If same day reporting of results of HIV antibody testing to patients is contemplated the counselling offered must take account of the probability that reactive (and not just equivocal) results will occasionally be obtained in truly seronegative subjects. DAVID J MORRIS GERALD CORBITT ELAINE CROSDALE North MN1anchester Regional Virus laboratory, Booth Hall (Children's Hospital, Manchester M19 2AA I Sqttire SB, hIford J, Bar R, Tilsed G, Salt H, Bagdades EK, et al. Open access clinic providing HIV-1 antibody results on day of tcsting: the first 12 months. BAIJ 1991;302:1383-6. (8 June.) 2 Miorris D)J, Corbitt G, Crosdale E. Effect of switching from first to second genieration immunosorbent assays on screening for human immunodeficiencv virus antibody. Serodiagn Immunother 1990;4:217-20.
Routine testing for HIV at infertility clinics SIR,-In Mr J R Smith and colleagues' article on managing infertility in HIV positive couples Professor Ian Craft of the London Fertility Centre expresses his views. Our members have made us aware that some infertility clinics, including the London Fertility Centre, routinely test patients for HIV. We are unhappy about this. From our knowledge, patients presenting for management of infertility have a low risk of developing AIDS, and in our view they should be tested only if their history indicates a higher risk-for example, if they have a history of drug misuse. We are particularly worried that treatment may be withheld from patients who refuse to be tested for HIV. This is putting pressure on people to be tested, and we are concerned about the quality of counselling on offer before the test is done. The fact that they have been tested may result in couples experiencing difficulty in obtaining life insurance or having to pay higher premiums. From information received we know that there are infertility clinics that share our views and do not see a need to test for HIV routinely. This is clearly an issue on which the medical profession is divided. In the interests of our members and of infertile patients in general we would like to see agreement within the medical profession that routine testing of such patients is unnecessary. SUSAN RICE
Chairman, National Association for the Childless, Birmingham B19 3RL
1 Smith JR, Forster GE, Kitchen VS, Hooi YS, Mundav I'E, Paintin D)B, et al. Infertilit-v management in HIV positive cotuples: a dilemma. BMJ 1991;302:1447-50. (15 June.)
Thalassaemia in pregnancy SIR,-Professor Geoffrey Chamberlain's advice regarding iron treatment in pregnant women with thalassaemia requires clarification.' [i Thalassaemia is primarily a disorder of the production of red cells by bone marrow resulting from inadequate synthesis of ,1 globin chains caused by a genetic disorder. In the homozygous form (thalassaemia major) it manifests itself as a severe, transfusion dependent anaemia, and before the advent ofeffective chelation treatment sufferers were certainly infertile and died in their 20s as a consequence of iron overload. Patients with the heterozygous form of the disease (thalassaemia minor) are usually symptom free and have a mild microcytic anaemia. As they may be unaware of this women from at risk populations attending antenatal clinics should be
120
screened.2 If the mean corpuscular haemoglobin concentration is less than 27 pg measurement of haemoglobin A2 will identify a thalassaemia trait. Iron concentrations, however., are no different from those in the normal population,3 and many women with i thalassaemia trait from the Asian subcontinent who eat a traditional diet present in pregnancy with iron deficiency. The haemoglobin concentration falls to a greater extent during pregnancy in women with , thalassaemia trait than in normal women,3 and this will be exacerbated by iron deficiency. It is therefore important to realise that D thalassaemia trait does not preclude iron deficiency. D BAREFORD
Department of Haematology, Dudley Road Hospital, Birmingham B 18 7QH 1 Chamberlain G. M\edical problems in pregnancy. II. BMJ 1991;302:1327-30. (I June.) 2 World Health Organisation. The haemoglohinopathies in Europe. A combined report on two WHO meetings: Brussels 14 March 1986 and Paris20-21 March 1987. WHO: Regional Office in Europe, 1988. 3 Weatherall DJ, Clegg JB, eds. The thalassaemia syndromes. Oxford: Blackwell Scientific, 1981:227-8.
Domiciliary thrombolytic treatment SIR,-Michael O'Donnell is to be congratulated on his informative and entertaining article on thrombolytic treatment.' Dr M C Petch subsequently described various ways, through health education and organisational changes, of reducing mortality from myocardial infarction.2 Dr Petch, however, looks forward to the results of the proposed trial of domiciliary thrombolytic treatment to be conducted by the Royal College of General Practitioners': "We will then be in a better position to make an informed decision." But will we? Having seen the outline of the protocol of this trial (sent to all members of the college),4 we are concerned that it will answer none of the many questions it asks. It will not be a randomised controlled trial, patients being allocated on the basis of the willingness of general practitioners to administer thrombolytic drugs. Given that a study by the Gruppo Italiano per lo Studio della Streptochinasi nell'Infarcto Miocardico (GISSI- 1) suggests only modest additional benefit from very early administration of such drugs' and the second international study of infarct survival (ISIS-2) and the anistreplase intervention mortality study (AIMS) show none,67 it is doubtful that the trial will have the power to detect a possible marginal benefit once selection bias has been addressed. Mr Richard Peto's analysis of ISIS-2 and GISSI-3 has shown an increased risk of cerebral haemorrhage with clot specific agents as opposed to streptokinase.' Does the suggested small benefit to the myocardium outweigh this? A regional seminar in Trent recommended using streptokinase on clinical as well as economic grounds.' Professor Peter Sleight's report serves only to confirm those recommendations. ' Kay's highly selected review of the evidence to support the Royal College of General Practitioners' trial failed properly to address the issue of marginal benefits. ' With delays reduced, potential benefits from home treatment would be even smaller.2 Even if patients were given thrombolytic agents at home they would still be admitted to hospital, so the additional cost of anistreplase (necessary for home administration) would not be offset by any savings. The economic equation becomes one of small marginal benefit and large marginal cost. The Royal College of General Practitioners should direct its enthusiasm at health education and organisation rather than pursuing yet another "high tech" solution. "Vorsprung durch Technik" continues to be a potent maxim in our age of
consumerism, but we should pay more heed to Dr O'Donnell's closing remarks.' J RADFORD R G RICHARDS
Department of Public Health Medicine, Central Nottinghamshire Health Authority, Mansfield NG2 1 OER
1 O'Donnell M. Battle of the clotbusters. BMJ 1991;302:1259-61. (25 May.) 2 Petch MC. Coronary thrombolytic treatment at home. BMJ 1991;302:1287-8. (1 June.) 3 Kay C. Management of myocardial infarction in the community: a new RCGP study. BrJ Gen Pract 1991;41:89-90. 4 Royal College of General Practitioners. Myocardial infarcton study. Manchester: Manchester Research Unit of RCGP, 1991. S Gruppo Italiano per lo Studio della Streptochinasi nell'Infarcto Miocardico (GISSI). Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet 1986;i: 397-402. 6 Second Intemational Study of Infarct Survival (ISIS-2) Collaborative Group. Randomised trial of intravenous steptokinase, oral aspirin, both, or neither among 17 187 cases of suspected acute myocardial infarction: ISIS-2. Lancet 1988;ii: 349-60. 7 Anistreplase Intervention Mortality Study (AIMS) Trial Study Group. Effect of intravenous APSAC on mortality after acute myocardial infarction: preliminary report of a placebo controlled trial. Lancet 1988;i:545-9. 8 Pemberton J, ed. Medicine and management. Proceedings of the eighth Trent regional seminar. Sheffield: Trent Regional Health Authority, 1989:16-41.
SIR,-What should we do? Dr M C Petch tells us that neither anistreplase nor alteplase is "clearly superior" to streptokinase. ' Dr Michael O'Donnell tells us that anistreplase and alteplase will cause an excess of four in 1000 strokes in our patients.2 As a general practitioner in a rural area, I was keen to enter the Royal College of General Practitioners' trial of anistreplase, but the thought of causing a stroke in someone with atypical gastritis somewhat lessened my enthusiasm. Further, it seems unlikely that I would be able, when dealing with an acutely ill patient, to obtain the patient's informed consent to accept this increased risk. If I was the patient I think that I would wait the extra hour to get to hospital and be given streptokinase there (incidentally saving a considerable amount of money). Should my general practitioner try to persuade me otherwise if, God forbid, I was in this situation? M S STEAD Health Centre, Bodmin, Cornwall PL31 2LB I Petch MC. Coronary thrombolytic treatment at home. BMJ
1991;302:1287-8. (I June.) 2 O'Donnell 1. Battle of the clotbusters. BMJ
(25 Mlay.)
1991;302:1259-61.
Recording diastolic blood pressure in pregnancy SIR,-Accurate measurement of blood pressure in pregnant women is critical to proper antenatal care. Clinicians remain divided over several aspects of measuring blood pressure in pregnancy, particularly whether the phase IV or phase V Korotkoff sound should be used for diastolic pressure.' 2 This was debated vigorously last year when the American National High Blood Pressure Education Program Working Group presented its report on high blood pressure in pregnancy at the eighth world congress of hypertension in pregnancy in Italy.3 We recently completed a study examining the accuracy of an auitomated blood pressure recorder in pregnant and non-pregnant women.4 As part of this study (not previously reported) a single trained observer recorded both phase IV and phase V Korotkoff sounds in 50 pregnant women whose arm circumference was normal (less than 33 cm). Phase IV diastolic blood pressure was significantly higher than phase V (mean (SD) 76 (11) v 71
BMJ VOLUME 303
13 JULY 1991
Routine testing for HIV at infertility clinics SIR,-In Mr J R Smith and colleagues' article on managing infertility in HIV positive couples Professor Ian Craft of the London Fertility Centre expresses his views. Our members have made us aware that some infertility clinics, including the London Fertility Centre, routinely test patients for HIV. We are unhappy about this. From our knowledge, patients presenting for management of infertility have a low risk of developing AIDS, and in our view they should be tested only if their history indicates a higher risk-for example, if they have a history of drug misuse. We are particularly worried that treatment may be withheld from patients who refuse to be tested for HIV. This is putting pressure on people to be tested, and we are concerned about the quality of counselling on offer before the test is done. The fact that they have been tested may result in couples experiencing difficulty in obtaining life insurance or having to pay higher premiums. From information received we know that there are infertility clinics that share our views and do not see a need to test for HIV routinely. This is clearly an issue on which the medical profession is divided. In the interests of our members and of infertile patients in general we would like to see agreement within the medical profession that routine testing of such patients is unnecessary. SUSAN RICE
Chairman, National Association for the Childless, Birmingham B19 3RL
1 Smith JR, Forster GE, Kitchen VS, Hooi YS, Mundav I'E, Paintin D)B, et al. Infertilit-v management in HIV positive cotuples: a dilemma. BMJ 1991;302:1447-50. (15 June.)
Thalassaemia in pregnancy SIR,-Professor Geoffrey Chamberlain's advice regarding iron treatment in pregnant women with thalassaemia requires clarification.' [i Thalassaemia is primarily a disorder of the production of red cells by bone marrow resulting from inadequate synthesis of ,1 globin chains caused by a genetic disorder. In the homozygous form (thalassaemia major) it manifests itself as a severe, transfusion dependent anaemia, and before the advent ofeffective chelation treatment sufferers were certainly infertile and died in their 20s as a consequence of iron overload. Patients with the heterozygous form of the disease (thalassaemia minor) are usually symptom free and have a mild microcytic anaemia. As they may be unaware of this women from at risk populations attending antenatal clinics should be
120
screened.2 If the mean corpuscular haemoglobin concentration is less than 27 pg measurement of haemoglobin A2 will identify a thalassaemia trait. Iron concentrations, however., are no different from those in the normal population,3 and many women with i thalassaemia trait from the Asian subcontinent who eat a traditional diet present in pregnancy with iron deficiency. The haemoglobin concentration falls to a greater extent during pregnancy in women with , thalassaemia trait than in normal women,3 and this will be exacerbated by iron deficiency. It is therefore important to realise that D thalassaemia trait does not preclude iron deficiency. D BAREFORD
Department of Haematology, Dudley Road Hospital, Birmingham B 18 7QH 1 Chamberlain G. M\edical problems in pregnancy. II. BMJ 1991;302:1327-30. (I June.) 2 World Health Organisation. The haemoglohinopathies in Europe. A combined report on two WHO meetings: Brussels 14 March 1986 and Paris20-21 March 1987. WHO: Regional Office in Europe, 1988. 3 Weatherall DJ, Clegg JB, eds. The thalassaemia syndromes. Oxford: Blackwell Scientific, 1981:227-8.
Domiciliary thrombolytic treatment SIR,-Michael O'Donnell is to be congratulated on his informative and entertaining article on thrombolytic treatment.' Dr M C Petch subsequently described various ways, through health education and organisational changes, of reducing mortality from myocardial infarction.2 Dr Petch, however, looks forward to the results of the proposed trial of domiciliary thrombolytic treatment to be conducted by the Royal College of General Practitioners': "We will then be in a better position to make an informed decision." But will we? Having seen the outline of the protocol of this trial (sent to all members of the college),4 we are concerned that it will answer none of the many questions it asks. It will not be a randomised controlled trial, patients being allocated on the basis of the willingness of general practitioners to administer thrombolytic drugs. Given that a study by the Gruppo Italiano per lo Studio della Streptochinasi nell'Infarcto Miocardico (GISSI- 1) suggests only modest additional benefit from very early administration of such drugs' and the second international study of infarct survival (ISIS-2) and the anistreplase intervention mortality study (AIMS) show none,67 it is doubtful that the trial will have the power to detect a possible marginal benefit once selection bias has been addressed. Mr Richard Peto's analysis of ISIS-2 and GISSI-3 has shown an increased risk of cerebral haemorrhage with clot specific agents as opposed to streptokinase.' Does the suggested small benefit to the myocardium outweigh this? A regional seminar in Trent recommended using streptokinase on clinical as well as economic grounds.' Professor Peter Sleight's report serves only to confirm those recommendations. ' Kay's highly selected review of the evidence to support the Royal College of General Practitioners' trial failed properly to address the issue of marginal benefits. ' With delays reduced, potential benefits from home treatment would be even smaller.2 Even if patients were given thrombolytic agents at home they would still be admitted to hospital, so the additional cost of anistreplase (necessary for home administration) would not be offset by any savings. The economic equation becomes one of small marginal benefit and large marginal cost. The Royal College of General Practitioners should direct its enthusiasm at health education and organisation rather than pursuing yet another "high tech" solution. "Vorsprung durch Technik" continues to be a potent maxim in our age of
consumerism, but we should pay more heed to Dr O'Donnell's closing remarks.' J RADFORD R G RICHARDS
Department of Public Health Medicine, Central Nottinghamshire Health Authority, Mansfield NG2 1 OER
1 O'Donnell M. Battle of the clotbusters. BMJ 1991;302:1259-61. (25 May.) 2 Petch MC. Coronary thrombolytic treatment at home. BMJ 1991;302:1287-8. (1 June.) 3 Kay C. Management of myocardial infarction in the community: a new RCGP study. BrJ Gen Pract 1991;41:89-90. 4 Royal College of General Practitioners. Myocardial infarcton study. Manchester: Manchester Research Unit of RCGP, 1991. S Gruppo Italiano per lo Studio della Streptochinasi nell'Infarcto Miocardico (GISSI). Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet 1986;i: 397-402. 6 Second Intemational Study of Infarct Survival (ISIS-2) Collaborative Group. Randomised trial of intravenous steptokinase, oral aspirin, both, or neither among 17 187 cases of suspected acute myocardial infarction: ISIS-2. Lancet 1988;ii: 349-60. 7 Anistreplase Intervention Mortality Study (AIMS) Trial Study Group. Effect of intravenous APSAC on mortality after acute myocardial infarction: preliminary report of a placebo controlled trial. Lancet 1988;i:545-9. 8 Pemberton J, ed. Medicine and management. Proceedings of the eighth Trent regional seminar. Sheffield: Trent Regional Health Authority, 1989:16-41.
SIR,-What should we do? Dr M C Petch tells us that neither anistreplase nor alteplase is "clearly superior" to streptokinase. ' Dr Michael O'Donnell tells us that anistreplase and alteplase will cause an excess of four in 1000 strokes in our patients.2 As a general practitioner in a rural area, I was keen to enter the Royal College of General Practitioners' trial of anistreplase, but the thought of causing a stroke in someone with atypical gastritis somewhat lessened my enthusiasm. Further, it seems unlikely that I would be able, when dealing with an acutely ill patient, to obtain the patient's informed consent to accept this increased risk. If I was the patient I think that I would wait the extra hour to get to hospital and be given streptokinase there (incidentally saving a considerable amount of money). Should my general practitioner try to persuade me otherwise if, God forbid, I was in this situation? M S STEAD Health Centre, Bodmin, Cornwall PL31 2LB I Petch MC. Coronary thrombolytic treatment at home. BMJ
1991;302:1287-8. (I June.) 2 O'Donnell 1. Battle of the clotbusters. BMJ
(25 Mlay.)
1991;302:1259-61.
Recording diastolic blood pressure in pregnancy SIR,-Accurate measurement of blood pressure in pregnant women is critical to proper antenatal care. Clinicians remain divided over several aspects of measuring blood pressure in pregnancy, particularly whether the phase IV or phase V Korotkoff sound should be used for diastolic pressure.' 2 This was debated vigorously last year when the American National High Blood Pressure Education Program Working Group presented its report on high blood pressure in pregnancy at the eighth world congress of hypertension in pregnancy in Italy.3 We recently completed a study examining the accuracy of an auitomated blood pressure recorder in pregnant and non-pregnant women.4 As part of this study (not previously reported) a single trained observer recorded both phase IV and phase V Korotkoff sounds in 50 pregnant women whose arm circumference was normal (less than 33 cm). Phase IV diastolic blood pressure was significantly higher than phase V (mean (SD) 76 (11) v 71
BMJ VOLUME 303
13 JULY 1991
