M, Iale E, Patella A,Turillazzi P.
Reference blood values of iron metabolism in cynomolgus
macaques. Lab Anim Sci 1991;41:606-8.
Guidelines partly explain
differences in referral rates
Editor
—
Forrest et al provide a useful
insight into the variation in specialty referral
rates between the United Kingdom and the
United States.1However, their assertion that,
given the low referral rates in the United
Kingdom relative to the United States, refer-
ral guidelines are unlikely to dramatically
enhance the capacity of specialties by
decreasing demand is both a non sequitur
and probably untrue.
We studied the referral rates for derma-
tology across the 16 practices in a primary
care group with a comparatively uniform
population mix. We found variations rang-
ing from 2 per 1000 practice population to
47 per 1000 (figure), and the dermatologists
thought that around 60% of referrals were
for conditions that should be easily manage-
able by general practitioners with access to
the right information. The practice with the
lowest referral rate had a clinical assistant in
dermatology and had modified its referral
process so that all patients were referred
through her.
We found similar variability in orthopae-
dics and cardiology.
Referral rates can be reduced in many
ways. The aim should be for the right
patients to have access to the right level of
skill at the right time without necessarily
going to a hospital. The means to achieve
this include better education, more commu-
nity based expertise, mature clinical net-
works, and better use of technology such as
clinical decision support (including referral
guidelines) and telemedicine. There is
plenty of room for improvement.
JohnFNavein consultant in healthcare modernisation
Modernising Healthcare Partnership,
Stratford-on-Avon CV37 7HU
john.navein@ntlworld.com
1 Forrest CB, Majeed A, Weiner JP, Carroll K, and
Bindman AB. Comparison of specialty referral rates in
the United Kingdom and the United States: retrospective
cohort analysis. BMJ 2002;325:370-1. (17 August.)
Tailored exercise is key to
preventing falls
Editor
—
The role of exercise in effectively
preventing falls has had a mixed press. Pro-
found conclusions have been drawn from
research studies with severe limitations,
including non-selection of those who had
had falls, brief intervention periods, and
exercise of insufficient intensity to stimulate
improvement. Many were alarmed by a trial
in which those who had falls fell more often
after being encouraged to walk
—
if the
authors had prescribed the balance, gait, and
strength exercises used in New Zealand
before walking, this unfortunate outcome
could have been avoided.12 Today, scepti-
cism about the true impact of exercise still
remains among professionals and decision
makers in the United Kingdom.
The study by Day et al is a welcome
addition to the literature countering this
alarmist view.3In the United Kingdom the
soon to be published falls management
exercise (FaME) trial by Skelton et al found
that in women aged over 65 with a history of
falls who participated in prolonged specific
group exercise, falls decreased by 60% and
injuries due to falls by 75%. Prescribed exer-
cises included those used by Campbell et al,
as well as dynamic endurance, balance train-
ing, floor exercise, and coping strategies
after a fall.2An accredited training course is
now available nationally which covers the
specific exercises used (see details below).
To test these study findings outside the
research environment we set up a falls and
injury prevention exercise service for people
who had had falls and were living in the
community (average age 81 years) in
London in January 2000. Participants
showed significant improvement in several
known functional risk factors for falls and
injuries, in addition to significantly increased
scores in the SF36 domains of social contact,
mental health, and change in health.
Improvement in functional capacity is
directly relevant to quality of life. As one
participant said: “I can walk upstairs now. I
haven’t been able to walk upstairs for four
years. I do my exercises every day at home. I
know it’s doing me good.”
Primary care trusts and social services
departments are under pressure to promote
the independence of their older residents.
They would do well not to overlook the broad
impact of tailored exercise in this area.
Piers W Simey physical activity lead
Wandsworth Primary Care Trust, Mitcham, Surrey
CR4 4TP
piers.simey@mswha.sthames.nhs.uk
Dawn Skelton senior research fellow
University College London Institute of Human
Performance, Royal National Orthopaedic
Hospital, Stanmore HA7 4LP
Susie Dinan clinical exercise practitioner
Royal Free Hospital and University College School
of Medicine, London NW3 2PF
Bob Laventure consultant, older people
British Heart Foundation National Centre for
Physical Activity and Health, University of
Loughborough, Loughborough LE11 3TU
Details of the postural stability training module can
be obtained from East Midlands and Pennine Train-
ing (tel 0116 229 5512). It was developed by S Dinan
andDASkelton with a national advisory group and
was funded by the Department of Health.
1 Ebrahim S, Thompson PW, Baskaran V, Evans K.
Randomized placebo-controlled trial of brisk walking in
the prevention of post menopausal osteoporosis. Age Age-
ing 1997;26:253-60.
2 Campbell AJ, Robertson MC, Gardner MM, Norton RN,
Tilyard MW,Buchner DM. Randomised controlled trial of
a general practice programme of home-based exercise to
prevent falls in elderly women. BMJ 1997;315:1065-9.
3 Day L, Fildes B, Gordon I, Fitzharris M, Flamer H,Lord S.
Randomised factorial trial of falls prevention among older
people living in their own homes. BMJ 2002;325:128.
(20 July.)
Being difficult is not
necessarily a bad thing
Editor
—
The tenor of King’s article on deal-
ing with difficult doctors is that being
difficult is a bad thing.1I have two role mod-
els, one fictional and one real
—
Jesus Christ
and the little boy who suggested that the
emperor was wearing no clothes. They were
both probably thought of as being difficult.
George Bernard Shaw said: “The rea-
sonable man adapts himself to the world: the
unreasonable one persists in trying to adapt
the world to himself. Therefore all progress
depends on the unreasonable man.”2
The NHS needs more difficult or unrea-
sonable doctors, not fewer.
Charles Essex consultant neurodevelopmental
paediatrician
Child Development Unit, Gulson Hospital,
Coventry CV1 2HR
room101@ntlworld.com
1 King J. Dealing with difficult doctors. BMJ 2002;325(sup-
pl):S43. (Career focus.) (10 August.)
2 Shaw GB. Man and superman: a comedy and a philosophy.
Cambridge, MA: University Press, 1903.
Practice No
Referral rate/1000
1
0
10
20
30
40
50
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Referral rates for dermatology to three trusts by 16
practices in primary care group Correspondence submitted electronically
is available on our website
Letters
1177BMJ VOLUME 325 16 NOVEMBER 2002 bmj.com