124 Postgrad Med J 2002;78:124–126

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M Thulasimani toxic agents. These diseases are sometimes

LETTERS Department of Medicine, Community Health Center, inaccurately referred to as “food poisoning”,
Mannadipet, Pondicherry 605 501, India; and they represent one of the most wide-
Prakram@md4 vsnl.net.in spread and overwhelming public health prob-
The role of tricyclic lems of the modern world. Infants, children,
S Ramaswamy
antidepressants and tramadol in Department of Clinical Pharmacology, Jawaharlal the elderly, and the immunocompromised are
palliative care Institute of Postgraduate Medical Education and more commonly affected.1 Infection of six
Research, Pondicherry 605 006, India members of a family is described here.
We read with interest the review article on
The head of a family (61 years), his wife (59
alternative opioids to morphine in palliative References
care.1 The author has mentioned in detail years), their son (38 years), daughter in law
1 Barnett M. Alternative opioids to morphine in
various factors—biomedical, genetic, and palliative care: a review of current practice (35 years), and two male grandchildren (14
psychological—which influence the effect of and evidence. Postgrad Med J and 11 years respectively) were admitted to
opioids. Though most of the aspects are well 2001;77:371–8. hospital with gastroenteritis. About four

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2 Gloth III FM. Geriatric pain. Factors that limit hours earlier they had consumed pieces of
covered, the role of depression has not been
pain relief and increase complications. freshly cut watermelon. During the past seven
discussed, and this has a tremendous impact Geriatrics 2000;55:46–52.
on the manifestation and management of days they had consumed home cooked food
3 Hardy PA. Analgesics. In: Hardy PA, ed.
pain.2 Initial control of depression greatly Chronic pain management: the essentials. and clear water from the domestic supply. The
facilitates pain management. Depression London: Greenwich Medical Media, 1977: head of the family, who had received the lion’s
must be treated aggressively (for example 31–6. share of the fruit, was affected the most and
with antidepressants and psychotherapy ses- 4 Salemo E. Analgesics. In: Salemo E, ed. was in a state of shock and acute renal failure.
Pharmacology for health professionals. USA: It took three days for his urinary output and
sions) or pain management will remain
Mosby, 1999: 124–53. renal parameters to improve. He was treated
elusive. It has also been shown that in 5 Bamigbade JA, Langford RM. Tramadol
patients who are taking opioid drugs, the bio- hydrochloride: an overview of current use. with intravenous fluids, ciprofloxacin, metro-
availability of opioids is increased with anti- Hospital Medicine 1998;59:373–6. nidazole, and other conservative measures for
depressants; the tricyclic drugs are membrane five days. Other members of the family had an
stabilising, which may account for the early uneventful stay in the hospital and were
onset of action in patients with chronic pain.3 discharged on the second day after admission.
Author’s reply The daughter in law, who had received the
The author mentioned the advantages of
transdermal administration of fentanyl. She First, I would like to address the apparent smallest share of the fruit, was affected the
noted that it is highly acceptable to patients omission of a discussion of depression. I am least and had just two or three loose stools in
and the patches can be applied by patients or entirely in agreement with the respondents’ hospital. Haematology, urinalysis, and chest
relatives themselves. We would like to stress comments that depression has a major role in radiography of all the family members were
that 25% to 50% of patients above the age of the manifestation and management of pain. normal. Blood biochemistry of the head of the
65 suffer from major pain problems. Age However, in this review I was considering the family suggested uraemia and acidosis. Stool
related changes in skin integrity, subcutan- differential factors influencing choice of cultures of all members of the family grew an
eous fat, and water content can affect patient opioid, not the assessment of pain per se. I enteroinvasive variety of Escherichia coli, which
response to transdermal products. In fact, pointed out at the outset that cancer pain was was non-motile with non-lactose ferments.
fentanyl patches have been associated with multifactorial, and that a thorough assess- We asked the fruit seller about the purchase
death in opioid-naive older adults in doses as ment was a prerequisite to successful man- of watermelon and this revealed the fact that
low as 50 µg/hour.2 Also, serum fentanyl con- agement, but that the review was of strong watermelons can be made more colourful and
centrations may increase by one third in opioids, and was beginning from the point at sweet without cutting them open. Instead a
patients with a body temperature of 40oC or which these were considered appropriate long needle, into the core, can inject sweet-
more. It has been suggested that fentanyl treatment. I did include the effect of antide- ener and colouring agents, three to four hours
should not be given to children younger than pressants in enhancing bioavailability of before sale. The nature of the injected agents
12 years of age or to patients younger than 18 opioids in the text and in table 5, but in the was not revealed by the fruit seller for obvious
years of age who weigh less than 50 kg. Addi- context of drug interactions. reasons. Culture from the solution that had
tionally, fentanyl has a long duration of action With regard to transdermal fentanyl: the been injected (which had been prepared and
(up to 72 hours) and therefore the side effects authors appear to imply that in beginning stored in an earthenware bowl), also grew
and adverse reactions are not easily reversed.4 with a discussion of its advantages, I was multiple colonies of the enteroinvasive variety
In view of this, we believe that transdermal advocating liberal use of this drug and route. I of E coli, which were biochemically lactose
fentanyl should not be used liberally. went on to describe all its disadvantages, positive, non-motile, with non-lactose fer-
It was also stated by the author that trama- including its interpatient variability and long ments.
dol is less potent than morphine and less duration of action causing potential problems Diarrhoeal diseases have been commonly
effective for managing severe pain. However, of overdose. I was attempting to provide a bal- attributed to a pathogen contaminated water
tramadol has been used extensively and anced overview of a drug that has proved very supply, but it is now recognised that food also
evaluated over the last 20 years. It has proved popular with patients and health profession- plays an equally important part in 70% of
as effective as the strong opioids in acute and als while cautioning on its overuse. such illnesses. Besides the usual foods, con-
chronic pain settings. In particular, tramadol On the question of tramadol, I do not tamination has been reported in other foods
administration results in little respiratory dispute that it is an effective analgesic and has such as raw fish, shellfish, bivalve molluscs
depression in comparison with equianalgesic a broad spectrum of clinical use. However, (oysters, cockles, mussels), raw shrimp, pork,
doses of opioids, such as morphine or both from personal practice and my review of mixed d’oeuvre, crabs, prawns, rock lobster,
pethidine. Tramadol has a long record of effi- literature pertinent to palliative care, I con- cooked squid, turkey, street foods, eggs, egg
cacy and safety, and although it should be cluded that its efficacy in the management of salad, cold asparagus, aquatic plants, bottle
avoided or used with caution in epileptic progressive severe cancer pain is less conclu- feeds (for infants), ice creams, chocolates,
sively demonstrated, and thus questioned its candies, etc. The chief contaminants are
patients, it is now the fourth most commonly
role in palliative care. Respiratory depression
prescribed analgesic worldwide.5 It is cer- bacteria (E coli, shigella, salmonella, Vibrio
is rarely an issue in palliative care, nor opioid cholera 01, Campylobacter jejuni, brucella, Bacil-
tainly useful in the treatment of chronic, non-
abuse, although I accept that low abuse
malignant, and malignant pain syndromes. lus cereus, Staphylococcus aureus, Clostridium perf-
potential may facilitate adequate analgesic
Another considerable advantage of tramadol ringens, and Clostridium botulinum),
prescribing in chronic non-malignant pain.
is its very low abuse potential. Consequently, helminthes (Trichinella spiralis, Taenia saginata,
it is not deemed a controlled (scheduled) Taenia solium, clonorchis, Fasciola opisthorchis,
drug. Paragonimus spp), protozoa (Entamoeba hysto-
In view of the above, we believe that trama- Watermelon poisoning litica, Giardia lamblia, Cryptosporidium spp), and
dol has an important role as an alternative Food borne diseases are a result of ingestion enteric viruses (rotavirus hepatitis A&E virus)
opioid to morphine in palliative care. of foods contaminated by either infectious or etc.1

www.postgradmedj.com
PostScript 125

Infections due to pathogenic strains of E coli There is evidence of tight editing in terms of sharp, and relevant photographs and illustra-
are probably the commonest cause of diar- chapter style and layout and excellent cross tions are an added bonus and the tables such
rhoea in developing countries. The contami- referencing between the chapters. The book is as those of causes of vaginal discharge and
nation of food with micro-organisms is enlivened by quotations in wide easy-on-the- genital ulceration are exemplary in their clar-
caused by: eye margins. These also host simple line ity and comprehensiveness. Relevant aspects
• Use of contaminated equipment. drawings of such important practical aspects of dermatology and even psychiatry are briefly
of teaching as the ideal distribution of teacher considered where appropriate.
• Infected food handlers. and taught round a bed. The advice to ensure Three opening chapters on aetiology of
• Use of raw and contaminated ingredients. students do not go off on electives to countries STIs, taking a sexual history and counselling
with military or civil unrest is not profound approaches, are followed by chapters dealing
• Cross contamination.
but well timed. Each chapter provides sugges- with STIs causes by bacterial, viral, and other
• Addition of toxic chemicals or use of foods tions for further reading. organisms in turn. For once a correct balance
containing natural toxicants like mush- The principles and examples are, as the edi- (in terms of their respective incidence in the
rooms etc.1 tors suggest, relevant to postgraduate medical UK) is shown between coverage of HIV and
Gastroenteritis by Salmonella javiana con- education and other healthcare professionals. non-HIV STIs. Other chapters are problem
tamination of watermelon has been described But for those involved in the teaching of oriented and consider such commonly pre-
in 26 cases in the USA.2 Contamination of medical students, this book from Dundee, a senting conditions as urethritis and pelvic
fruit by such a novel method as described here teaching centre of excellence, is warmly inflammatory disease. Comprehensive treat-
may prove to be a major public health hazard, recommended for those who want to improve ment guidelines for both the UK and USA
and hence is noteworthy. their understanding and performance and conclude the book.

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hence enjoyment of this Hippocratic responsi- As STIs continue to rise in the UK, this text
T K Pande, A H Khan, R Pipersania, bility. will prove an indispensable ready reference
S K Sethi, Y Rath guide for paediatricians, physicians, GPs,
Department of Internal Medicine, J L N Hospital B I Hoffbrand gynaecologists, dermatologists, and surgeons.
and Research Center, Bhilai 490 009, India; Fellowship of Postgraduate Medicine, I will add my copy to the other three essential
pandetk@mantraonline.com London, UK
reference books on my surgery desk.
References T G Stammers
1 World Health Organization. Food borne
Making Sense of Statistics and General Practitioner,
disease: a global health and economic Healthcare. Merton Park, London, UK
problem. Food borne disease: a focus for
health education. Geneva, Switzerland: By Anna Hart. (Pp 162; £19.95.) Radcliffe
WHO, 2000: 1–34. Medical Press, 2001. ISBN 1-85775-472- 400 MCQs in Paediatrics for
2 Blostein J. An outbreak of Salmonella javiana
associated with consumption of watermelon.
7.**** MRCPCH Part I.
Journal of Environmental Health This book describes the essentials of statistics
1993;56:29–31. By Nagi G Barakat. (Pp 212; £14.95.) Royal
and data presentation. The first chapters deal Society of Medicine Press, 2001. ISBN
with the different types of study designs, the 1-85315-491-1.**
various forms of data and the characteristics
of pictorial forms of presenting data. Subse- This paperback book in fact has 463 questions
quent chapters deal with distributions, means including a 60 question examination. The for-
BOOK REVIEWS and medians, and measures of variability. The mat is of MCQs as used in the part I of the
author describes confidence intervals, p MRCPCH examination and the question
values, statistical power, and type I and II material does cover the full syllabus for this.
The reviewers have been asked to rate these errors. The final sections are on confounders, The answers provide some explanations for
books in terms of four items: readability, how interactions, measures of correlation, hierar- the questions but not all. The evidence for the
up to date they are, accuracy and reliability, chy of evidence, causality, and how to assess answers isn’t related to specific text. However,
and value for money, using simple four point papers. The author describes the terms used in there are a number of recommended texts and
scales. From their opinions we have derived evidence based medicine such as absolute references listed, but at least one of these
an overall “star” rating: * = poor, ** = reason- risks and the number needed to treat. A glos- texts, that for neonatology, does not show the
able, *** = good, **** = excellent. sary of terms used is contained in the appen- most recent edition edited by Roberton and
dices. Rennie.
The book will be of invaluable use for those As with all MCQ questions, some of the
A Practical Guide for Medical just starting a research career or in its early answers are arguable but there are certain
stages. It is comprehensive and clearly written answers given that are clearly completely
Teachers. with many illustrative examples. The text wrong, which will further mislead the exam-
covers well all the areas that are of interest to ination candidate.
Edited by John A Dent and Ronald M Harden.
those commencing their own research Although the material covers the syllabus,
(Pp 453; £34.95.) Churchill Livingstone,
projects. The pitfalls of different tests are well the questions that have been prepared do not
2001. ISBN 0-443-06273-0.****
described and the book is competitively reflect the quality of the questions expected in
This book tells you all you wanted to know priced. the membership examination.
and a good deal more that you now need to Given the thirst for examination questions
A R Hart among membership candidates, however, it is
know about the revolution that has been tak- Consultant Gastroenterologist,
ing place in undergraduate medical education likely that some candidates will find the book
West Norwich Hospital, UK
in the past decade or more. The editors’ stated useful in their preparation.
intention is to provide jargon-free under-
A C Elias-Jones
standing of contemporary educational princi- Fast Facts—Sexually Transmitted Consultant Paediatrician,
ples and provide practical advice on dealing Infections. Leicester General Hospital,
with all aspects of teaching. They succeed and Examination Committee,
brilliantly well. By Ann Edwards, Jackie Sherrard, and Royal College of Paediatrics and Child Health, UK
The book is divided into seven sections Jonathan Zenilman. (Pp 104; £12.00.) Health
(totalling 39 chapters in all) starting with Press, 2001. ISBN 1-899541-04-7.****
aspects of the curriculum, learning situations Imaging Picture Tests for the
such as lectures, small groups, wards, primary In a month when all GPs in my area have been MRCPCH.
care etc, educational strategies (independent, notified of an epidemic of syphilis in London,
problem based, integrated and multi- the publication of this book could not be more By A P Winrow. (Pp 205; £19.95.) Churchill
professional), aids such as computers, audio- timely. Livingstone, 2000. ISBN 0-443-06445-
video, and guides, themes (basic sciences, There has long been a need for a concise, 8.****
communication skills, ethics, informatics etc), affordable, accessible, and accurate textbook
means of assessment, and aspects of students on sexually transmitted infections (STIs) for This is a useful paediatric teaching book for
and staff such as selection, support staff non-specialists in genitourinary medicine and candidates studying for the MRCPCH final
development, and course monitoring. this volume fills the gap perfectly. The clear, examination. It may also be useful for

www.postgradmedj.com
126 PostScript

candidates for the Diploma for Child Health. 020-7288-3134, email: k.stephens@chime.
It contains a selection of 100 varied paediatric DIARY ucl.ac.uk).
and neonatal cases of the types commonly
seen in the examination. There is an easily Thackray Museum
accessible question and answer format on the Fellowship of Postgraduate
following page with useful comments rel- Medicine & CHIME, Royal Free & 25 April 2002—History of herbals, a talk by
Bruce Madge of the British Library.
evant to the condition being demonstrated. University College Medical
There are also useful examination tips applied 11 May 2002—Use and abuse: a history of
to each case. School opium, University of Leeds Medical History
The author admits that some of the images Clinical Governance, Thursday, 21 Day School.
were obtained from copy film and as a result For further information contact the Thackray
February 2002 Museum, Beckett Street, Leeds LS9 7LN (tel:
some of the images are perhaps not as clear as
they might have been. However, the examina- A one day conference for doctors wishing to 0113 244 4343, fax: 0113 247 0219, email:
tion candidate with the help of the answers become more involved in clinical governance info@thackraymuseum.org, web site: thack
and comments should be able to follow the at the Commonwealth Conference Centre, raymuseum.org).
demonstrated abnormalities. Kensington High Street, London.
The examination candidates will find this a
useful additional text to assist their learning. PACES (MRCP) Part II CORRECTION
It could also provide useful CPD for self Two two day courses designed as final

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assessment by already qualified paediatri- preparation for the PACES examination to be
cians in addition. held at the Whittington Hospital, London.
Hypokalaemia and
Communication Skills and Ethics: 7 and 8
hyperkalaemia
A C Elias-Jones
Consultant Paediatrician,
February 2002. Cost: £500. An error occurred in the above paper, pub-
Leicester General Hospital, Clinical: 12 and 13 February 2002. Cost: £500. lished in the December issue of the journal
and Examination Committee, For details contact Kate Stephens, CHIME, (2001;77:759–64). The name of the first
Royal College of Paediatrics 4th Floor Holborn Union Building, Archway author was spelt incorrectly; the correct spell-
and Child Health, UK Campus, Highgate Hill, London N19 3UA (tel: ing is A Rastegar.

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