exception the emphasis is on ethnic minority groups having worse health. Even when there is good news-for example, higher immunisation rates' or lower mortality from most cancers-this is not acknowledged. The fact is that members of ethnic minority groups are alive, kicking, and whenever possible vigorously contributing to our ailing, recession-bitten community. The overall standardised mortality ratio of most ethnic minority groups is close to the national average,, and the proper interpretation of this requires noting their greater socioeconomic deprivation. For British Punjabis living in Glasgow, in comparison with the general population, health status was better in several respects, comparable in most measures, and worse in others.8 The report ignores several powerful critiques of traditional thinking on ethnicity and health.-' Why? The cynical view would be that an emphasis on personal behaviour, cultural factors, and genetics deflects attention from deep and disturbing issues about the structure of society; a strategy also seen in relation to the inequalities in health debate. The misleading interpretations are too many to discuss so I shall merely observe that: * The study of ethnicity and health is far from new in this country and a vast literature exists,'-" so ignorance is no excuse for past inaction; * The lumping together of "Asians" to calculate standardised smoking and drinking ratios is inappropriate when there are huge variations between men and women, and between "Asian" subgroups; the result is not of theoretical or practical value; * The problems of health education or health promotion is not simply one of appropriate presentation, but of availability of relevant materials'5; * Most importantly of all, an effect strategy for assessment of health needs cannot be achieved by concentrating on differences between groups but requires a sound understanding of the priorities of each group.'8 The comparative analysis is of value only for fine tuning the development of services and for hypothesis generation.
As one of the few "black" members of a health authority I shall not be recommending this report to my fellow officers. The principles which I shall recommend are not based on the flawed analysis of differences but on whether acceptable standards of care are achieved and on actual, not relative, priorities." RAJ BHOPAL
Division of Epidemiology and Public Health, School of Health Care Sciences, Medical School, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4HH 1 Beecham L. NHS must tune into needs of black and ethnic minorities. BMJ 1992;305:795. (3 October.) 2 On the State of the Public Health 1991. London: HMSO, 1992. (Chapter 3, Health of black and ethnic minorities.) 3 Bhopal RS, Phillimore P, Kohli HS. Inappropriate use of the term "Asian": an obstacle to ethnicity and health research. JPublic Health Med 1992;13:244-6. 4 Ramaiya KL, Swai ABM, McLarty DG, Bhopal RS, Alberti KGMM. Differences in diabetes and coronary risk factors in Hindu subcommunities in Tanzania. BM) 1991;303:271-6. 5 Baker MR, Bandaranayake R, Schwieger MS. Differences in rate of uptake of immunisation among ethnic groups. BM] 1984;288: 1075-8. 6 Bhopal RS, Samim AK. Immunisation uptake of Glasgow Asian children: paradoxical benefit of communication barriers? Community Med 1988;10:215-20. 7 Marmot MG, Adelstein AM, Bulusu L. Imt'migranit mortality in England and Wales 1978. London: HMSO, 1984. (Studies on medical and populations subjects No 47.) 8 Williams R, Bhopal R, Hunt K. The health of a Punjabi ethnic minority in Glasgow: a comparison with the general population. I Epidemiol Community Health (in press). 9 Johnson MRD. Ethnic minorities and health. 7 R Coll Physicians 1 984;18:228-30. 10 Donovan JL. Ethnicity and health: a research review. Soc Sci Med 1984;19:663-70. 11 McNaught A. Race and health care in the United Kingdom. London: Health Education Council, 1985. (Occasional paper No 2.) 12 Ahmad WIU. Policies, pills and political will: a critique of policies to improve the health status of ethnic minorities. Lancet 1989;i:148-9.
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13 Sheldon TA, Parker H. Race and ethnicity in health research. jPaiblic Health Aed 1992;14:104-10. 14 Pearson M. Sociology of race and health. In: Chuickshank JK, Beevers DG. Ethnic facton int health anid disease. London: Wright, 1990:71-83. 15 Bhopal RS, Donaldson LJ. Health education for ethnic minortties-current provision and future directions. Health EducationJ_oi4nzal 1988;47:137-40. 16 Bhopal RS. Health care for Asians: conflict in need, demand and provision. In: Eq'itv. A prereqaizsite for health. Proceedinlgs of the 1987 siant)zer scienzjific conzferenice of the Facultv of Contntawtity Medicin'e. Londoni: Facults of Community Medicine and World Health Organisation, 1988.
Serum cholesterol and mortality in Finland EDITOR,-Minerva accepts too uncritically' Pekkanen et al's view of the results of their 25 year follow up of the Finnish cohorts in the seven countries study.2 She states that "in the end high cholesterol predicted both high mortality from heart disease and high overall mortality." Pekkanen et al show, however, that over the 25 years men with cholesterol concentrations below the lowest quartile (below 5 8 mmoUl) had a lower risk of death due to coronary heart disease and a higher risk of death from other causes, giving an all cause mortality that was similar to that in men with higher concentrations. Furthermore, during the first 10 years men with cholesterol concentrations below the lowest quartile had the highest relative risk of death from causes other than coronary heart disease. Minerva also comments that men with high serum concentrations of cholesterol had low overall death rates in the first 10 years because relatively few died of cancer, although the reported figures show that the most significant deficit in relative risk was for causes other than cancer, stroke, and coronary heart disease, which presumably includes murder, suicide, and accidental death. In the same issue of the BMJ George Davey Smith and Andrew N Phillips's persuasive paper on confounding in epidemiological studies recommends that "the first responsibility of [epidemiological] investigators should be to retain the proper degree of caution when interpreting and discussing their findings."' Pekkanen et al show no such caution, for despite the absence in their data of any evidence that altering serum cholesterol concentration improves the quality or the duration of life of men aged 40 to 59, they conclude that community wide efforts to lower cholesterol concentrations in a whole population are probably the most effective, safest, and cheapest way of reducing total mortality. ALEXANDER MACNAIR London WI M 7AD 1 Minerva. BM_ 1992;305:784. (26 September.) 2 Pekkanen J, Nissinen A, Punsar S, Karvonen MJ. Short- and long-term association of serum cholesterol with mortality: the 25-year follow-up of the Finnish cohorts of the seven countries
study. An_ffEpidenuiol 1992;l35:1251-8. 3 Davey Smith G, Phillips AN. Confounding in epidemiological studies: why "independent" effects may not be all they seem.
BMJ 1992;305:757-9. (26 September.)
Adolescent perpetrators of sexual abuse EDITOR,-AS the coordinator of a social services project working with adolescent perpetrators of sexual abuse, I was interested in the personal view written by someone whose daughter had been abused.' It is possible that, had the social services department mentioned in the article followed the guidelines set out in Working Together' and held a case conference about the perpetrator, more progress might have been made.
Our programme offers assessment and intervention work to a wide range of young abusers, sometimes after court appearances but more often after a case conference. The case conference gives us the chance to explain to the parents and the young person the concerns about a young perpetrator and to offer an assessment. In our experience (we have seen over 60 young people) many families welcome this and are willing to allow us to carry out a six to eight session assessment. Surprisingly, perhaps, we are often able to break down at least some of the denial during this period, although the level of parental denial and avoidance is clearly crucial. We have had only one instance of refusal to undergo assessment after a case conference (in this case, for various reasons, court action was not possible). In the more relaxed atmosphere of the assessment sessions, as opposed to the formal atmosphere of a police interview, adolescents are much more ready to disclose their sexual behaviour. This then enables work to be done to help the perpetrator take responsibility for his or her actions and, at the least, enables the risk of further offending to be assessed and reported back to the case conference. The article clearly points out the need to take adolescent offending seriously. Many adolescents continue to offend as adults, and we don't yet know how to identify those who will stop. Common sense, as well as information from adult abusers themselves, suggests that the longer abuse continues without disclosure the more likely it is to become an addictive cycle of behaviour and thus to continue into adulthood. Decisions about whether young people who have abused others may pose serious risks later should be based on an assessment. This sort of information and discussion is best handled in the multiagency forum of a case conference. ALIX BROWN
Adolescent Sexual Offences Programme, Shropshire County Council Social Services Department, Donnington, Telford TF2 8AE 1 Stop, look, listen. BMJ 1992;305:838-9. (3 October.) 2 Home Office, Department of Health, Department of Education and Science, and Welsh Office. Working together (under the Children Act 1989): a guide to arrangemzents for interagency cooperationz for the protectiotn of children front abuse. London: HMSO, 1991.
EDITOR,-I am a general practitioner and happily married with two children, and I wonder what healthy sexual development is. I recall, when I was 4-5 years old, my girl friend and I stuffing leaves into our "botties," while another game as a child involved intricate investigations with a knitting needle. Overnight at 11 years of age the opposite sex became very interesting, and we played "kiss, cuddle, or torture." We soon learnt that the torture was the most interesting-either a grope up the vest to find budding breasts or a poke down the pants. Nobody seemed to come to any harm, though I didn't like being pursued by one particular older, bigger boy-I feared he might want more from this game. I describe these events as I think they must all be part of normal physical, emotional, and sexual development. But when does the normal become the perverse? An incident within my family makes me wonder. One day my daughter-about 4 years old and already playing a healthy game of "doctors" under a rug with her girl friends-told me that her brother, 11 years older, had given her some sweets, looked at her bottom in the bath, and told her not to tell. I immediately told him that he shouldn't be doing this. A year or two later I left my son to babysit his sister. I returned home, and my daughter soon told me that her brother had given her a big bag of sweets and some money. When I asked why (it wasn't usually his nature to be so generous) she described how he had looked at her again and had
1157
asked her to touch his penis. The sweets were a bribe to keep the secret. I was shocked. Was this child sexual abuse in our house? Only a few weeks earlier I had attended a day's workshop on child sexual abuse and learnt that it usually occurred within the household-perpetrated by an older member of the family who often used bribes. I decided that I must challenge my son straight away, and the same evening I questioned him in the most non-accusatory voice I could muster. He didn't say much and denied the part involving my daughter touching him. I wasn't too surprised so did not press him further but concluded our talk with the advice that it was not appropriate to do this with his sister, who was much younger than him. From then on I made sure the two of them were not left alone together. I was alone at the time as my husband was working abroad. I shared my concern with a close friend (a paediatrician and mother), who supported my action. When I did tell my husband on his return I found him unhelpful. He would make no comment, nor would he talk further to our son. However, he has never talked to our son about sexual concerns, and when our son was 17 and met a girl it was I who watched the relationship develop into a caring and sexual one, I who advised on birth control, and I who insisted that they did not sleep in the same bedroom in our house. We have all undergone our sexual development and have all had sexual experiences good and bad. We are talking about it more, especially in schools, but sadly not enough-not enough to little children when they are receptive to discussion about their bodies, not enough to growing children so that they know they can talk about what is happening to them, and not enough so that when they are adult they can confide in others if they are having problems. Perhaps if more families could be more open about sexuality there would be fewer problems of sexual and related abuse. These problems could and should be prevented. 1 Stop, look, listen. BMJ 1992;305:838-9. (3 October.)
Site of injection for vaccination EDITOR,-Mark Henley correctly states that the anterolateral aspect of the thigh is an acceptable alternative to the upper arm for injecting hepatitis B vaccine.' But his assertion that the only indications for administering the vaccine in the upper arm are convention and convenience is misleading. The reason why public health bodies recommend that hepatitis B vaccination should be given in the upper arm is to prevent vaccine being administered into the buttock. There are over 100 reports of unexpectedly low antibody seroconversion rates after hepatitis B vaccination by injection into the buttock, confirmed by studies carried out at the Royal Free Hospital.2 In one centre in the United States a low antibody response was noted in 54% of healthy adult health care staff. Many studies have since shown the antibody response rate to be significantly higher in centres using deltoid injection than centres using the buttock. On the basis of antibody tests after vaccination, the advisory committee on immunisation practices of the Centers for Disease Control recommended that the arm be used as the site for hepatitis B vaccination in adults,3 as have the departments of health in the United Kingdom.4 A more recent comprehensive study by Shaw et al showed that participants who received the vaccine in the deltoid had antibody titres that were up to 17 times higher than those of subjects who received the injections into the buttock.5 Furthermore, those who were injected in the buttock were two to four times more likely to fail to reach a minimum antibody level of 10mIU/ml after vaccination. Recent reports have also implicated
1158
buttock injection as a possible factor in a failure of rabies postexposure prophylaxis using human diploid cells rabies vaccine.' The injection of vaccine into deep fat in the buttocks is thought likely with needles shorter than 5 cm, and there is a lack of phagocytic or antigen presenting cells in layers of fat. Another factor may involve the rapidity with which antigen becomes available to the circulation from deposition in fat, leading to delay in processing by macrophages and eventually presentation to T and B cells. An additional factor may be denaturation by enzymes of antigen which has remained in fat for hours or days. The importance of these factors is supported by the finding both at the Royal Free Hospital and by Shaw et aP that thicker skinfold was associated with a lowered antibody response. These observations have important public health implications, well illustrated by the estimate that about 20% of subjects immunised against hepatitis B via the buttock in the United States by March 1985 (about 60000 people) failed to attain a minimum level of antibody of 10 mIU/ml and were therefore not protected. We strongly urge that hepatitis B surface antibody titres should be measured in all people who have been immunised against hepatitis B by injection into the buttocks, and when this is not possible a complete course of three injections of vaccine should be administered into the deltoid muscle or the anterolateral aspect of the thigh, the only acceptable sites for hepatitis B immunisation.8 JANE N ZUCKERMAN
ANNE COCKCROFT ARIE J ZUCKERMAN
Occupational Health Unit and WHO Collaborating Centre for Reference and Research on Viral Diseases, Royal Free Hospital School of Medicine, London NW3 2PF 1 Henley M. Site of injection for vaccination. BMJ 1 992;305: 773-4. (26 September.) 2 Cockcroft A, Soper P, Insail C, Kennard Y, Chapman S, Gooch C, et al. Antibody response after hepatitis B immunisation in health care workers. Brjl Indust Med 1990;47:199-202. 3 Centers for Disease Control. Suboptimal response to hepatitis B vaccine given by injection into the buttock. MMWR 1985;34: 4
5
6 7 8
105,108,119. Department of Health, Welsh Office, Scottish Home and Health Department. Immunisation against infectious disease. London: HMSO, 1990:104. Shaw FE Jr, Guess IJA, Roets JM, Mohr FE, Coleman PJ, Mandel EJ, et al. Effect of anatomic site, age and smoking on the immune response to hepatitis B vaccination. Vaccine 1989;7:425-30. Baer GM, Fishbein DR. Rabies post-exposure prophylaxis. NEngl3'Med 1987;316:1270-1. Zuckerman AJ. Appraisal of intradermal immunisation against hepatitis B. Lancet 1 987;i:435-7. Zuckerman AJ. Immunization against hepatitis B. Br Med Bull 1 990;46:383-98.
Dyspnoea in palliative care EDITOR,-Opioid drugs used to control both pain and dyspnoea in palliative care do not, by any means, always hasten death. A recent review of the treatment of intractable dypnoea is both informative and interesting' but, as Minerva points out, makes "rather depressing" reading.2 The paper is not, in fact, a comprehensive review of the literature. Though there is good evidence that single doses of morphine cause a deterioration in blood gas concentrations, the same is not true for long term treatment. Gray et al reported no difference in opiate consumption between patients with chronic lung disease who developed respiratory failure and those who did not.' Furthermore, in a study of 20 terminally ill patients (including 12 with chronic airflow limitation) receiving regular oral morphine in doses exceeding 100 mg morphine sulphate/24 h Walsh found a raised arterial carbon dioxide concentration in only one.4 New routes of administration have been investigated, and anecdotal
evidence and one published report indicate the efficacy of low dose nebulised morphine in breathlessness.5 In palliative care dyspnoea is often regarded as the poor relation to pain. The results of current research, however, are encouraging and should lead to therapeutic advances and improvements in patients' quality of life. CAROL L DAVIS
Royal Marsden Hospital, Sutton, Surrey SM2 5PT I Cohen MH, Johnston-Anderson A, Krasnow SH, Wadleigh RG. Treatment of intractable dyspnea. Cancer Invest 1992;10: 317-21. 2 Minerva. BMJ 1992;305:842. (3 October.) 3 Gray JM, Henry DA, Paice B, Gettingby G, Moran F, Lawson DH. Acute respiratory failure and CNS-depressing drugs.
PossgradMedJ 1981;57:279-82. 4 Walsh TD. Opiates and respiratorv function in advanced cancer. Recent Results Cancer Res 1984;89:1 15-7. 5 Young IH, Daviskas E, Keena VA. The effect of low dose nebulized morphine on exercise endurance in patients with chronic lung disease. Thorax 1989;44:387-90.
Faecal incontinence EDITOR,-E S Kiffs article on faecal incontinence rightly says that impaction of faeces in elderly people is a cause of faecal incontinence and diarrhoea.' A diagram indicates that impaction is caused by hard faeces in the rectum. This is often so, but in my long experience of geriatrics I have found "soft" impaction-in which the rectum and colon are distended by soft faeces-to be probably more common. Presumably peristalsis is ineffective in this condition. Beside overflow, distention, vomiting, general deterioration, and excessive gas shadows can occur. Stimulant laxatives aggravate the symptoms and should be avoided until the bowel is cleaned from below. Small volume enemas are less effective than soap and water. The bowel may take over a week to clean, even with enemas on alternate days. N A NICHOLLS Roadhead, Cumbria CA6 6NF 1 Kiff ES. Faecal incontinence. BMJ 1992;305:702-4. (19 Sep-
tember.)
Neuroleptic sensitivity in dementia with cortical Lewy bodies EDITOR,-Ian McKeith and colleagues' paper' adds to the published clinical data on dementia with cortical Lewy bodies.2 The authors make no comment on the severity and frequency of parkinsonian symptoms in dementia with cortical Lewy bodies found by other groups,35 although four of their 20 patients presented with Parkinson's disease-a proportion similar to the 14-40% reported previously." In the later stages of the disease parkinsonian symptoms are reported in most cases (70-87%).3 Parkinsonian symptoms responsive to levodopa have also been reported in young patients with the disease.57 We recently confirmed the severity of such symptoms and their responses to levodopa.8 With such a high frequency of important parkinsonian symptoms it is perhaps not surprising that the patients reported on by McKeith and colleagues were sensitive to neuroleptic drugs. Most of the patients were elderly and were receiving fairly high doses of neuroleptics. We have not observed sensitivity to such drugs in our patientseither those in whom dementia with cortical Lewy bodies was diagnosed after death3 or living patients in whom the diagnosis was made according to
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As one of the few "black" members of a health authority I shall not be recommending this report to my fellow officers. The principles which I shall recommend are not based on the flawed analysis of differences but on whether acceptable standards of care are achieved and on actual, not relative, priorities." RAJ BHOPAL
Division of Epidemiology and Public Health, School of Health Care Sciences, Medical School, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4HH 1 Beecham L. NHS must tune into needs of black and ethnic minorities. BMJ 1992;305:795. (3 October.) 2 On the State of the Public Health 1991. London: HMSO, 1992. (Chapter 3, Health of black and ethnic minorities.) 3 Bhopal RS, Phillimore P, Kohli HS. Inappropriate use of the term "Asian": an obstacle to ethnicity and health research. JPublic Health Med 1992;13:244-6. 4 Ramaiya KL, Swai ABM, McLarty DG, Bhopal RS, Alberti KGMM. Differences in diabetes and coronary risk factors in Hindu subcommunities in Tanzania. BM) 1991;303:271-6. 5 Baker MR, Bandaranayake R, Schwieger MS. Differences in rate of uptake of immunisation among ethnic groups. BM] 1984;288: 1075-8. 6 Bhopal RS, Samim AK. Immunisation uptake of Glasgow Asian children: paradoxical benefit of communication barriers? Community Med 1988;10:215-20. 7 Marmot MG, Adelstein AM, Bulusu L. Imt'migranit mortality in England and Wales 1978. London: HMSO, 1984. (Studies on medical and populations subjects No 47.) 8 Williams R, Bhopal R, Hunt K. The health of a Punjabi ethnic minority in Glasgow: a comparison with the general population. I Epidemiol Community Health (in press). 9 Johnson MRD. Ethnic minorities and health. 7 R Coll Physicians 1 984;18:228-30. 10 Donovan JL. Ethnicity and health: a research review. Soc Sci Med 1984;19:663-70. 11 McNaught A. Race and health care in the United Kingdom. London: Health Education Council, 1985. (Occasional paper No 2.) 12 Ahmad WIU. Policies, pills and political will: a critique of policies to improve the health status of ethnic minorities. Lancet 1989;i:148-9.
BMJ
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7 NOVEMBER 1992
13 Sheldon TA, Parker H. Race and ethnicity in health research. jPaiblic Health Aed 1992;14:104-10. 14 Pearson M. Sociology of race and health. In: Chuickshank JK, Beevers DG. Ethnic facton int health anid disease. London: Wright, 1990:71-83. 15 Bhopal RS, Donaldson LJ. Health education for ethnic minortties-current provision and future directions. Health EducationJ_oi4nzal 1988;47:137-40. 16 Bhopal RS. Health care for Asians: conflict in need, demand and provision. In: Eq'itv. A prereqaizsite for health. Proceedinlgs of the 1987 siant)zer scienzjific conzferenice of the Facultv of Contntawtity Medicin'e. Londoni: Facults of Community Medicine and World Health Organisation, 1988.
Serum cholesterol and mortality in Finland EDITOR,-Minerva accepts too uncritically' Pekkanen et al's view of the results of their 25 year follow up of the Finnish cohorts in the seven countries study.2 She states that "in the end high cholesterol predicted both high mortality from heart disease and high overall mortality." Pekkanen et al show, however, that over the 25 years men with cholesterol concentrations below the lowest quartile (below 5 8 mmoUl) had a lower risk of death due to coronary heart disease and a higher risk of death from other causes, giving an all cause mortality that was similar to that in men with higher concentrations. Furthermore, during the first 10 years men with cholesterol concentrations below the lowest quartile had the highest relative risk of death from causes other than coronary heart disease. Minerva also comments that men with high serum concentrations of cholesterol had low overall death rates in the first 10 years because relatively few died of cancer, although the reported figures show that the most significant deficit in relative risk was for causes other than cancer, stroke, and coronary heart disease, which presumably includes murder, suicide, and accidental death. In the same issue of the BMJ George Davey Smith and Andrew N Phillips's persuasive paper on confounding in epidemiological studies recommends that "the first responsibility of [epidemiological] investigators should be to retain the proper degree of caution when interpreting and discussing their findings."' Pekkanen et al show no such caution, for despite the absence in their data of any evidence that altering serum cholesterol concentration improves the quality or the duration of life of men aged 40 to 59, they conclude that community wide efforts to lower cholesterol concentrations in a whole population are probably the most effective, safest, and cheapest way of reducing total mortality. ALEXANDER MACNAIR London WI M 7AD 1 Minerva. BM_ 1992;305:784. (26 September.) 2 Pekkanen J, Nissinen A, Punsar S, Karvonen MJ. Short- and long-term association of serum cholesterol with mortality: the 25-year follow-up of the Finnish cohorts of the seven countries
study. An_ffEpidenuiol 1992;l35:1251-8. 3 Davey Smith G, Phillips AN. Confounding in epidemiological studies: why "independent" effects may not be all they seem.
BMJ 1992;305:757-9. (26 September.)
Adolescent perpetrators of sexual abuse EDITOR,-AS the coordinator of a social services project working with adolescent perpetrators of sexual abuse, I was interested in the personal view written by someone whose daughter had been abused.' It is possible that, had the social services department mentioned in the article followed the guidelines set out in Working Together' and held a case conference about the perpetrator, more progress might have been made.
Our programme offers assessment and intervention work to a wide range of young abusers, sometimes after court appearances but more often after a case conference. The case conference gives us the chance to explain to the parents and the young person the concerns about a young perpetrator and to offer an assessment. In our experience (we have seen over 60 young people) many families welcome this and are willing to allow us to carry out a six to eight session assessment. Surprisingly, perhaps, we are often able to break down at least some of the denial during this period, although the level of parental denial and avoidance is clearly crucial. We have had only one instance of refusal to undergo assessment after a case conference (in this case, for various reasons, court action was not possible). In the more relaxed atmosphere of the assessment sessions, as opposed to the formal atmosphere of a police interview, adolescents are much more ready to disclose their sexual behaviour. This then enables work to be done to help the perpetrator take responsibility for his or her actions and, at the least, enables the risk of further offending to be assessed and reported back to the case conference. The article clearly points out the need to take adolescent offending seriously. Many adolescents continue to offend as adults, and we don't yet know how to identify those who will stop. Common sense, as well as information from adult abusers themselves, suggests that the longer abuse continues without disclosure the more likely it is to become an addictive cycle of behaviour and thus to continue into adulthood. Decisions about whether young people who have abused others may pose serious risks later should be based on an assessment. This sort of information and discussion is best handled in the multiagency forum of a case conference. ALIX BROWN
Adolescent Sexual Offences Programme, Shropshire County Council Social Services Department, Donnington, Telford TF2 8AE 1 Stop, look, listen. BMJ 1992;305:838-9. (3 October.) 2 Home Office, Department of Health, Department of Education and Science, and Welsh Office. Working together (under the Children Act 1989): a guide to arrangemzents for interagency cooperationz for the protectiotn of children front abuse. London: HMSO, 1991.
EDITOR,-I am a general practitioner and happily married with two children, and I wonder what healthy sexual development is. I recall, when I was 4-5 years old, my girl friend and I stuffing leaves into our "botties," while another game as a child involved intricate investigations with a knitting needle. Overnight at 11 years of age the opposite sex became very interesting, and we played "kiss, cuddle, or torture." We soon learnt that the torture was the most interesting-either a grope up the vest to find budding breasts or a poke down the pants. Nobody seemed to come to any harm, though I didn't like being pursued by one particular older, bigger boy-I feared he might want more from this game. I describe these events as I think they must all be part of normal physical, emotional, and sexual development. But when does the normal become the perverse? An incident within my family makes me wonder. One day my daughter-about 4 years old and already playing a healthy game of "doctors" under a rug with her girl friends-told me that her brother, 11 years older, had given her some sweets, looked at her bottom in the bath, and told her not to tell. I immediately told him that he shouldn't be doing this. A year or two later I left my son to babysit his sister. I returned home, and my daughter soon told me that her brother had given her a big bag of sweets and some money. When I asked why (it wasn't usually his nature to be so generous) she described how he had looked at her again and had
1157
asked her to touch his penis. The sweets were a bribe to keep the secret. I was shocked. Was this child sexual abuse in our house? Only a few weeks earlier I had attended a day's workshop on child sexual abuse and learnt that it usually occurred within the household-perpetrated by an older member of the family who often used bribes. I decided that I must challenge my son straight away, and the same evening I questioned him in the most non-accusatory voice I could muster. He didn't say much and denied the part involving my daughter touching him. I wasn't too surprised so did not press him further but concluded our talk with the advice that it was not appropriate to do this with his sister, who was much younger than him. From then on I made sure the two of them were not left alone together. I was alone at the time as my husband was working abroad. I shared my concern with a close friend (a paediatrician and mother), who supported my action. When I did tell my husband on his return I found him unhelpful. He would make no comment, nor would he talk further to our son. However, he has never talked to our son about sexual concerns, and when our son was 17 and met a girl it was I who watched the relationship develop into a caring and sexual one, I who advised on birth control, and I who insisted that they did not sleep in the same bedroom in our house. We have all undergone our sexual development and have all had sexual experiences good and bad. We are talking about it more, especially in schools, but sadly not enough-not enough to little children when they are receptive to discussion about their bodies, not enough to growing children so that they know they can talk about what is happening to them, and not enough so that when they are adult they can confide in others if they are having problems. Perhaps if more families could be more open about sexuality there would be fewer problems of sexual and related abuse. These problems could and should be prevented. 1 Stop, look, listen. BMJ 1992;305:838-9. (3 October.)
Site of injection for vaccination EDITOR,-Mark Henley correctly states that the anterolateral aspect of the thigh is an acceptable alternative to the upper arm for injecting hepatitis B vaccine.' But his assertion that the only indications for administering the vaccine in the upper arm are convention and convenience is misleading. The reason why public health bodies recommend that hepatitis B vaccination should be given in the upper arm is to prevent vaccine being administered into the buttock. There are over 100 reports of unexpectedly low antibody seroconversion rates after hepatitis B vaccination by injection into the buttock, confirmed by studies carried out at the Royal Free Hospital.2 In one centre in the United States a low antibody response was noted in 54% of healthy adult health care staff. Many studies have since shown the antibody response rate to be significantly higher in centres using deltoid injection than centres using the buttock. On the basis of antibody tests after vaccination, the advisory committee on immunisation practices of the Centers for Disease Control recommended that the arm be used as the site for hepatitis B vaccination in adults,3 as have the departments of health in the United Kingdom.4 A more recent comprehensive study by Shaw et al showed that participants who received the vaccine in the deltoid had antibody titres that were up to 17 times higher than those of subjects who received the injections into the buttock.5 Furthermore, those who were injected in the buttock were two to four times more likely to fail to reach a minimum antibody level of 10mIU/ml after vaccination. Recent reports have also implicated
1158
buttock injection as a possible factor in a failure of rabies postexposure prophylaxis using human diploid cells rabies vaccine.' The injection of vaccine into deep fat in the buttocks is thought likely with needles shorter than 5 cm, and there is a lack of phagocytic or antigen presenting cells in layers of fat. Another factor may involve the rapidity with which antigen becomes available to the circulation from deposition in fat, leading to delay in processing by macrophages and eventually presentation to T and B cells. An additional factor may be denaturation by enzymes of antigen which has remained in fat for hours or days. The importance of these factors is supported by the finding both at the Royal Free Hospital and by Shaw et aP that thicker skinfold was associated with a lowered antibody response. These observations have important public health implications, well illustrated by the estimate that about 20% of subjects immunised against hepatitis B via the buttock in the United States by March 1985 (about 60000 people) failed to attain a minimum level of antibody of 10 mIU/ml and were therefore not protected. We strongly urge that hepatitis B surface antibody titres should be measured in all people who have been immunised against hepatitis B by injection into the buttocks, and when this is not possible a complete course of three injections of vaccine should be administered into the deltoid muscle or the anterolateral aspect of the thigh, the only acceptable sites for hepatitis B immunisation.8 JANE N ZUCKERMAN
ANNE COCKCROFT ARIE J ZUCKERMAN
Occupational Health Unit and WHO Collaborating Centre for Reference and Research on Viral Diseases, Royal Free Hospital School of Medicine, London NW3 2PF 1 Henley M. Site of injection for vaccination. BMJ 1 992;305: 773-4. (26 September.) 2 Cockcroft A, Soper P, Insail C, Kennard Y, Chapman S, Gooch C, et al. Antibody response after hepatitis B immunisation in health care workers. Brjl Indust Med 1990;47:199-202. 3 Centers for Disease Control. Suboptimal response to hepatitis B vaccine given by injection into the buttock. MMWR 1985;34: 4
5
6 7 8
105,108,119. Department of Health, Welsh Office, Scottish Home and Health Department. Immunisation against infectious disease. London: HMSO, 1990:104. Shaw FE Jr, Guess IJA, Roets JM, Mohr FE, Coleman PJ, Mandel EJ, et al. Effect of anatomic site, age and smoking on the immune response to hepatitis B vaccination. Vaccine 1989;7:425-30. Baer GM, Fishbein DR. Rabies post-exposure prophylaxis. NEngl3'Med 1987;316:1270-1. Zuckerman AJ. Appraisal of intradermal immunisation against hepatitis B. Lancet 1 987;i:435-7. Zuckerman AJ. Immunization against hepatitis B. Br Med Bull 1 990;46:383-98.
Dyspnoea in palliative care EDITOR,-Opioid drugs used to control both pain and dyspnoea in palliative care do not, by any means, always hasten death. A recent review of the treatment of intractable dypnoea is both informative and interesting' but, as Minerva points out, makes "rather depressing" reading.2 The paper is not, in fact, a comprehensive review of the literature. Though there is good evidence that single doses of morphine cause a deterioration in blood gas concentrations, the same is not true for long term treatment. Gray et al reported no difference in opiate consumption between patients with chronic lung disease who developed respiratory failure and those who did not.' Furthermore, in a study of 20 terminally ill patients (including 12 with chronic airflow limitation) receiving regular oral morphine in doses exceeding 100 mg morphine sulphate/24 h Walsh found a raised arterial carbon dioxide concentration in only one.4 New routes of administration have been investigated, and anecdotal
evidence and one published report indicate the efficacy of low dose nebulised morphine in breathlessness.5 In palliative care dyspnoea is often regarded as the poor relation to pain. The results of current research, however, are encouraging and should lead to therapeutic advances and improvements in patients' quality of life. CAROL L DAVIS
Royal Marsden Hospital, Sutton, Surrey SM2 5PT I Cohen MH, Johnston-Anderson A, Krasnow SH, Wadleigh RG. Treatment of intractable dyspnea. Cancer Invest 1992;10: 317-21. 2 Minerva. BMJ 1992;305:842. (3 October.) 3 Gray JM, Henry DA, Paice B, Gettingby G, Moran F, Lawson DH. Acute respiratory failure and CNS-depressing drugs.
PossgradMedJ 1981;57:279-82. 4 Walsh TD. Opiates and respiratorv function in advanced cancer. Recent Results Cancer Res 1984;89:1 15-7. 5 Young IH, Daviskas E, Keena VA. The effect of low dose nebulized morphine on exercise endurance in patients with chronic lung disease. Thorax 1989;44:387-90.
Faecal incontinence EDITOR,-E S Kiffs article on faecal incontinence rightly says that impaction of faeces in elderly people is a cause of faecal incontinence and diarrhoea.' A diagram indicates that impaction is caused by hard faeces in the rectum. This is often so, but in my long experience of geriatrics I have found "soft" impaction-in which the rectum and colon are distended by soft faeces-to be probably more common. Presumably peristalsis is ineffective in this condition. Beside overflow, distention, vomiting, general deterioration, and excessive gas shadows can occur. Stimulant laxatives aggravate the symptoms and should be avoided until the bowel is cleaned from below. Small volume enemas are less effective than soap and water. The bowel may take over a week to clean, even with enemas on alternate days. N A NICHOLLS Roadhead, Cumbria CA6 6NF 1 Kiff ES. Faecal incontinence. BMJ 1992;305:702-4. (19 Sep-
tember.)
Neuroleptic sensitivity in dementia with cortical Lewy bodies EDITOR,-Ian McKeith and colleagues' paper' adds to the published clinical data on dementia with cortical Lewy bodies.2 The authors make no comment on the severity and frequency of parkinsonian symptoms in dementia with cortical Lewy bodies found by other groups,35 although four of their 20 patients presented with Parkinson's disease-a proportion similar to the 14-40% reported previously." In the later stages of the disease parkinsonian symptoms are reported in most cases (70-87%).3 Parkinsonian symptoms responsive to levodopa have also been reported in young patients with the disease.57 We recently confirmed the severity of such symptoms and their responses to levodopa.8 With such a high frequency of important parkinsonian symptoms it is perhaps not surprising that the patients reported on by McKeith and colleagues were sensitive to neuroleptic drugs. Most of the patients were elderly and were receiving fairly high doses of neuroleptics. We have not observed sensitivity to such drugs in our patientseither those in whom dementia with cortical Lewy bodies was diagnosed after death3 or living patients in whom the diagnosis was made according to
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