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Br Med J (Clin Res Ed): first published as on 5 May 1984. Downloaded from

JOURNAL SATURDAY 5 MAY 1984

LEADING ARTICLES

Prenatal diagnosis ofthalassaemia D J WEATHERALL ...... 1321 Marathon medicine DAN TUNSTALL PEDOE ...... 1322 The dynamic approach to residential care ofthe disabled DAPHNE GLOAG ...... 1323 Cardiopulmonary resuscitation: chances ofsuccess GILLIAN C HANSON ...... 1324 Time trends in cancer mortality in England and Wales D J P BARKER ...... 1325 Medicine in the workplace w R LEE ...... 1326 CLINICAL RESEARCH * PAPERS AND SHORT REPORTS * PRACTICE OBSERVED Prenatal diagnosis of homozygous c thalassaemia by direct DNA analysis of uncultured amniotic fluid cells VIVIAN CHAN, A GHOSh, T K CHAN, VIVIAN WONG, D TODD ...... 1327 Fetal circulation during epidural analgesia for caesarean section A LINDBLAD, K MARSAL, E VERNERSSON, H RENCK ...... 1329 Bleeding oesophageal varices and hepatic dysfunction in adult polycystic kidney disease P J RATCLIFFE, S REEDERS, J MTHEAKER ...... 1330 Erythrocytic cation transport receptor numbers and activity in pregnancies complicated by essential hypertension and pre-eclampsia J K ARONSON, M P MOORE, C W G REDMAN, C HARPER ...... 1332 Late mortality after vagotomy and drainage for duodenal ulcer PC H WATT, C C PATTERSON, T L KENNEDY ...... 1335 Mammary skin oedema: a new prognostic indicator for breast cancer H S SHUKLA, I H GRAVELLE, LE HUGHES, R G NEWCOMBE, S WILLIAMS 1338 Acute obstructive after subarachnoid Y M KOHI, R A UP DEVKOTA ...... 1342 hydrocephalus haemorrhage JOHNSTON, http://www.bmj.com/ Response ofurinary albumin to submaximal exercise in newly diagnosed non-insulin dependent diabetes A MOHAMED, TERENCE WILKIN, B A LEATHERDALE, D ROWE ...... 1342 Spinal cord disease due to Schistosoma mansoni successfully treated with oxamniquine JOHN EFTHIMIOU, DAVID DENNING ...... 1343 Salicylate intoxication in the elderly due to benorylate T R 0 BERINGER ...... 1344 Hypercalcaemia during resolution ofcalcinosis in juvenile dermatomyositis ML WILSHER, I M HOLDAWAY, J D K NORTH ...... 1345 Unreviewed reports ...... 1346 Clinical judgment in the diagnosis and management offrequency and dysuria in general practice TC O'DOWD, J E SMAIL, R R WEST . 1347

Urethral syndrome: a selflimiting illness T C O'DOWD, C D RIBEIRO, J MUNRO, R R WEST, C H L HOWELLS, R HARVARD DAVIS ...... 1349 on 30 September 2021 by guest. Protected copyright. What Annoys Me Most: Independence S R ILIFFE ...... 1352 Minimum standards fortrainingpractices MIKE PRINGLE ...... 1353 MEDICAL PRACTICE Contemporary Themes: Popular marathons, half marathons, and other long distance runs: recommendations for medical support RECOMMENDATIONS OF A CONSENSUS CONFERENCE ...... 1355 Green College Lectures: 1984: Medicine in the European Communities ROGER BREARLEY ...... 1360 Appropriate Technology: Immunisation, rehydration, and transfusion KATHERINE ELLIOTT ...... 1364 Hospital Topics: Contribution ofgeneral practitioner hospitals in Scotland J A GRANT I...... 1366 Lesson ofthe Week: Visual hallucinations in children receivingdecongestants R J SANKEY, A J NUNN, J ASILLS ...... 1369 ABC ofAsthma: Definition and diagnosis JOHN REES ...... 1370 Any Questions? ...... 1359

Medicine and Books ...... 1373

PersonalView COLVINGOONARATNA ..... r43 ±yi...i. . . . . *., . 1377

CORRESPONDENCE-List ofContents ...... 1378 OBITUARY ...... z. i " " 1381387 r i

NEWS AND NOTES SUPPLEMENT ; Views ...... 1384 The Week ...... 1390 Medical News . 1385 From the GMSC: Parallel importing: proposed action to protect patients deferred ...... 1391 BMANotices . 1385 Learning to live with cash limits - and other financial matters One Man's Burden MICHAEL O'DONNELL . 1386 GORDON GREENSHIELDS ...... 1393

NO 6427 BRITISH MEDICAL JOURNAL 1984 VOLUME 288 1321-1396 WEEKLY. ISSN 0007-1447 BRITISH MEDICAL ASSOCIATION TAVISTOCK SQUARE LONDON WC1H 9JR. ASTM CODEN: BMJOAE 288 (6427) 1321-13% (1984) 1378 BRITISH MEDICAL JOURNAL VOLUME 288 5 MAY 1984 CORRESPONDENCE Br Med J (Clin Res Ed): first published as on 5 May 1984. Downloaded from

Benzodiazepines on trial Lethal osteogenesis imperfecta and a MB; Margaret Ounsted, MRCP, and C W G M C Gerald, PHD, and I Khan, MB; S W gene deletion Redman, FRCP ...... 1382 Lewis, MB; R P Snaith, FRCPSYCH; F B Sykes, PHD, and D Ogilvie, BA; F M Selection of GP trainers Kraupl Taylor, FRCPSYCH ...... 1378 Pope, FRCP, and A C Nicholls, PHD ...... 1380 G Strube, MRCP ...... 1382 Psychosis after cannabis abuse Use of a conical spacer device in severe P Carney, MB, and M Lipsedge, FRCPSYCH; or for asthma M G Brook, MB ...... 1381 endoscopy? S J Williams, MRCP; Christine E Bucknall, Psychiatry and violent offenders J R B Green, MRCP, and others ...... 1383 MRCP ...... 1379 S Novosel, MRCPSYCH ...... 1381 Self help Women in prison R B Tabor and R E Gann ...... 1383 Poor management of unconscious Kathleen Kinahan, and J 0 Woods, FRCGP 1382 rugby player watched by Factors associated with intellectual Unfairness in oral exams millions ability of children born to mothers B W Perriss, FFARCS ...... 1383 P N Paterson-Brown, MB; CC Smith, with high risk pregnancies BMA and nuclear war MRCGP.... 1380 Jill R Meara, DRCOG, and J H Williams, R G Chapman, MRCOG, and others ...... 1383

We may shorten letters to the editor unless the authors specifically state that we may not. This is so that we can offer our readers as wide a selection of letters as possible. We receive so many letters each week that we have to omit some of them. Letters must be typed with double spacing between lines and must be signed personally by all their authors, who should include their degrees. Letters critical of a paper may be sent to the authors of the paper so that their reply may appear in the same issue. Correspondents should present their references in the Vancouver style (see examples in these columns). In particular, the names and initials of all authors must be given unless there are more than six, when only the first three should be given, followed by et al; and the first and last page numbers of articles and chapters should be included.

Benzodiazepines on trial is abused a Rexed B, Edmondson K, Khan I, Samson RJ. SIR,-We support the view of Dr P J Tyrer it being on scale warranting Guidelines for the control of narcotic and psychotropic (14 April, p 1101) that benzodiazepines, international control. The results of experi- substances in the context of the international treaties. http://www.bmj.com/ Geneva: WHO, 1984. which are relatively safe and efficacious mental studies suggest that it possesses low to Anonymous. UN Commission on Narcotic Drugs. drugs, should be "prescribed more carefully moderate psychological dependence potential Lancet 1984;i:637. 3WHO Review Group. Use and abuse of benzo- and with better awareness of their dangers." relative to the short acting , psycho- diazepines. Bull WHO 1983;61 :551-62. These concerns were the basis for the recent motor stimulants, and opiates (WHO, un- World Health Organisation recommendation published document MNH/83.28).3 that benzodiazepines be subject to inter- Individual evaluation of the other 32 benzo- SIR,-Dr Heather Ashton (p 1135) and Dr P J national control by the 76 signatories to the diazepines led to the conclusion that their Tyrer suggest that the symptoms of benzo- 1971 Convention on Psychotropic Substances. abuse liability had been actually shown or diazepine withdrawal constitute a syndrome

Among the activities of the WHO on drug could be predicted because of their similarity qualitatively different from other withdrawal on 30 September 2021 by guest. Protected copyright. dependence are evaluation of the evidence on to diazepam in chemical structure, receptor syndromes, particularly because ofthe unusual the dependence liability of substances and binding characteristics, and pharmacological frequency of perceptual disturbances. formulation of recommendations to the United action. The other drugs to be subject to inter- Both y-aminobutyric acid and benzo- Nations Commission on Narcotic Drugs for national control are: , , diazepine receptors are widely distributed their control.' At its February 1984 meeting , , , throughout the central nervous system, and over two thirds of the 40 members of the , , , cloxazo- the general y-aminobutyric acid facilitatory commission endorsed the recommendation that lam, , , ethyl loflazapate, properties of benzodiazepines as , the 33 derivatives marketed , , , halox- muscle relaxants, and are to as of February 1983 be placed under schedule azolam, , , , be distinguished from their more specific IV of the Psychotropic Convention.2 In addi- , , , norda- effects. These are probably mediated tion to requiring a prescription, when the de- zepam, , oxazolam, , by depression of activity in septum and cision takes effect licenses will be required , , , and triazo- hippocampus by ascending noradrenergic and nationally for their manufacture, trade, and lam. serotinergic pathways and the ascending distribution. This least restrictive control will Over the years differencies in abuse potential dopaminergic mesolimbic pathway acting via serve primarily to alert the health professions, have been recognised among barbiturates and prefrontal and cingulate cortices.' Rebound governments, and the public about the abuse non- hypnotics. While activity in this latter pathway may well be potential of these agents. The measures will differences may also exist among benzo- responsible for the perceptual disturbances have the greatest impact in countries currently diazepines, insufficient evidence has been that seem to make benzodiazepine withdrawal lacking adequate national drug control adduced in experimental or clinical published different; Dr Ashton's observation that these mechanisms. reports permitting their differentiation on the disturbances responded to haloperidol would Among the 14 drugs with abuse potential basis of absolute or even relative dissimilarities support this. previously added to schedule IV were selected in abuse potential. It may be that when such Alterations in septohippocampal function barbiturate and non-barbiturate sedative evidence is evinced some benzodiazepine are receiving renewed attention in recent hypnotics (for example, , mepro- derivatives willbe descheduledwhileothers may research into the pathogenesis of the func- bamate), anorectics (for example, phendi- be rescheduled subject to more rigorous tional psychoses, and changes predominantly metrazine), and psychostimulants (for example, international control. in this area have been shown on depth pipradrol). electroencephalography,2 computed tomo- The recommendation to control diazepam MICHAEL C GERALD graphy,3 and at necropsy (paper presented by was based partly on clinical evidence show- INAYAT KHAN R Brown and others at the biannual workshop and clinical Division of Mental Health, on ing physical dependence partly on World Health Organisation, schizophrenia in Davos, Switzerland, reports and epidemiological studies that show Geneva 27 1984). Lesions in septum and hippocampus