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TAIWAN AND THE GLOBAL OUTBREAK ALERT AND RESPONSE NETWORK

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Correspondence

www.thelancet.com Vol 367 June 10, 2006 1901

The effi cacy and safety of a propofol-ketamine mixture for sedation in children has been confi rmed.5 We believe this issue

could be addressed by future studies in large series comparing propofol alone versus the propofol-ketamine combination.

We declare that we have no confl ict of interest.

*Laura Badina, Stefania Norbedo, Egidio Barbi

lau.bad@gmail.com

Department of Paediatrics, IRCCS Burlo Garofolo, Università di Trieste, 34137 Trieste, Italy 1 Krauss B, Green MG. Procedural sedation

and analgesia in children. Lancet 2006; 367: 766–80.

2 Picard P, Tramer MR. Prevention of pain on injection with propofol: a quantitative systematic review. Anesth Analg 2002; 94: 1040–41.

3 Cameron E, Johnston G, Crofts S, Morton NS. The minimum eff ective dose of lignocaine to prevent injection pain due to propofol in children. Anaesthesia 1992; 47: 604–06. 4 Barbi E, Marchetti F, Gerarduzzi T, et al.

Pretreatment with intravenous ketamine reduces propofol injection pain. Paediatr Anaesth 2003; 13: 764–68.

5 Akin A, Esmaoglu A, Guler G, Demircioglu R, Narin N, Boyaci A. Propofol and propofol-ketamine in pediatric patients undergoing cardiac catheterization. Pediatr Cardiol 2005;

26: 553–57.

Authors’ reply

Laura Badina and colleagues raise an important issue. Pain on injection with propofol is well documented, occurring in about 70% of patients.1

There are numerous studies, with varying success, on ways to minimise pain, including the use of non-steroidal anti-infl ammatory drugs, opioids, lidocaine, α agonists, steroids, barbiturates, nitrous oxide, topical anaesthesia, warming, ionto phoresis, nitrates, opioid agonist–antagonists, antiemetics, and different formu-lations of the lipid emulsion base. Low-dose ketamine has also been studied and seems promising for injection pain2–4 as well as in

mitigating the respiratory depression and hypotension associated with propofol.5 We look forward to further

studies delineating the efficacy of low doses of ketamine compared with, or in combination with, the

other agents and techniques listed above.

BK is a consultant for Oridion Medical (a capnography manufacturer), and holds two patents in the area of capnography. SMG declares that he has no confl ict of interest.

*Baruch Krauss, Steven M Green

baruch.krauss@childrens.harvard.edu Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA (BK); and Loma Linda University Medical Center and Children‘s Hospital, Loma Linda, CA, USA (SMG)

1 Picard P, Tramer MR. Prevention of pain on injection with propofol: a quantitative systematic review. Anesth Analg 2000; 90: 963–69.

2 Tan CH, Onsiong MK, Kua SW. The eff ect of ketamine pretreatment on propofol injection pain in 100 women. Anaesthesia 1998; 53: 302–05.

3 Barbi E, Marchetti F, Gerarduzzi T, et al. Pretreatment with intravenous ketamine reduces propofol injection pain. Paediatr Anaesth 2003; 13: 764–68.

4 Batra YK, Al Qattan AR, Marzouk HM, Smilka M, Agzamov A. Ketamine pretreatment with venous occlusion attenuates pain on injection with propofol. Eur J Anaesthesiol 2005; 22: 69–70. 5 Tomatir E, Atalay H, Gurses E, Erbay H, Bozkurt P.

Eff ects of low dose ketamine before induction on propofol anaesthesia for paediatric magnetic resonance imaging. Paediatr Anaesth 2004; 14: 845–50.

UK medical schools:

undervalued and

undermined

Your Editorial (April 1, p 1029)1 misses

a major concern about the new process by which UK medical students apply for their fi rst foundation year (F1)—ie, supervision of the weaker graduate.

In Liverpool, the university has a close working relationship with the Postgraduate Deanery and jointly pioneered many new schemes for professional learning and appraisal, not only in foundation years but also in the fi nal year, to ready our graduates. Such schemes were developed after the realisation that our traditional fi nal examination system alone did not fully equip all students to enter practice.

Our changes included allocating a House Offi cer post after interview at the end of fourth year examinations, with

extensive House Offi cer shadowing (along with other practical training attachments in acute and community care) to prepare students for work. Alas, not all students fi nd the transition easy and over the years by close professional monitoring of our students we have been able to identify a few who need some extra help and support. Knowing where these graduates are going to work allows the University and the Deanery to monitor and support graduates jointly in a continuum.

The new national scheme disrupts well structured local arrangements and runs the risk of allowing young graduates to disappear off the radar screen. We continue to produce outstanding graduates, and yes, I share the concern that expression of excellence for many is lost, but equally worrying is that the mediocrity of some could slide into lack of competence for a few if the University and Deanery in partnership are unable to monitor closely and lend support where needed.

I declare that I have no confl ict of interest.

Richard D Griffi ths

rdg@liverpool.ac.uk

Division of Metabolic and Cellular Medicine, School of Clinical Science and Acting Head of School of Medical Education, University of Liverpool L69 3GA, UK

1 The Lancet. UK medical schools: undervalued and undermined. Lancet 2006;

367: 1029.

Taiwan and the Global

Outbreak Alert and

Response Network

We would like to re-emphasise the urgency of the need to close gaps in the global surveillance system identifi ed in the excellent Comment by Martin McKee and Rifat Atun (April 15, p 1224),1 especially under the

threat of avian infl uenza.

The critical role of migratory birds in transmitting H5N1 virus has

been confi rmed. Northern Cyprus, Science Photo Library

Rights were not granted to include

this image in electronic media. Please refer to the printed journal.

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Correspondence

1902 www.thelancet.com Vol 367 June 10, 2006

the outpatient clinic.1 Another reason

behind the passivity of our patients could be the infantilisation and loss of identity that is known to occur on entering a hospital.2

Simultaneous consultation of two diff erent doctors by a single patient has been assessed, with promising results, in a randomised trial.3 However,

the opposite situation has not been scientifi cally studied. Therefore, although it could represent a powerful tool in the hands of new managers, it should not yet be recommended.

I declare that I have no confl ict of interest.

Juan Gomez-Alonso

juan.gomez.alonso@sergas.es Servicio de Neurologia, Hospital Universitario Xeral-Cies, Pizarro 22, 36204 Vigo, Spain 1 Sellu D. Have we reached crisis management in

outpatient clinics? BMJ 1998; 316: 635–36. 2 Hill J. Strangers in a strange land. Lancet 2003;

361: 790.

3 Wallace P, Haines A, Harrison R, et al. Joint teleconsultations (virtual outreach) versus standard outpatient appointments for patients referred by their general practitioner for a specialist opinion: a randomised trial. Lancet 2002; 359: 1961–68.

Department of Error

Bochenek M, Delgado F. Children in custody in Brazil. Lancet 2006; 367: 696–97—In this Essay Focus (Feb 25), Michael Bochenek and Fernando Delgado should both be affi liated with Human Rights Watch. Fernando Delgado is a JD candidate at Harvard Law School, but neither the Human Rights Program at Harvard Law School nor any other segment of Harvard University is responsible for the essay or the views it contains.

ART-LINC Collaboration and ART-CC groups. Mortality of HIV-1-infected patients in the fi rst year of antiretroviral therapy: comparison between low-income and high-income countries. Lancet 2006; 367: 817–24—In fi gure 2 of this Article (March 11, 2006), the y axis should read “Hazard ratio (95% CI)”.

Multiple headaches

A year ago, a male patient visited my consulting room accompanied by another man. The patient had had daily occipital headaches for 12 months. The neurological examination was normal, so I concluded that his clinical picture was consistent with a chronic tension-type headache. The patient agreed that his imminent retirement and diffi cult family circumstances could be contributing to his pain. Meanwhile, the man accompanying him remained silent.

I am used to seeing people bring domestic confl icts to our offi ces, and behave inappropriately by showing verbal aggressiveness or extreme coldness towards them, so did not think too much of it. However, once the patient said goodbye, the other man remained seated. When I told him that we had fi nished, he gently answered that he was still waiting for his consultation. This second patient shared with the previous one not only part of his name, but also the occipital headache. I made my apologies to both of them, and I asked another neurologist to see the new patient.

This unjustifi able mistake, and possibly the patients’ acceptance of such an embarrassing situation, might be partly explained by overcrowding in Transdneistria (Moldova), Nagorno

Karabakh (Azerbaijan), Abkhazia and South Ossetia (Georgia), Kosovo, and the Gaza Strip and West Bank are located along the Black Sea Mediterranean migratory fl yway, and Taiwan is on the east Asian migratory fl yway. These are “new regions at risk” according to a joint study by the Food and Agriculture Organization, the World Organization for Animal Health, and WHO.2 Yet WHO has not

incorporated these regions into the Global Outbreak Alert and Response Network (GOARN).3

It is encouraging to see cooperative developments in avian infl uenza control in Cyprus and the Middle East. However, it is depressing to learn from Mckee and Atun that the memorandum of understanding between WHO and China was the main reason why Taiwan’s participation in several important WHO avian infl uenza control meetings in the past year was limited.

We propose that WHO could work with Taiwan through the World Trade Organization (WTO). Taiwan, ranked 17th in the world for exports and 16th for imports in 2004,4 has been a

member of the WTO since Jan 1, 2002. We believe that an International Health Regulation focal point5 refl ecting

Taiwan’s WTO status is a pragmatic way to integrate Taiwan into GOARN.

The SARS epidemic showed us that WHO could have detected the disease earlier and saved more lives if all aff ected countries, including Taiwan, were part of the global public health system. We should not repeat the same mistakes in our fi ght against the even greater threat of an infl uenza pandemic.

We declare that we have no confl ict of interest.

*Chang-Chuan Chan, Feng-Jen Tsai

ccchan@ntu.edu.tw

*International Health Center in Taiwan (IHCT), College of Public Health, National Taiwan University, Rm 722, No.17 Xu-Zhou Road, Taipei, 10020 Taiwan 1 McKee M, Atun R. Beyond borders:

public-health surveillance. Lancet 2006; 367: 1224–26.

2 Food and Agriculture Organization, World Organization for Animal Health, World Health Organization. A global strategy for the progressive control of highly pathogenic avian infl uenza (HPAI). http://www.fao.org/ ag/againfo/subjects/documents/ai/HPAIGlob alStrategy31Oct05.pdf (accessed April 19, 2006).

3 WHO. Global outbreak alert and response: report of a WHO meeting. Geneva: World Health Organization, 2000. http://www.who. int/csr/resources/publications/surveillance/ whocdscsr2003.pdf (accessed April 19, 2006). 4 World Trade Organization. Trade profi les:

Taipei, Chinese. http://stat.wto.org/ CountryProfi le/WSDBCountryPFView.aspx?Lan guage=E&Country=TW (accessed April 19, 2006).

5 WHO. WHO pandemic infl uenza draft protocol for rapid response and containment. Geneva: World Health Organization, 2006. http://www. who.int/csr/disease/avian_infl uenza/ guidelines/fl uprotocol_17.03.pdf (accessed April 19, 2006).

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