mortality within the heterosexual population, but there is a serious danger in interpreting every morbid phenomenon in our lives today in the context of HIV. That we have reached the stage where it is fashionable to blame most deaths in the population on HIV or AIDS may distort the perception of what the real problem is. JAMES EDEH Division of Addictive Behaviour, St George's Hospital Medical School, London SW17 ORE 1 Aldous J, Hickman M, Ellam A, Gazzard B, Hargreaves S. Impact of HIV infection on mortality in young men in a London health authority. BMJ 1992;305:219-21. (25 July.) 2 McCormick A. Excess morbidity associated with the HIV epidemic in England and Wales. BMJ7 1991;302:1375-6. 3 Mienties GH, Van Amei;den EJ, Van den Hoek AJAR, Continho RA. Increasing morbidity without rise in non-AIDS mortality among HIV infected intravenous drug users in Amsterdam. AIDS 1992;6:207-12. 4 Selwyn PA, Hartel D, Wasserman W, Drucker E. Impact of AIDS epidemic on morbidity and mortality among intravenous drug users in a New York city methadone maintenance programme; AmJ7 Public Health 1989;79:1358-62.
EDITOR,-John Aldous and colleagues report the mortality in men with HIV infection in Riverside Health Authority; eight of the 213 men who died committed suicide.' Suicidal behaviour in people with HIV infection has been the subject of considerable interest, and Marzuk et al argued that suicide is considerably increased in this group,2 although there are complex methodological problems in establishing its prevalence accurately. ' We have identified six completed suicides in people with HIV infection over two years in Riverside Health Authority. Four of the patients had a history of psychiatric illness: in two this preceded the diagnosis of HIV infection and included a history of deliberate self harm. The two patients without a history of psychiatric illness were in an advanced stage of disease, and one had planned his death for over a year. The mode of suicide was predominantly by jumping-usually a rare form of suicide-but suicides by overdose may be underreported in patients with AIDS. We also looked at deliberate self harm and found 23 cases in people positive for HIV over two years; HIV infection played a part in most cases.4 In recent years a significant increase in suicides in young men has been noted, and HIV infection may well be a contributing factor.5 Staff who care for patients with HIV infection should be aware of the risk of suicidal behaviour and should refer to psychiatric services patients with suicidal ideas, particularly those with a history of psychiatric illness or deliberate self harm, especially as the disease becomes more advanced. KATHRYN PUGH JOSE CATALAN Academic and Clinical Department of Psychological Medicine, Charing Cross and Westminster Medical School, London SWIP 2NS 1 Aldous J, Hickman M, Ellam A, Gazzard B, Hargreaves S. Impact of HIV infection in young men in a London health
authority. BMJ 1992;305:219-21. (25 July.) 2 Marzuk P, Tierney H, Tardiff K, Gross EM, Morgan EB, Hsu M-A, et al. Increased risk of suicide in patients with AIDS.
JAMA 1988;259:1333-7. 3 Marzuk P. Suicidal behaviour and HIV illnesses. International Review ofPsychiatry 1991;3:367. 4 Catalan J. Deliberate self-harm in HIV disease. Research into clinical and ethical aspects. In: Beskow JE, Bellini M, Sampaio Faria JG, Kerkhof AD, eds. Report on the WHO consultation, Bologna, September 1990, HIV and AIDS related suicidal behaviour. Bologna: Monduzzi Editore, 1991:61-8. S Hawton K. Suicide in young men. BMJ 1992;304:100O.
Treatment of natal cleft sinus EDITOR,-Patients who have had recurrent treatment for persistent pilonidal sinus' 2 are sometimes referred, in the last resort, to plastic surgeons. This is done in the hope that the plastic surgeon can either create skin flaps to obliterate the natal cleft 648
or perform expert skin grafting which will remove the hair follicles in and around the natal cleft. In a few patients who have tightly opposed, muscular buttocks friction between the buttocks may play an important part in the persistence of pilonidal disease. I carried out a combination of liposuction and limited skin grafting in such a patient. Liposuction of the medial aspect of the buttocks reduced the sharp angle of the cleft -and eliminated the tendency of one buttock to rub against the other. Excision of the scarred area in the base of the cleft and use of a quilted meshed skin graft completed the procedure. This was followed by primary healing, and the patient has been free of any pilonidal problems for the past six months. He had suffered recurrent disease every month or so for the previous four years despite innumerable operations. I hesitate to make any claims for this procedure based merely on one case, but I thought it worth reporting because other surgeons might be interested in trying it. I am unlikely to be able to build up a series because these difficult recurrent cases are relatively rare. H P HENDERSON
Department of Plastic Surgery, Leicester Royal Infirmary, Leicester LEI 5WW 1 Correspondence. Treatment of natal cleft sinus. BMJ 1992;305: 311-2. (1 August.) 2 Khawaja HT, Bryan S, Weaver PC. Treatment of natal cleft sinus: a prospective clinical and economic evaluation. BMJ 1992;304:1282-3. (16 May.)
Over the counter candidiasis
trlatment for
EDITOR,-Susan Mitchell and Caroline Bradbeer provide an interesting interpretation of the presentation patterns for vaginal candidiasis that may follow the change in legal status for intravaginal imidazoles.' The recommendation of the Committee on Safety of Medicines to exempt such antifungals from prescription only control recognises the efficacy of the products and the role of community pharmacy in primary health care and resolves the distinction between infection in men for whom over the counter preparations have been available for some time, and that in women. Because of the complexity of the differential diagnosis in women presenting with "thrush," over the counter imidazoles are available only to clients experiencing a suspected recurrence of candidiasis. The pharmaceutical press has made strenuous efforts to ensure that pharmacists are aware of the circumstances for medical referral, describing 11 scenarios in which over the counter treatment would be inappropriate.2 Accurate diagnosis of vaginal candidiasis will therefore necessitate assimilation of potentially embarrassing information from a client who may expect to receive her over the counter preparation automatically on request. This requires a private area for counselling and competency in communication skills on the part of the pharmacist. The importance of communication skills forms an integral part of undergraduate education for pharmacists.3 The most problematic issue, however, is obtaining a history of sexually transmitted disease or exposure to a partner with sexually transmitted disease. A client may presume that she has a recurrence of candidiasis when the aetiological agent is in fact a sexually transmitted pathogen, such as herpes simplex virus or Trichomonas vaginalis. The danger is that a woman may not disclose, or even be aware of, exposure to a sexually transmitted disease. Exempting vaginal imidazoles from prescription only control may be of considerable benefit to women who can recognise their recurrent symptoms and can afford to pay for their treatment over the counter. The caveat is clearly that wider
availability may lead to more cases of treatment failure and undiagnosed sexually transmitted diseases. Ultimately, medical practitioners will detect whether a change in the pattern of presentation of vaginal candidiasis has indeed occurred. GRETA FORSTER DAVID G WEBB
Royal London Trust, Royal London Hospital, London El 1BB I Mitchell S, Bradbeer C. Over the counter treatment for candidiasis. BMJ 1992;304:1648. (27 June.) 2 Li Wan Po A. Treatment of vaginal candidiasis. Pharmaceutical 3rournal 1992;249: i-is. 3 Committee of Inquiry. Pharmacy: a report to the Nuffield Foundatnm. London: Nuffield Foundation, 1986:85-104.
Screening for depression in elderly patients EDITOR,-In describing use of a new screening instrument for depression in elderly patients' Fiona Adshead and colleagues address a problem with self rating scales2": many elderly patients are unable to use them and require help. This difficulty is illustrated by the use of a mixed mode of presentation of the geriatric depression scale in the study (self administered or staff assisted). This is clinically relevant as a staff assisted scale is associated with a lower score than the self administered form.2 Two points are worthy of comment. The brief assessment schedule depression cards (BASDEC) are printed in a large typeface. If all patients could read the BASDEC but some could not read the geriatric depression scale this suggests that the typefaces were of different sizes: could this partly explain the patients' modest preference for the BASDEC? Although the BASDEC took less time to administer in Adshead and colleagues' study, a shortened form of the geriatric depression scale is under evaluation4 and may reduce the difference in time required to perform the measures. The geriatric depression scale has an advantage over the BASDEC in that it has been shown to be useful in people with mild to moderate cognitive impairment.' If the BASDEC can be shown to share this quality its utility to clinicians will be further enhanced. DESMOND O'NEILL
Elderly Services, Selly Oak Hospital, Birmingham B29 6JD I Adshead F, Day Cody D, Pitt B. BASDEC: a novel screening instrument for depression in elderly medical inpatients. BMJ 1992;305:397. (15 August.) 2 O'Neill D, Rice I, Blake P, Walsh JB, Coakley D. The geriatric depression scale: rater-administered or self-administered? International Journal of Geriatric Psychiatry 1992;7:511-5. 3 Toner J, Gurland B, Teresi J. Comparison of self-administered and rater-administered methods of assessing levels of severity of depression in elderly patients. J Gerontol 1988;43:136-40. 4 Yesavage JA. Geriatric depression scale. Psychopharmacol Bull 1988;24:709-1 1. 5 O'Riordan T, Hayes J, O'Neill D, Shelley R, Walsh JB, Coakley D. The effect of mild to moderate dementia on the geriatric depression scale and on the general health questionnaire in the hospitalized elderly. Age Ageing 1990;19:57-61.
Human milk banks EDITOR,-In an editorial on human milk banks D P Davies states, "At 9 months the mean developmental quotient was shown to be significantly lower in infants fed donor breast milk than in those fed a preterm formula,"' citing the work of Lucas et al.I Although this is widely believed, it is a view not entirely borne out by the data. According to Lucas et al's paper, at 9 months of age the mean (SD) developmental quotient of the babies fed banked human milk was 97-2 (8 5) and that of the babies fed preterm formula 98-2 (11.0).2 Thus the difference between the groups was not BMJ
VOLUME 305
12 SEPTEMBER 1992
significant. It is true that significant differences in the developmental quotient were found when various subgroups of infants were studied, such as those receiving more or less than half of their intake as maternal milk; but there remains the paradox that the mean developmental quotient of those infants who received banked human milk with a lesser contribution of maternal milk was lower than that of those fed banked human milk alone. Perhaps, therefore, the message about banked human milk and neurodevelopmental attainment is more complex than many acknowledge. I agree that the value of banked human milk in neonatal care warrants re-examination; the pendulum has swung too far in favour of low birthweight formulas. Comparative studies examining the relative incidence of infection34 and necrotising enterocolitis' in babies fed human milk or artificial formula suggest that differences in mortality may be apparent between the two feeding regimens. Unfortunately, the haphazard organisation of milk banks in the United Kingdom continues to prove an obstacle both to the national study of this issue and to the sophistication of processing techniques capable of controlling or changing the nutritional composition of human milk.6 A F WILLIAMS
1982;71:441-5. 4 Naryanan I, Prakash K. Murthy NS, Guiral WV. Randomised controlled trial of effect of raw and Holder pasteurised human milk and of formula supplements on incidence of neonatal infection. Lancet 1984;ii: 1111-2. 5 Lucas A, Cole TJ. Breast milk and neonatal necrotising enterocolitis. Lancet 1990;336:1519-23. 6 Williams AF. How should we use banked human milk? In: Xanthou M, ed. New aspects of nutrition in pregnancy, infancy and premnaturity. Amsterdam: Elsevier, 1987:117-27.
Self help organisation's advice on myalgic encephalomyelitis EDITOR,-I should like to assure Simon Wessely' that neither the ME Association nor ME Action regards Michael Sharpe and colleagues' findings in patients with chronic fatigue' as another attack on its credibility. Nor do we see why the paper should "further sour relations between the organisations and the profession." As Wessely points out, the apparent relation between functional impairment and membership of a self help organisation at follow up does not mean that membership of such an organisation is responsible for the impairment. Aside from the fact that the study did not focus on myalgic encephalomyelitis, or on the work the ME Association does, Sharpe reassured us that there was no evidence of a causal relation between membership of a patient group and level of disability. As regards the potential damage resulting from inaccurate information about myalgic encephalomyelitis, it is worth emphasising that the quote that illustrates this came from Nursing Standard and not from a magazine for patients. The British organisations have long been unhappy with the way the media have portrayed the illness and reviewed existing research, and it is often extremely difficult to get erroneous or biased information corrected. Sometimes we get a right of reply, but usually we don't. Finally, I wish to make clear that our current advice on exercise and stress is based on sound
305
1 Wessely S. Outcome of chronic fatigue syndrome. BMJ 1992; 305:365. (8 August.) 2 Sharpe M, Hawton K, Seagroatt V, Pasvol G. Follow up of patients presenting with fatigue to an infectious diseases clinic. 3 Cope H, David AS. Outcome in the chronic fatigue syndrome. BMJ 1992;305:365. (8 August.)
1 Davies DP. Future of human milk banks. BMJ 1992;305:433-4. (22 August.) 2 Lucas A, Morley R, Cole TJ, Gore SM, Davis JA, Bamford MFM, et al. Early diet in pre-term babies and developmental status in infancy. Arch Dis Child 1989;64:1570-8. 3 Naryanan I, Prakash K, Prabhakar AK, Guiral VV. A planned prospective evaluation of the anti-infective property of varying quantities of expressed human milk. Acia Paediatr Scand
VOLUME
M C HUME
ME Association, Stanford le Hope, Essex SS17 OHA
BMJ 1992;305:147-52. (18 July.)
Department of Child Health, St George's Hospital Medical School, London SW17 ORE
BMJ
scientific research, the recommendations of our medical advisers, and 50 years' experience. Since our aim is to help patients it would be ridiculous for us to ignore good research and to stick instead to outdated explanations, speculation, or even prejudice. No one gains from such a narrow minded approach, least of all us. The main reason why our beliefs tend to differ from those of Wessely and H Cope and A S David3 is that the authors do not distinguish between myalgic encephalomyelitis and chronic fatigue and we do. We see myalgic encephalomyelitis as more than "mental and physical fatigue," and we have evidence that treatments that seem to help patients with chronic fatigue do not always benefit people with myalgic encephalomyelitis (C Hickie, conference "Unravelling the mystery," North Carolina, 17-18 November 1990). Our cautious attitude may worry those who disagree with us, but a less critical approach may lead to mistakes and we are anxious to avoid this.
12
SEPTEMBER
1992
Using cytokines EDITOR,-Salem Malik and Jonathan Waxman point out that the recent increase in understanding of cytokine biology offers great promise for clinical medicine.' Their editorial focuses particularly on the use of cytokines as antitumour agents and on the role of these substances in the pathology of cancer. The relevance of cytokines extends to other aspects of clinical medicine in which the immune system has a role. Cytokines play an essential part in the functioning of this system, yet paradoxically they can damage tissue and be life threatening if produced in excessive amounts or under inappropriate circumstances. For example, tumour necrosis factor and interleukin 1 cause morbidity and death in conditions related to infection (for example, sepsis, adult respiratory distress syndrome, and cerebral malaria) and in chronic inflammatory diseases such as rheumatoid arthritis and ulcerative colitis.2'4 Advances in clinical medicine related to cytokine biology should therefore be targeted at enhancing their beneficial properties while suppressing their harmful effects. Thus, for example, in treating cancer the aim should be to retain the tumour killing properties of cytokines while suppressing their anorectic and tissue wasting actions. These aims can be achieved by using drugs, cytokine receptor antagonists, and nutrients. The widespread metabolic changes that result from the induction or application of cytokines depend on secondary messengers and intracellular signalling. These offer broad scope for nutritional modulation.' Fish oil reduces production of interleukin 1 and tumour necrosis factor in patients with rheumatoid disease and brings about an amelioration of symptoms. It is also beneficial in ulcerative colitis and psoriasis. Fish oil and saturated fats reduce the anorectic effects of interleukin 1 and tumour necrosis factor in experimental animals.'6 Thus consideration of the nature of fat in patients' diets offers scope for manipulating cytokine biology. Recent studies showing that free radicals enhance production of cytokines draw attention to the importance of the effectiveness of the antioxidant defences of patients in whom cytokines are operating.67 Key nutrients, such as vitamins E and C, play a major part in these defences. This highlights their importance in the diets of patients
who are undergoing cytokine treatment, or are producing cytokines in amounts that are incompatible with the restoration of normal tissue function and health. ROBERT GRIMBLE
Department of Nutrition, Medical School, Southampton University, Southampton S09 3TU 1 Malik S, Waxman J. Cytokines and cancer. BMJ 1992;305: 265-7. (1 August.) 2 Tracey KJ, Wei H, Manogue KR, Fong Y, Herse DG, Nguyen HT, et al. Cachectin/tumour necrosis factor induces cachexia, anemia and inflammation. J Exp Med 1988; 167: 1211-27. 3 Kwiatkowski D, Hill AVS, Sambon I. TNF concentration in fatal cerebral, non fatal cerebral, and uncomplicated Plasmodium falciparum malaria. Lancet 1990;336:1201-4. 4 Mahida YR, Wu K, Jewell DP. Enhanced production of interleukin 15 by mononuclear cells isolated from mucosa with active ulcerative colitis of Crohn's disease. Gut 1989;30:835-8. 5 Grimble RF. Nutrition and cytokine action. Nutrition Research Reviews 1990;3:193-210. 6 Grimble RF. Dietary manipulation of the inflammatory response. Proc NutrSoc 1992;51:285-94. 7 Chaudhri G, Clark IA. Reactive oxygen species facilitate the in vitro and in vivo lipopolysaccharide-induced release of tumour necrosis factor. I Immunol 1989;143:1290-4.
Perineal tears EDITOR,-Though M Stokes and D J Jones are correct to state that a perineal tear may lead to injury to the anal sphincter mechanism, they seem to imply that all tears lead to such injury.' They also suggest that a "prophylactic episiotomy should be performed if the perineum seems likely to tear." Only a small proportion of perineal tears result in damage to the sphincter. A prophylactic episiotomy gives no guarantee of protecting the sphincter. A properly sutured tear is generally associated with less short term and long term morbidity than a repaired episiotomy. "Episiotomy should be used only to relieve fetal or maternal distress, or to achieve adequate progress when it is the perineum that is responsible for the lack of progress."2 Advice concerning the use of episiotomy is more properly the province of midwives, other professionals concerned with intrapartum care, and the women themselves. MALCOLM GRIFFITHS Department of Obstetrics and Gynaecology, Royal Berkshire Hospital, Reading RG1 5AN I Stokes M, Jones DJ. Colorectal trauma. BMJ 1992;305:303-6. (1 August.) 2 Sleep J, Roberts J, Chalmers I. Care during the second stage of labour. In: Chalmers I, Enkin M, Keirse MJNC, eds. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989:1129-44.
Cardiac rehabilitation programmes EDITOR,-Hannah McGee and John H Horgan note the increasing relevance of smaller uptake rates of cardiac rehabilitation programmes in older women and asks what factors might be responsible for this.' A short inpatient cardiac rehabilitation programme began in this district in July 1989 and was extended to include a 12 session outpatient programme in July 1990. Both of these were discontinued in April 1992 owing to insufficient funding. During the 34 months 784 myocardial events were recorded (myocardial infarctions, coronary artery bypass graft surgery, angioplasties, and heart transplants), of which 554 occurred in males and 230 in females. A total of 62% of male patients and 63% of female patients participated in the inpatient cardiac rehabilitation programme. Later, entry to the outpatient programme was determined by a
649
EDITOR,-John Aldous and colleagues report the mortality in men with HIV infection in Riverside Health Authority; eight of the 213 men who died committed suicide.' Suicidal behaviour in people with HIV infection has been the subject of considerable interest, and Marzuk et al argued that suicide is considerably increased in this group,2 although there are complex methodological problems in establishing its prevalence accurately. ' We have identified six completed suicides in people with HIV infection over two years in Riverside Health Authority. Four of the patients had a history of psychiatric illness: in two this preceded the diagnosis of HIV infection and included a history of deliberate self harm. The two patients without a history of psychiatric illness were in an advanced stage of disease, and one had planned his death for over a year. The mode of suicide was predominantly by jumping-usually a rare form of suicide-but suicides by overdose may be underreported in patients with AIDS. We also looked at deliberate self harm and found 23 cases in people positive for HIV over two years; HIV infection played a part in most cases.4 In recent years a significant increase in suicides in young men has been noted, and HIV infection may well be a contributing factor.5 Staff who care for patients with HIV infection should be aware of the risk of suicidal behaviour and should refer to psychiatric services patients with suicidal ideas, particularly those with a history of psychiatric illness or deliberate self harm, especially as the disease becomes more advanced. KATHRYN PUGH JOSE CATALAN Academic and Clinical Department of Psychological Medicine, Charing Cross and Westminster Medical School, London SWIP 2NS 1 Aldous J, Hickman M, Ellam A, Gazzard B, Hargreaves S. Impact of HIV infection in young men in a London health
authority. BMJ 1992;305:219-21. (25 July.) 2 Marzuk P, Tierney H, Tardiff K, Gross EM, Morgan EB, Hsu M-A, et al. Increased risk of suicide in patients with AIDS.
JAMA 1988;259:1333-7. 3 Marzuk P. Suicidal behaviour and HIV illnesses. International Review ofPsychiatry 1991;3:367. 4 Catalan J. Deliberate self-harm in HIV disease. Research into clinical and ethical aspects. In: Beskow JE, Bellini M, Sampaio Faria JG, Kerkhof AD, eds. Report on the WHO consultation, Bologna, September 1990, HIV and AIDS related suicidal behaviour. Bologna: Monduzzi Editore, 1991:61-8. S Hawton K. Suicide in young men. BMJ 1992;304:100O.
Treatment of natal cleft sinus EDITOR,-Patients who have had recurrent treatment for persistent pilonidal sinus' 2 are sometimes referred, in the last resort, to plastic surgeons. This is done in the hope that the plastic surgeon can either create skin flaps to obliterate the natal cleft 648
or perform expert skin grafting which will remove the hair follicles in and around the natal cleft. In a few patients who have tightly opposed, muscular buttocks friction between the buttocks may play an important part in the persistence of pilonidal disease. I carried out a combination of liposuction and limited skin grafting in such a patient. Liposuction of the medial aspect of the buttocks reduced the sharp angle of the cleft -and eliminated the tendency of one buttock to rub against the other. Excision of the scarred area in the base of the cleft and use of a quilted meshed skin graft completed the procedure. This was followed by primary healing, and the patient has been free of any pilonidal problems for the past six months. He had suffered recurrent disease every month or so for the previous four years despite innumerable operations. I hesitate to make any claims for this procedure based merely on one case, but I thought it worth reporting because other surgeons might be interested in trying it. I am unlikely to be able to build up a series because these difficult recurrent cases are relatively rare. H P HENDERSON
Department of Plastic Surgery, Leicester Royal Infirmary, Leicester LEI 5WW 1 Correspondence. Treatment of natal cleft sinus. BMJ 1992;305: 311-2. (1 August.) 2 Khawaja HT, Bryan S, Weaver PC. Treatment of natal cleft sinus: a prospective clinical and economic evaluation. BMJ 1992;304:1282-3. (16 May.)
Over the counter candidiasis
trlatment for
EDITOR,-Susan Mitchell and Caroline Bradbeer provide an interesting interpretation of the presentation patterns for vaginal candidiasis that may follow the change in legal status for intravaginal imidazoles.' The recommendation of the Committee on Safety of Medicines to exempt such antifungals from prescription only control recognises the efficacy of the products and the role of community pharmacy in primary health care and resolves the distinction between infection in men for whom over the counter preparations have been available for some time, and that in women. Because of the complexity of the differential diagnosis in women presenting with "thrush," over the counter imidazoles are available only to clients experiencing a suspected recurrence of candidiasis. The pharmaceutical press has made strenuous efforts to ensure that pharmacists are aware of the circumstances for medical referral, describing 11 scenarios in which over the counter treatment would be inappropriate.2 Accurate diagnosis of vaginal candidiasis will therefore necessitate assimilation of potentially embarrassing information from a client who may expect to receive her over the counter preparation automatically on request. This requires a private area for counselling and competency in communication skills on the part of the pharmacist. The importance of communication skills forms an integral part of undergraduate education for pharmacists.3 The most problematic issue, however, is obtaining a history of sexually transmitted disease or exposure to a partner with sexually transmitted disease. A client may presume that she has a recurrence of candidiasis when the aetiological agent is in fact a sexually transmitted pathogen, such as herpes simplex virus or Trichomonas vaginalis. The danger is that a woman may not disclose, or even be aware of, exposure to a sexually transmitted disease. Exempting vaginal imidazoles from prescription only control may be of considerable benefit to women who can recognise their recurrent symptoms and can afford to pay for their treatment over the counter. The caveat is clearly that wider
availability may lead to more cases of treatment failure and undiagnosed sexually transmitted diseases. Ultimately, medical practitioners will detect whether a change in the pattern of presentation of vaginal candidiasis has indeed occurred. GRETA FORSTER DAVID G WEBB
Royal London Trust, Royal London Hospital, London El 1BB I Mitchell S, Bradbeer C. Over the counter treatment for candidiasis. BMJ 1992;304:1648. (27 June.) 2 Li Wan Po A. Treatment of vaginal candidiasis. Pharmaceutical 3rournal 1992;249: i-is. 3 Committee of Inquiry. Pharmacy: a report to the Nuffield Foundatnm. London: Nuffield Foundation, 1986:85-104.
Screening for depression in elderly patients EDITOR,-In describing use of a new screening instrument for depression in elderly patients' Fiona Adshead and colleagues address a problem with self rating scales2": many elderly patients are unable to use them and require help. This difficulty is illustrated by the use of a mixed mode of presentation of the geriatric depression scale in the study (self administered or staff assisted). This is clinically relevant as a staff assisted scale is associated with a lower score than the self administered form.2 Two points are worthy of comment. The brief assessment schedule depression cards (BASDEC) are printed in a large typeface. If all patients could read the BASDEC but some could not read the geriatric depression scale this suggests that the typefaces were of different sizes: could this partly explain the patients' modest preference for the BASDEC? Although the BASDEC took less time to administer in Adshead and colleagues' study, a shortened form of the geriatric depression scale is under evaluation4 and may reduce the difference in time required to perform the measures. The geriatric depression scale has an advantage over the BASDEC in that it has been shown to be useful in people with mild to moderate cognitive impairment.' If the BASDEC can be shown to share this quality its utility to clinicians will be further enhanced. DESMOND O'NEILL
Elderly Services, Selly Oak Hospital, Birmingham B29 6JD I Adshead F, Day Cody D, Pitt B. BASDEC: a novel screening instrument for depression in elderly medical inpatients. BMJ 1992;305:397. (15 August.) 2 O'Neill D, Rice I, Blake P, Walsh JB, Coakley D. The geriatric depression scale: rater-administered or self-administered? International Journal of Geriatric Psychiatry 1992;7:511-5. 3 Toner J, Gurland B, Teresi J. Comparison of self-administered and rater-administered methods of assessing levels of severity of depression in elderly patients. J Gerontol 1988;43:136-40. 4 Yesavage JA. Geriatric depression scale. Psychopharmacol Bull 1988;24:709-1 1. 5 O'Riordan T, Hayes J, O'Neill D, Shelley R, Walsh JB, Coakley D. The effect of mild to moderate dementia on the geriatric depression scale and on the general health questionnaire in the hospitalized elderly. Age Ageing 1990;19:57-61.
Human milk banks EDITOR,-In an editorial on human milk banks D P Davies states, "At 9 months the mean developmental quotient was shown to be significantly lower in infants fed donor breast milk than in those fed a preterm formula,"' citing the work of Lucas et al.I Although this is widely believed, it is a view not entirely borne out by the data. According to Lucas et al's paper, at 9 months of age the mean (SD) developmental quotient of the babies fed banked human milk was 97-2 (8 5) and that of the babies fed preterm formula 98-2 (11.0).2 Thus the difference between the groups was not BMJ
VOLUME 305
12 SEPTEMBER 1992
significant. It is true that significant differences in the developmental quotient were found when various subgroups of infants were studied, such as those receiving more or less than half of their intake as maternal milk; but there remains the paradox that the mean developmental quotient of those infants who received banked human milk with a lesser contribution of maternal milk was lower than that of those fed banked human milk alone. Perhaps, therefore, the message about banked human milk and neurodevelopmental attainment is more complex than many acknowledge. I agree that the value of banked human milk in neonatal care warrants re-examination; the pendulum has swung too far in favour of low birthweight formulas. Comparative studies examining the relative incidence of infection34 and necrotising enterocolitis' in babies fed human milk or artificial formula suggest that differences in mortality may be apparent between the two feeding regimens. Unfortunately, the haphazard organisation of milk banks in the United Kingdom continues to prove an obstacle both to the national study of this issue and to the sophistication of processing techniques capable of controlling or changing the nutritional composition of human milk.6 A F WILLIAMS
1982;71:441-5. 4 Naryanan I, Prakash K. Murthy NS, Guiral WV. Randomised controlled trial of effect of raw and Holder pasteurised human milk and of formula supplements on incidence of neonatal infection. Lancet 1984;ii: 1111-2. 5 Lucas A, Cole TJ. Breast milk and neonatal necrotising enterocolitis. Lancet 1990;336:1519-23. 6 Williams AF. How should we use banked human milk? In: Xanthou M, ed. New aspects of nutrition in pregnancy, infancy and premnaturity. Amsterdam: Elsevier, 1987:117-27.
Self help organisation's advice on myalgic encephalomyelitis EDITOR,-I should like to assure Simon Wessely' that neither the ME Association nor ME Action regards Michael Sharpe and colleagues' findings in patients with chronic fatigue' as another attack on its credibility. Nor do we see why the paper should "further sour relations between the organisations and the profession." As Wessely points out, the apparent relation between functional impairment and membership of a self help organisation at follow up does not mean that membership of such an organisation is responsible for the impairment. Aside from the fact that the study did not focus on myalgic encephalomyelitis, or on the work the ME Association does, Sharpe reassured us that there was no evidence of a causal relation between membership of a patient group and level of disability. As regards the potential damage resulting from inaccurate information about myalgic encephalomyelitis, it is worth emphasising that the quote that illustrates this came from Nursing Standard and not from a magazine for patients. The British organisations have long been unhappy with the way the media have portrayed the illness and reviewed existing research, and it is often extremely difficult to get erroneous or biased information corrected. Sometimes we get a right of reply, but usually we don't. Finally, I wish to make clear that our current advice on exercise and stress is based on sound
305
1 Wessely S. Outcome of chronic fatigue syndrome. BMJ 1992; 305:365. (8 August.) 2 Sharpe M, Hawton K, Seagroatt V, Pasvol G. Follow up of patients presenting with fatigue to an infectious diseases clinic. 3 Cope H, David AS. Outcome in the chronic fatigue syndrome. BMJ 1992;305:365. (8 August.)
1 Davies DP. Future of human milk banks. BMJ 1992;305:433-4. (22 August.) 2 Lucas A, Morley R, Cole TJ, Gore SM, Davis JA, Bamford MFM, et al. Early diet in pre-term babies and developmental status in infancy. Arch Dis Child 1989;64:1570-8. 3 Naryanan I, Prakash K, Prabhakar AK, Guiral VV. A planned prospective evaluation of the anti-infective property of varying quantities of expressed human milk. Acia Paediatr Scand
VOLUME
M C HUME
ME Association, Stanford le Hope, Essex SS17 OHA
BMJ 1992;305:147-52. (18 July.)
Department of Child Health, St George's Hospital Medical School, London SW17 ORE
BMJ
scientific research, the recommendations of our medical advisers, and 50 years' experience. Since our aim is to help patients it would be ridiculous for us to ignore good research and to stick instead to outdated explanations, speculation, or even prejudice. No one gains from such a narrow minded approach, least of all us. The main reason why our beliefs tend to differ from those of Wessely and H Cope and A S David3 is that the authors do not distinguish between myalgic encephalomyelitis and chronic fatigue and we do. We see myalgic encephalomyelitis as more than "mental and physical fatigue," and we have evidence that treatments that seem to help patients with chronic fatigue do not always benefit people with myalgic encephalomyelitis (C Hickie, conference "Unravelling the mystery," North Carolina, 17-18 November 1990). Our cautious attitude may worry those who disagree with us, but a less critical approach may lead to mistakes and we are anxious to avoid this.
12
SEPTEMBER
1992
Using cytokines EDITOR,-Salem Malik and Jonathan Waxman point out that the recent increase in understanding of cytokine biology offers great promise for clinical medicine.' Their editorial focuses particularly on the use of cytokines as antitumour agents and on the role of these substances in the pathology of cancer. The relevance of cytokines extends to other aspects of clinical medicine in which the immune system has a role. Cytokines play an essential part in the functioning of this system, yet paradoxically they can damage tissue and be life threatening if produced in excessive amounts or under inappropriate circumstances. For example, tumour necrosis factor and interleukin 1 cause morbidity and death in conditions related to infection (for example, sepsis, adult respiratory distress syndrome, and cerebral malaria) and in chronic inflammatory diseases such as rheumatoid arthritis and ulcerative colitis.2'4 Advances in clinical medicine related to cytokine biology should therefore be targeted at enhancing their beneficial properties while suppressing their harmful effects. Thus, for example, in treating cancer the aim should be to retain the tumour killing properties of cytokines while suppressing their anorectic and tissue wasting actions. These aims can be achieved by using drugs, cytokine receptor antagonists, and nutrients. The widespread metabolic changes that result from the induction or application of cytokines depend on secondary messengers and intracellular signalling. These offer broad scope for nutritional modulation.' Fish oil reduces production of interleukin 1 and tumour necrosis factor in patients with rheumatoid disease and brings about an amelioration of symptoms. It is also beneficial in ulcerative colitis and psoriasis. Fish oil and saturated fats reduce the anorectic effects of interleukin 1 and tumour necrosis factor in experimental animals.'6 Thus consideration of the nature of fat in patients' diets offers scope for manipulating cytokine biology. Recent studies showing that free radicals enhance production of cytokines draw attention to the importance of the effectiveness of the antioxidant defences of patients in whom cytokines are operating.67 Key nutrients, such as vitamins E and C, play a major part in these defences. This highlights their importance in the diets of patients
who are undergoing cytokine treatment, or are producing cytokines in amounts that are incompatible with the restoration of normal tissue function and health. ROBERT GRIMBLE
Department of Nutrition, Medical School, Southampton University, Southampton S09 3TU 1 Malik S, Waxman J. Cytokines and cancer. BMJ 1992;305: 265-7. (1 August.) 2 Tracey KJ, Wei H, Manogue KR, Fong Y, Herse DG, Nguyen HT, et al. Cachectin/tumour necrosis factor induces cachexia, anemia and inflammation. J Exp Med 1988; 167: 1211-27. 3 Kwiatkowski D, Hill AVS, Sambon I. TNF concentration in fatal cerebral, non fatal cerebral, and uncomplicated Plasmodium falciparum malaria. Lancet 1990;336:1201-4. 4 Mahida YR, Wu K, Jewell DP. Enhanced production of interleukin 15 by mononuclear cells isolated from mucosa with active ulcerative colitis of Crohn's disease. Gut 1989;30:835-8. 5 Grimble RF. Nutrition and cytokine action. Nutrition Research Reviews 1990;3:193-210. 6 Grimble RF. Dietary manipulation of the inflammatory response. Proc NutrSoc 1992;51:285-94. 7 Chaudhri G, Clark IA. Reactive oxygen species facilitate the in vitro and in vivo lipopolysaccharide-induced release of tumour necrosis factor. I Immunol 1989;143:1290-4.
Perineal tears EDITOR,-Though M Stokes and D J Jones are correct to state that a perineal tear may lead to injury to the anal sphincter mechanism, they seem to imply that all tears lead to such injury.' They also suggest that a "prophylactic episiotomy should be performed if the perineum seems likely to tear." Only a small proportion of perineal tears result in damage to the sphincter. A prophylactic episiotomy gives no guarantee of protecting the sphincter. A properly sutured tear is generally associated with less short term and long term morbidity than a repaired episiotomy. "Episiotomy should be used only to relieve fetal or maternal distress, or to achieve adequate progress when it is the perineum that is responsible for the lack of progress."2 Advice concerning the use of episiotomy is more properly the province of midwives, other professionals concerned with intrapartum care, and the women themselves. MALCOLM GRIFFITHS Department of Obstetrics and Gynaecology, Royal Berkshire Hospital, Reading RG1 5AN I Stokes M, Jones DJ. Colorectal trauma. BMJ 1992;305:303-6. (1 August.) 2 Sleep J, Roberts J, Chalmers I. Care during the second stage of labour. In: Chalmers I, Enkin M, Keirse MJNC, eds. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989:1129-44.
Cardiac rehabilitation programmes EDITOR,-Hannah McGee and John H Horgan note the increasing relevance of smaller uptake rates of cardiac rehabilitation programmes in older women and asks what factors might be responsible for this.' A short inpatient cardiac rehabilitation programme began in this district in July 1989 and was extended to include a 12 session outpatient programme in July 1990. Both of these were discontinued in April 1992 owing to insufficient funding. During the 34 months 784 myocardial events were recorded (myocardial infarctions, coronary artery bypass graft surgery, angioplasties, and heart transplants), of which 554 occurred in males and 230 in females. A total of 62% of male patients and 63% of female patients participated in the inpatient cardiac rehabilitation programme. Later, entry to the outpatient programme was determined by a
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