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Discussion

Two well-known syndromes with ILQTS are known.Jervell and Lange-Neilsen syndrome! is characterised byprolongation of the QT interval, deafness, and autosomalrecessive inheritance, while in Romano-Ward syndrome3,4the prolonged QT interval has an autosomal dominantinheritance without deafness. All four mothers and onefather in this small series had ILQTS, suggesting anautosomal dominant inheritance, and the absence ofdeafness suggests Romano-Ward syndrome.The QT interval is inversely related to heart rate and can

be corrected (QTc) using Bazett’s formula.s Children withILQTS differ from normal in that their QT interval doesnot shorten after exercise.6 The normal QT interval iscontroversial.’ We decided to use 0-44 S,2,8 but genetic-linkage studies have shown the pitfalls of using an arbitraryQTc of 0-44 s as normal.9 Unless ECG data are interpretedin the light of clinical information, diagnostic errors can stillbe made.Some paediatric neurologists would recommend ECGs

on all patients presenting with seizures. However, any testwhere the diagnostic yield is only one in several hundredinvariably gets discarded, and even if the policy is followed, asingle QT measurement may not be adequate.1o In somepatients even several measurements may not lead to the rightdiagnosis and only an exercise test may show ILQTS.6 Abetter approach is to use a screening method to selectcandidate patients with ILQTS from the large group withseizures, and then to measure the QT interval several times.If negative, these patients should be subjected to exercisetests. The screening method need not be very specific butmust be extremely sensitive. We think the answer to thisproblem lies in the history. Patients with ILQTS haveseizures secondary to cerebral ischaemia caused byventricular arrhythmias. Older children and adults candescribe the sequence of dizziness, lightheadedness,blackouts, loss of consciousness and then seizures

accurately. A mention of the first part of this sequence willlead most of us to the right diagnosis. In young children whoare unable to describe early symptoms of cerebral ischaemia,a history of loss of consciousness preceding a seizuresuggests ILQTS.

Partial response of two of our patients to anticonvulsantsis noteworthy. These patients stopped having tonic-clonicseizures but the frequency of their episodes of loss ofconsciousness remained unchanged. We thinkanticonvulsants increased the seizure threshold, but did notaffect the other ischaemic symptom.

In conclusion, the following points in the history arestrongly suggestive of ILQTS as the aetiology of "epilepsy"in young children:

(1) Episodes of loss of consciousness preceding convulsions(2) Episodes of loss of consciousness alternating with episodes of

loss of consciousness and convulsions

(3) Patients whose convulsions respond to anticonvulsants butwho continue to have episodes of loss of consciousness

(4) Family history of sudden and unexplained death(5) History of deafness in the patient or other family member.

REFERENCES

1. Jervell A, Lange-Nielsen F. Congenital deaf-mutism, functional heartdisease with prolongation of the Q-T interval, and sudden death.Am Heart J 1957; 54: 59-68.

2. Moss AJ, Schwartz PJ, Crampton RS, et al. The long Q-T syndrome.Circulation 1991; 84: 1136-44.

3. Romano C, Genrme G, Pongiglione R. Aritmie cardiache rare dell’etapediatrica. Clin Pediatr 1963; 45: 656-83.

4. Ward OC. A new familial cardiac syndrome in children. J Ir Med Assoc1964; 54: 103-06.

5. Bazett HC. An analysis of the time relationship of the electrocardiogram.Heart 1920; 7: 353-70.

6. Schwartz PJ, Pereti M, Malliani A. The long Q-T syndrome. Am Heart J1975; 89: 378-90.

7. Shaw TRD. Recurrent ventricular fibrillation associated with normal QTintervals. QJ Med 1981; 200: 451-62.

8. Moss A. Prolonged Q-T interval syndromes. JAMA 1986; 256: 2985-87.9. Vincent GM, Timothy KW, Leppert M, Keating M. The spectrum of of

symptoms and QT intervals in carriers of the gene for the long-QTsyndrome. N Engl J Med 1992; 327: 846-52.

10. Chaudron JM, Heller F, Van den Berghe HB, et al. Attacks of ventricularfibrillation and unconsciousness in a patient with prolonged Q-Tinterval: a family study. Am Heart J 1976; 91: 783-91.

WRITING FOR PUBLICATION

Conflict of interest

INTERNATIONAL COMMITTEE OF MEDICAL

JOURNAL EDITORS*

The following statement was agreed by the ICMJE(the ’Vancouver Group’) at its meeting in January

Conflict of interest for a given manuscript exists when aparticipant in the peer review and publication process-author, reviewer, and editor-has ties to activities that couldinappropriately influence his or her judgment, whether ornot judgment is in fact affected. Financial relationships withindustry (for example, employment, consultancies, stockownership, honoraria, expert testimony), either directly orthrough immediate family, are usually considered the mostimportant conflicts of interest. However, conflicts can occurfor other reasons, such as personal relationships, academiccompetition, and intellectual passion.

Public trust in the peer review process and the credibilityof published articles depend in part on how well conflict ofinterest is handled during writing, peer review, and editorialdecision making. Bias can often be identified and eliminatedby careful attention to the scientific methods andconclusions of the work. Financial relationships and theireffects are less easily detected than other conflicts of interest.Participants in peer review and publication should disclosetheir conflicting interests, and the information should bemade available, so that others can judge their effects forthemselves. Because readers may be less able to detect bias inreview articles and editorials than in reports of originalresearch, some journals do not accept reviews and editorialsfrom authors with a conflict of interest.

Authors

When they submit a manuscript, whether an article or aletter, authors are responsible for recognising and disclosingfinancial and other conflicts of interest that might bias their

*Marcia Angell (N Engl J Med); Linda Clever (West J Med); Lois-AnnColaianni (Index Medicus); Suzanne and Robert Fletcher (Ann Intern Med);Robin Fox (The Lancet); Jerome Kassirer (N Engl J Med); GeorgeLundberg (JAMA); Magne Nylenna (Tidsskr Nor Laegerforen); RichardRobinson (N Z Med J); Richard Smith (BMJ); Bruce Squires (Can MedAssoc J); Laurel Thomas (Med J Aust).

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work. They should acknowledge in the manuscript allfinancial support for the work and other financial or personalconnections to the work.

Reviewers

External peer reviewers should disclose to editors anyconflicts of interest that could bias their opinions of themanuscript and they should disqualify themselves fromreviewing specific manuscripts if they believe it appropriate.The editors must be made aware of reviewers’ conflicts ofinterest to interpret the reviews and judge for themselveswhether the reviewer should be disqualified. Reviewersshould not use knowledge of the work, before its

publication, to further their own interests.

Editors and staff

Editors who make final decisions about manuscriptsshould have no personal financial involvement in any of theissues they might judge. Other members of the editorialstaff, if they participate in editorial decisions, should provideeditors with a current description of their financial interests,as they might relate to editorial judgments, and disqualifythemselves from any decisions where they have a conflict ofinterest.

Published articles and letters should include a descriptionof all financial support and any conflict of interest that, in theeditors’ judgment, readers should know about.

Editorial staff should not use for private gain theinformation gained through working with manuscripts.

BOOKSHELF

The Making of a Doctor

Medical Education in Theory and Practice. R. S. Downie,B. Charlton. Oxford: Oxford University Press. 1992. Pp 203.22.50. ISBN 0-19262136X.

Recent excavations at the Asclepion have shown noevidence that Hippocrates and his team were carryingbleeps. This is the first conclusive evidence that medicinehas changed; it is now much more effective. We can cureinfections, take out gallbladders, blast away stones, anderadicate tumours. Everybody wants some of the action andpatients ask that this will be given politely, quickly, and freeof complication. Managers require that this action shall takeplace without increasing the budget. There is a danger thatmedicine will become a patching-up service, forgetting itsadditional role as a positive promoter of health. Theremarkable thing is that there are still queues of recruits atthe medical schools to join the battle. Is it certain that newdoctors will be equipped to meet these pressures andparadoxes?Change is fashionable, and medicine as a reflection of

society is expected to change also. Yet before turning themedical course on its head, it is worth remembering thatmillions of satisfactory consultations between doctor andpatient are taking place every year. Is there really a need for adramatic metamorphosis? R. S. Downie and BruceCharlton argue strongly that there is. The whole medicalcourse is rotten and this particular tree of knowledge willsoon collapse. Medical student selection is arbitrary, thepreclinical course is irrelevant, the clinical course is a kind of"careers fair" of short visits to departments, and thehousemanship is pure graft. The authors suggest gradualbut sweeping changes to the UK medical course.

Their suggestion for more adventurousness in medicalstudent selection is interesting although somewhat

worrying. A conservative profession should look at thefigures from the medical defence organisations and GeneralMedical Council before changing selection procedures. Themain legal complaints against the medical profession areerrors of omission-failure to visit, failure to refer, andfailure to reach a correct diagnosis. The GMC proceedingsalso suggest a failure to cope-alcohol, sex, drugs, and fraud.

If we are going to select for good communication skills,conscientiousness, and robustness of personality, this is

unlikely to be detected by A levels or interview. Wouldpersonality tests or a two-day assault course be morereliable? (By the way, what happened to the results of thesinister test inflicted on us as entrants to Newcastle medicalschool in 1963?)Downie and Charlton believe that the preclinical

curriculum should concentrate on a core of informationessential for clinical practice rather than the presentinformation overload approach. They also suggest thatmuch of the time in preclinical work should be dedicated to aparticular student project to teach scientific method. Theymake no mention of information technology or managementskills as essential inputs into this phase. Computer-assistedlearning could be an efficient way for some students to learnthe "core" information. Certainly, time vacated in thepreclinical course could be occupied with other interestingactivities. Instead of academic occupational health lectures,let students accompany someone in their daily work routinesand invite their critical assessment of the health implicationsof their way of life. Instead of adding clinical presentations tothe end of the study of a system, bring it forward so thatpreclinical learning projects are built around the patient.Downie and Charlton suggest more arts involvement in a

preclinical course-perhaps they could study a novel asproject work.

In the clinical phase, short visits to departments musthave some function in acquainting the clinical student withthe diversity of medicine. Downie and Charlton are right insaying that this approach can be overdone, and personalemulation or "modelling" cannot take place with such shortimpersonal exposure. A return to the clinical clerkship maybe the ideal; a student would be attached to particular firmsor general practices for longer intervals to absorb the ethosand to become a part of the clinical team. Improvement inthe preregistration year cannot be achieved without asubstantial amount of money. The recent allocation of 50%of resources for training posts to the postgraduate deans isone way of forcing improvement, but it is not a magicsolution and does not increase the total cash available.

Perhaps the final year at medical school could become a