several Gram positive bacteria but that other factors must also play a part, an observation consistent with our findings in Gram negative shock.6 Nevertheless, if these results can be confirmed in vivo it will give added impetus to the trials of antibody to tumour necrosis factor as empirical treatment in septic shock.7 We thank A Wienecke and Dr R Gilbert of the Food Hygiene Laboratory, CPHL Colindale, for toxin analysis of some of our strains. J COHEN K BAYSTON M TOMLINSON Infectious Diseases Unit, Hammersmith Hospital, London W12 OHS 1 Sanderson PS. Do streptococci cause toxic shock? BMJ 1990; 301:1006-7. (3 November.) 2 Ispahani P, Pearson NJ, Greenwood D. An analysis of community and hospital-acquired bacteraemia in a large teaching hospital in the United Kingdom. QJ3Med 1987;63:427-40. 3 Fong Y, Lowry SL. Tumor necrosis factor in the pathophysiology of infection and sepsis. Clin Immunol Immunopathol 1990;55: 157-70. 4 Tracey KJ, Vlassara H, Cerami A. Cachectin/tumour necrosis factor. Lancet 1989;i: 1122-6. 5 GuttebergTJ, Osterud B, VodenG, JorgensonT. Theproduction of tumour necrosis factor, tissue thromboplastin, lactoferrin and cathepsin C during lipopolysaccharide stimulation in whole blood. Scandj Clin Lab Invest 1990;50:421-7. 6 Silva AT, Appelmelk BJ, Buurman WA, Bayston KF, Cohen J. Monoclonal antibody to endotoxin core protects mice from Escherichia coli sepsis by a mechanism independent of tumor necrosis factor and interleukin-6. J Infect Dis 1990;162:454-9. 7 Exley AR, Cohen J, Buurman WA, et al. Monoclonal antibody to [NF in severe septic shock. Lancet 1990;335:1275-7.
arthritis. We found no significant difference in antibody titres between the two groups.2 This observation does not disprove the hypothesis as the advances in the molecular biology suggest that traditional lymphocytotoxicity assays for HLA-DR typing are not sufficiently sensitive to detect the five amino acid epitope around position 70 of the first domain of the HLA-DR P chain, which is thought to predispose to rheumatoid arthritis irrespective of HLA-DR type.3 These observations suggest that the possibility of cross reactivity between proteus and HLA-DR needs to be examined at a molecular level. People with HLA-DR4 may possess immune response genes that promote a vigorous antibody response to proteus so that the link between rheumatoid arthritis and the antibodies is the association of both variables with HLA-DR4. This is unlikely as in a study of people with inactive rheumatoid arthritis and people without arthritis we have found low titres of antibodies to proteus, irrespective of HLA-DR4 state. The association between rheumatoid arthritis and the antibodies has something to do with the disease and its activity. We now have longitudinal data on 36 patients with rheumatoid arthritis and have found a strong positive correlation between changes in C reactive protein concentration and proteus antibody titres over time. C M DEIGHTON J W GRAY A J BINT D J WALKER
Royal Victoria Infirmary, Newcastle upon Tyne NEI 4LP
Crutches SIR,-As two orthopaedic surgeons who have recently had a ruptured Achilles tendon we can testify to the difficulties associated with the use of crutches as reported by Ms Barbara E Potter and Dr W Angus Wallace.' In particular, mobility is severely restricted because of rapid fatigue and useful function of the hands is precluded. Fortunately we were able to use the K9 orthopaedic scooter. This device, which is basically a shin cradle on wheels,' allowed us to carry on with our normal activities such as ward rounds, clinics, and even operating lists and never failed to amuse the patients. We carried out oxygen consumption studies and found that the energy expenditure of walking with the orthopaedic scooter is 25% less than that with crutches.' We strongly recommend the scooter's use in the rehabilitation of patients with ankle and foot injuries who must remain non-weightbearing with their hands free. P ROBERTS R J GRIMER
Royal Orthopaedic Hospital, Birmingham B31 2AP I Potter BE, Wallace WA. Crutches. BMJ 1990;301:1037-9.
03 November.)
2 Reid M. Medicine and the media. BMJ 1986;293:196. 3 Roberts P, Carnes S. The orthopaedic scooter. J Bone Joint
Surg[Br] 1990;72:620-1.
Bacteria and arthritis SIR,-We would like to comment on some of the issues raised in Dr Bernard Dixon's article.' The theory that proteus reactive arthritis occurs during active phases of rheumatoid arthritis relies on cross reactivity between HLA-DR4 and a proteus antigen so that a humoral response directed against proteus will also attack self tissues expressing HLA-DR4. Thus patients with active rheumatoid arthritis who expressed HLA-DR4 might be expected to have higher antibody titres than those who did not express the antigen. We compared 42 patients with HLA-DR4 with 15 without, all of whom had active rheumatoid
1278
1 Dixon B. Bacteria and arthritis. BMJ7 1990;301:1043. (3 November.) 2 Gray JW, Deighton CM, Bint AJ, Walker DJ. Anti-proteus antibodies in rheumatoid arthritis same-sexed sibships. BrJ Rheumatol 1990;29(suppl II): 102. 3 Gregersen PK, Silver J, Winchester RJ. The shared epitope hypothesis: an approach to understanding the molecular genetics of susceptibility to rheumatoid arthritis. Arthritis Rheum 1987;30:1205-13.
Home treatment for acute psychiatric illness SIR,-Dr C Dean and Dr E M Gadd confirm that domiciliary treatment of acute mental illness is feasible.' Their caveat that the findings may not apply generally is crucial. In 1987 we conducted a study of emergency psychiatric assessments in Paddington and North Kensington. A total of 443 assessments were made by the on call registrar in one year. Of the patients, 45% did not live in the catchment area, 67% lived alone, 13% were completely homeless. Sixteen per cent of patients were brought to the hospital by the police. Schizophrenia was the commonest diagnosis (35%), accounting for 70% of admissions. Depressive disorders were uncommon ( 1%). Three quarters of the patients were unmarried, less than a quarter were employed, and a quarter were not registered with a general practitioner. The typical patient in inner London is psychotic, socially dislocated, itinerant, and lacking support. Given such characteristics I am not optimistic that domiciliary treatment represents a viable alternative to inpatient care. The severity of the illness at the time of admission to hospital may be another important factor, and studies are currently underway to see how this varies among hospitals in North West Thames region. Certainly one recent study points to violence being a common occurrence among acutely ill inpatients in London hospitals.2 Thus it is important to emphasise the differences in the nature ofpsychiatric practice among different areas and caution against generalising from the results of Drs Dean and Gadds. Perhaps what the most deprived areas need is a domiciliary treatment
service in addition to a full complement of inpatient beds. But that, of course, would require extra funding. C J HAWLEY
Charing Cross Hospital, Fulham W6 8RF
1 Dean C, Gadd EM. Home treatment for acute psychiatric illness. BMJ 1990;301:1021-3. (3 November.) 2 James DV, Fineberg NA, Shah AK, Priest RG. An increa1se in violence on an acute psychiatric ward. A studv of associated factors. Brj Psychiat-v 1990;156:846-52.
Crisis in our schools SIR,-Drs Rachel K Jewkes and Brendan H O'Connor highlight the poor state of toilets in British schools.' Many medical officers for environmental health and consultants for communicable disease control will be heartened to learn that after recommendations were made substantial work was undertaken in the toilets of at least one school. Many school buildings are suffering from acute on chronic "deferred maintenance syndrome." School governors are forced to spend time, money, and effort on emergency repairs to the fabric that should be devoted to supporting the educational work of the school. Reductions in cleaning and caretaking time have followed efficiency savings and the process of contracting out the work. The progressive steps taken to support disabled children in normal schools do not always include modification of toilets and other basic hygiene facilities. A recent hepatitis A outbreak in a primary school in this city was associated with a child who had faecal incontinence; no shower or other provision had been made to help this child and her teachers to overcome the basic hygiene problems or to maintain her dignity. Children unwilling to use the toilets often spend the last part of the school day hoping that their bladders will not burst. This does not help them concentrate on their lessons. Poor sanitation causes serious problems other than the control of infection. If children are denied the means to implement the most basic, noncontroversial, health behaviours of hand washing after using the toilet and before meals how can we expect them to develop more complex health behaviours? Efforts to protect the current generation of schoolchildren from alcohol and substance misuse, smoking, dental decay, and AIDS are being frustrated for the lack of basic amenities. MARTIN SCHWEIGER Leeds LS8 2RG 1 Jewkes RK, O'Connor BH. Crisis in our schools: survey of sanitation facilities in schools in Bloomsbury health district.
BMJ 1990;301:1085-7. (10 November.)
Detecting bladder cancer SIR,-Mr Roger Plail's conclusion that all patients with microhaematuria should be investigated calls for comment.' The importance of the age of the patient, the common occurrence of benign renal microhaematuria, and the availability of simple tests to identify or exclude it should have been stressed. An analysis of the medical records of 1000 asymptomatic men in the air force in Israel showed not only that microhaematuria was very common (38 7%) but also that the incidence of urological neoplasms in this group of men aged 40 or less, was as expected for the general population (0 -1 %).2 A population based study in Rochester, Minneapolis also showed that asymptomatic haematuria was a common finding in 781 adults (13%) and was often not associated with any urologic disease. Age was a significant factor, especially in men. Thus, 63% of
BMJ
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1990
arthritis. We found no significant difference in antibody titres between the two groups.2 This observation does not disprove the hypothesis as the advances in the molecular biology suggest that traditional lymphocytotoxicity assays for HLA-DR typing are not sufficiently sensitive to detect the five amino acid epitope around position 70 of the first domain of the HLA-DR P chain, which is thought to predispose to rheumatoid arthritis irrespective of HLA-DR type.3 These observations suggest that the possibility of cross reactivity between proteus and HLA-DR needs to be examined at a molecular level. People with HLA-DR4 may possess immune response genes that promote a vigorous antibody response to proteus so that the link between rheumatoid arthritis and the antibodies is the association of both variables with HLA-DR4. This is unlikely as in a study of people with inactive rheumatoid arthritis and people without arthritis we have found low titres of antibodies to proteus, irrespective of HLA-DR4 state. The association between rheumatoid arthritis and the antibodies has something to do with the disease and its activity. We now have longitudinal data on 36 patients with rheumatoid arthritis and have found a strong positive correlation between changes in C reactive protein concentration and proteus antibody titres over time. C M DEIGHTON J W GRAY A J BINT D J WALKER
Royal Victoria Infirmary, Newcastle upon Tyne NEI 4LP
Crutches SIR,-As two orthopaedic surgeons who have recently had a ruptured Achilles tendon we can testify to the difficulties associated with the use of crutches as reported by Ms Barbara E Potter and Dr W Angus Wallace.' In particular, mobility is severely restricted because of rapid fatigue and useful function of the hands is precluded. Fortunately we were able to use the K9 orthopaedic scooter. This device, which is basically a shin cradle on wheels,' allowed us to carry on with our normal activities such as ward rounds, clinics, and even operating lists and never failed to amuse the patients. We carried out oxygen consumption studies and found that the energy expenditure of walking with the orthopaedic scooter is 25% less than that with crutches.' We strongly recommend the scooter's use in the rehabilitation of patients with ankle and foot injuries who must remain non-weightbearing with their hands free. P ROBERTS R J GRIMER
Royal Orthopaedic Hospital, Birmingham B31 2AP I Potter BE, Wallace WA. Crutches. BMJ 1990;301:1037-9.
03 November.)
2 Reid M. Medicine and the media. BMJ 1986;293:196. 3 Roberts P, Carnes S. The orthopaedic scooter. J Bone Joint
Surg[Br] 1990;72:620-1.
Bacteria and arthritis SIR,-We would like to comment on some of the issues raised in Dr Bernard Dixon's article.' The theory that proteus reactive arthritis occurs during active phases of rheumatoid arthritis relies on cross reactivity between HLA-DR4 and a proteus antigen so that a humoral response directed against proteus will also attack self tissues expressing HLA-DR4. Thus patients with active rheumatoid arthritis who expressed HLA-DR4 might be expected to have higher antibody titres than those who did not express the antigen. We compared 42 patients with HLA-DR4 with 15 without, all of whom had active rheumatoid
1278
1 Dixon B. Bacteria and arthritis. BMJ7 1990;301:1043. (3 November.) 2 Gray JW, Deighton CM, Bint AJ, Walker DJ. Anti-proteus antibodies in rheumatoid arthritis same-sexed sibships. BrJ Rheumatol 1990;29(suppl II): 102. 3 Gregersen PK, Silver J, Winchester RJ. The shared epitope hypothesis: an approach to understanding the molecular genetics of susceptibility to rheumatoid arthritis. Arthritis Rheum 1987;30:1205-13.
Home treatment for acute psychiatric illness SIR,-Dr C Dean and Dr E M Gadd confirm that domiciliary treatment of acute mental illness is feasible.' Their caveat that the findings may not apply generally is crucial. In 1987 we conducted a study of emergency psychiatric assessments in Paddington and North Kensington. A total of 443 assessments were made by the on call registrar in one year. Of the patients, 45% did not live in the catchment area, 67% lived alone, 13% were completely homeless. Sixteen per cent of patients were brought to the hospital by the police. Schizophrenia was the commonest diagnosis (35%), accounting for 70% of admissions. Depressive disorders were uncommon ( 1%). Three quarters of the patients were unmarried, less than a quarter were employed, and a quarter were not registered with a general practitioner. The typical patient in inner London is psychotic, socially dislocated, itinerant, and lacking support. Given such characteristics I am not optimistic that domiciliary treatment represents a viable alternative to inpatient care. The severity of the illness at the time of admission to hospital may be another important factor, and studies are currently underway to see how this varies among hospitals in North West Thames region. Certainly one recent study points to violence being a common occurrence among acutely ill inpatients in London hospitals.2 Thus it is important to emphasise the differences in the nature ofpsychiatric practice among different areas and caution against generalising from the results of Drs Dean and Gadds. Perhaps what the most deprived areas need is a domiciliary treatment
service in addition to a full complement of inpatient beds. But that, of course, would require extra funding. C J HAWLEY
Charing Cross Hospital, Fulham W6 8RF
1 Dean C, Gadd EM. Home treatment for acute psychiatric illness. BMJ 1990;301:1021-3. (3 November.) 2 James DV, Fineberg NA, Shah AK, Priest RG. An increa1se in violence on an acute psychiatric ward. A studv of associated factors. Brj Psychiat-v 1990;156:846-52.
Crisis in our schools SIR,-Drs Rachel K Jewkes and Brendan H O'Connor highlight the poor state of toilets in British schools.' Many medical officers for environmental health and consultants for communicable disease control will be heartened to learn that after recommendations were made substantial work was undertaken in the toilets of at least one school. Many school buildings are suffering from acute on chronic "deferred maintenance syndrome." School governors are forced to spend time, money, and effort on emergency repairs to the fabric that should be devoted to supporting the educational work of the school. Reductions in cleaning and caretaking time have followed efficiency savings and the process of contracting out the work. The progressive steps taken to support disabled children in normal schools do not always include modification of toilets and other basic hygiene facilities. A recent hepatitis A outbreak in a primary school in this city was associated with a child who had faecal incontinence; no shower or other provision had been made to help this child and her teachers to overcome the basic hygiene problems or to maintain her dignity. Children unwilling to use the toilets often spend the last part of the school day hoping that their bladders will not burst. This does not help them concentrate on their lessons. Poor sanitation causes serious problems other than the control of infection. If children are denied the means to implement the most basic, noncontroversial, health behaviours of hand washing after using the toilet and before meals how can we expect them to develop more complex health behaviours? Efforts to protect the current generation of schoolchildren from alcohol and substance misuse, smoking, dental decay, and AIDS are being frustrated for the lack of basic amenities. MARTIN SCHWEIGER Leeds LS8 2RG 1 Jewkes RK, O'Connor BH. Crisis in our schools: survey of sanitation facilities in schools in Bloomsbury health district.
BMJ 1990;301:1085-7. (10 November.)
Detecting bladder cancer SIR,-Mr Roger Plail's conclusion that all patients with microhaematuria should be investigated calls for comment.' The importance of the age of the patient, the common occurrence of benign renal microhaematuria, and the availability of simple tests to identify or exclude it should have been stressed. An analysis of the medical records of 1000 asymptomatic men in the air force in Israel showed not only that microhaematuria was very common (38 7%) but also that the incidence of urological neoplasms in this group of men aged 40 or less, was as expected for the general population (0 -1 %).2 A population based study in Rochester, Minneapolis also showed that asymptomatic haematuria was a common finding in 781 adults (13%) and was often not associated with any urologic disease. Age was a significant factor, especially in men. Thus, 63% of
BMJ
VOLUME
301
1
DECEMBER
1990
