les afin de poser le bon diagnostic. La methode de depistage en quatre parties preconisee par Margolis et Heller,2 citee par Welch Allyn dans le mode d'emploi du MicroTymp' et adoptee comme marche a suivre par l'American Speech-Language-Hearing Association,6 a laquelle s'ajoutent les antecedents du sujet ainsi que l'otoscopie et l'audiometrie, est essentielle pour obtenir tous les renseignements necessaires a une evaluation precise de l'audition et a l'orientation du sujet vers un specialiste. James R. Herrmann Service de recherche et de mise au point Welch Allyn, Inc. Skaneateles Falls, NY
References 1. Manuel d'instructions MicroTymp et combine imprimante-chargeur (no 236187), Welch Allyn, Skaneateles Falls (NY), 1987 2. Margolis RH, Heller J: Screening tympanometry: criteria for medical referral. Audiology 1987; 26: 197-208 3. DeJonge R, Cummings D: Daily fluctuation in middle ear pressure. Presentation donnee A I'American SpeechLanguage-Hearing Association en 1985 4. Riedel CL, Wiley TL, Block MG Tympanometric measures of eustachian tube function. J Speech Hear Res 1987; 30: 207-214 5. Reiter LA, Sillman S : Detecting meatal collapse. Presentation donnee a l'American Speech-Language-Hearing Association en 1990 6. American Speech-Language-Hearing Association : Guidelines for Screening for Hearing Impairment and Middle Ear Disorders, ASHA, Rockville, Md, 1989
Preventing alcohol problems: the challenge for medical education
(1060-1069) have suggested a number of useful tools for early identification of such problems. However, the utility of the CAGE questions deserves further emphasis. In June 1989 they were used in a self-administered questionnaire as part of a pilot survey of ambulatory patients who presented to the emergency department of an urban hospital with problems not related to alcohol.' The questions were answered by 87% of the patients (n = 200). Of these, 30% were identified as having an alcohol problem requiring further exploration (CAGE score of 1 or more) and 16% as probably alcohol dependent (CAGE score of 2 or more). These figures are remarkably similar to those reported by Moore and associates,2 who used other methods as well as CAGE questions to diagnose alcohol-related problems. I found the comment by Professor Robert E. Kendell (10421047) that alcohol dependence might be treated best by nonphysicians quite misguided. The wide spectrum of problem drinking and alcohol dependence necessitates increased efforts toward rehabilitation. A multimodal approach is generally required for the treatment of addiction,3 and health care providers (including the physician) with varied expertise must work together as a team. I am sure no physician would abdicate responsibility for the management of other cases of chronic, progressive disease, such as diabetes mellitus, multiple sclerosis or acquired immunodeficiency syndrome. Further, physicians' knowledge and skill in effecting changes in patient behaviour are useful in the management of any illness. Kendell described a study in which there was no difference in outcome between patients who had a single session ending with firm advice to stop drinking and
I would like to commend CMAJ for publishing the special supplement on alcoholrelated problems (1990; 143: 1041-1098). Drs. John B. Saun- those who received more extenders and Katherine M. Conigrave sive treatment. However, one 1388
CAN MED ASSOC J 1991; 144 (11)
must consider the severity of the problem, the quality of the treatment and the appropriateness of the outcome measures before dismissing the utility of the more extensive treatment. Raju Hajela, MD, MPH 122-1929 Russell Rd. Ottawa, Ont.
References 1. Hajela R, Dufour S: Assessment of drug and alcohol use among patients presenting to the emergency room. Paper presented at the First Annual Conference of Canadian Medical Society on Alcohol and Other Drugs, Calgary, Oct. 21-
22, 1989 2. Moore RD, Bone LR, Geller G et al: Prevalence, detection and treatment of alcoholism in hospitalized patients. JAMA 1989; 261: 403-407 3. Frye RV: A multimodality approach to the treatment of addiction. In Milkman HB, Schaffer HJ (eds): The Addictions, Lexington Bks, Lexington, Mass, 1985
Informed consent to HIV antibody testing A lthough I have a high regard for Dr. Eike-Henner Kluge's debating skills I
disagree with his philosophy regarding informed consent to HIV antibody testing (Can Med Assoc J 1991; 144: 403-404). When he invokes R. v. Dyment' as a precedent for HIV testing he compares apples and oranges. It is an offence to operate a motor vehicle if under the influence of alcohol. It is not an offence to be HIV positive or for that matter to have AIDS. The
taking of blood from Dyment had legal rather than medical repercussions. It is my impression that the informed consent imbroglio has played no small part in the mismanagement of the AIDS epidemic. I feel very strongly that the correction of this problem is urgent and have attempted to influence politicians, public opinion and other members of the medical LE
ler JUIN 1991
profession in this regard. Some background information may illustrate my concerns. My knowledge of C retroviruses, although amateur, goes back a few years.2 My teacher was Professor W. Jarrett, in the Department of Veterinary Pathology, Glasgow University. His isolation of the feline leukemia virus (FeLv) paved the way for the isolation of other horizontally transmitted retroviruses, including HIV. FeLv, like HIV, is incorporated into the host genome through reverse transcription. The mechanics of infection are similar in the two cases and involve cellular suspensions. The degree of infectivity increases with the density of cellular suspension. Although saliva is less infective than blood or semen it is, nevertheless, infective to some degree. By analogy, HIV could be expected to be transmitted in saliva. This is in keeping with horizontal transmission between young children3 and between a Florida dentist and three patients.4 The good news is that FeLv infection can be prevented with a vaccine that triggers the development of antibodies to feline oncornavirus membrane-associated antigen (FOCMA). Immunity is acquired not to the virus itself but, rather, to the "viral footprint" - the antigen. In 1986 I suggested a search for a human analogue to FOCMA in the AIDS situation; Professor Jarrett replied that this was the protein gpl20. He had prepared a subunit vaccine that had produced antibodies in primates. A high level of antigp120 antibodies in HIV-infected mothers has been associated with a diminished risk of newborn infection.5'6 Once again the veterinary pathologists have shown a certain flair for prophesy. What has all this to do with HIV antibody testing? The tragedy of the AIDS epidemic has been the endorsement of ignorance. JUNE 1, 1991
Emotional involvement by vocal self-interest groups has paradoxically presented a roadblock to investigation. Confusion of the disease with lifestyle and of medical issues with legal and ethical ones has served to promote obfuscation. If HIV infection follows the course of other known retrovirus models (e.g., FeLv), then many of the widely touted social programs (e.g., condom dispensers in high schools, free needles for drug abusers, promotion of safer sex and early sex education) will not stem the epidemic. These same social programs together with universal body fluid precautions are no substitute for the established principles of epidemic containment, the cornerstone of which is early and effective screening. This cannot be achieved without appropriate testing, which may be significantly impeded by a requirement for informed consent. James E. Parker, MA, MB, FRCPC 303-2151 McCallum Rd. Abbotsford, BC
References
that R. v. Dyment' does not deal with HIV seropositivity. He is also correct to say that operating a motor vehicle under the influence of alcohol is an offence, whereas being HIV positive is not. However, that was neither the issue nor the point of mentioning the Dyment case. Supreme Court decisions deal with matters of principle. The issue in the Dyment case was this: Is it permissible to use body fluids obtained in the course of providing health care for another purpose entirely and without the consent of the person from whom the fluid is taken? The decision of the court was No. This decision therefore applies whether we are dealing with testing for alcohol levels, HIV seropositivity or anything else. It therefore has important implications for nonconsensual testing in general. The case may not be quite as explicit as Parker would like it to be, but that is typical of Supreme Court cases; they deal with principles - that is precisely why they have such overriding
importance.
Eike-Henner Kiluge, PhD 1. R. v. Dyment, 2 SCR 417 (1988) 2. Parker JE: Cat leukemia and the cluster Director of ethics and legal affairs controversy. Can Med Assoc J 1978; Canadian Medical Association 118: 550-551 3. Wahn V, Kramer HH, Voit T et al: Horizontal transmission of HIV infection between two siblings [C]. Lancet 1986; 2: 694 4. Update: transmission of HIV infection during an invasive dental procedure Florida. JAMA 1991; 265: 563, 567568 5. Rossi P, Moschese V, Broliden PA et al: Presence of maternal antibodies to I n the first paragraph of the human immunodeficiency virus 1 envesection on contact-tracing of lope glycoprotein gpl2O epitopes correlates with the uninfected status of chilthis statement (Can Med dren born to seropositive mothers. Proc Assoc J 1991; 144: 997-1000), by Natl Acad Sci USA 1989; 86: 8055the Advisory Committee on Epi8058 6. Goedert JJ, Mendez H, Drummond JE demiology, the first sentence was et al: Mother-to-infant transmission of incorrect. It should have read as human immunodeficiency virus type 1: follows: "Measles is highly infecassociation with prematurity or low antious once any symptoms of the ti-gpl2O. Lancet 1989; 2: 1351-1354
Guidelines for measles control in Canada
Icorrection]
prodromal phase have appeared (usually within 3 to 5 [rather than [Dr. Kluge responds.] 15] days before onset of rash)." Dr. Parker is quite correct to say Ed. CAN MED ASSOC J 1991; 144 (I1)
1389
References 1. Manuel d'instructions MicroTymp et combine imprimante-chargeur (no 236187), Welch Allyn, Skaneateles Falls (NY), 1987 2. Margolis RH, Heller J: Screening tympanometry: criteria for medical referral. Audiology 1987; 26: 197-208 3. DeJonge R, Cummings D: Daily fluctuation in middle ear pressure. Presentation donnee A I'American SpeechLanguage-Hearing Association en 1985 4. Riedel CL, Wiley TL, Block MG Tympanometric measures of eustachian tube function. J Speech Hear Res 1987; 30: 207-214 5. Reiter LA, Sillman S : Detecting meatal collapse. Presentation donnee a l'American Speech-Language-Hearing Association en 1990 6. American Speech-Language-Hearing Association : Guidelines for Screening for Hearing Impairment and Middle Ear Disorders, ASHA, Rockville, Md, 1989
Preventing alcohol problems: the challenge for medical education
(1060-1069) have suggested a number of useful tools for early identification of such problems. However, the utility of the CAGE questions deserves further emphasis. In June 1989 they were used in a self-administered questionnaire as part of a pilot survey of ambulatory patients who presented to the emergency department of an urban hospital with problems not related to alcohol.' The questions were answered by 87% of the patients (n = 200). Of these, 30% were identified as having an alcohol problem requiring further exploration (CAGE score of 1 or more) and 16% as probably alcohol dependent (CAGE score of 2 or more). These figures are remarkably similar to those reported by Moore and associates,2 who used other methods as well as CAGE questions to diagnose alcohol-related problems. I found the comment by Professor Robert E. Kendell (10421047) that alcohol dependence might be treated best by nonphysicians quite misguided. The wide spectrum of problem drinking and alcohol dependence necessitates increased efforts toward rehabilitation. A multimodal approach is generally required for the treatment of addiction,3 and health care providers (including the physician) with varied expertise must work together as a team. I am sure no physician would abdicate responsibility for the management of other cases of chronic, progressive disease, such as diabetes mellitus, multiple sclerosis or acquired immunodeficiency syndrome. Further, physicians' knowledge and skill in effecting changes in patient behaviour are useful in the management of any illness. Kendell described a study in which there was no difference in outcome between patients who had a single session ending with firm advice to stop drinking and
I would like to commend CMAJ for publishing the special supplement on alcoholrelated problems (1990; 143: 1041-1098). Drs. John B. Saun- those who received more extenders and Katherine M. Conigrave sive treatment. However, one 1388
CAN MED ASSOC J 1991; 144 (11)
must consider the severity of the problem, the quality of the treatment and the appropriateness of the outcome measures before dismissing the utility of the more extensive treatment. Raju Hajela, MD, MPH 122-1929 Russell Rd. Ottawa, Ont.
References 1. Hajela R, Dufour S: Assessment of drug and alcohol use among patients presenting to the emergency room. Paper presented at the First Annual Conference of Canadian Medical Society on Alcohol and Other Drugs, Calgary, Oct. 21-
22, 1989 2. Moore RD, Bone LR, Geller G et al: Prevalence, detection and treatment of alcoholism in hospitalized patients. JAMA 1989; 261: 403-407 3. Frye RV: A multimodality approach to the treatment of addiction. In Milkman HB, Schaffer HJ (eds): The Addictions, Lexington Bks, Lexington, Mass, 1985
Informed consent to HIV antibody testing A lthough I have a high regard for Dr. Eike-Henner Kluge's debating skills I
disagree with his philosophy regarding informed consent to HIV antibody testing (Can Med Assoc J 1991; 144: 403-404). When he invokes R. v. Dyment' as a precedent for HIV testing he compares apples and oranges. It is an offence to operate a motor vehicle if under the influence of alcohol. It is not an offence to be HIV positive or for that matter to have AIDS. The
taking of blood from Dyment had legal rather than medical repercussions. It is my impression that the informed consent imbroglio has played no small part in the mismanagement of the AIDS epidemic. I feel very strongly that the correction of this problem is urgent and have attempted to influence politicians, public opinion and other members of the medical LE
ler JUIN 1991
profession in this regard. Some background information may illustrate my concerns. My knowledge of C retroviruses, although amateur, goes back a few years.2 My teacher was Professor W. Jarrett, in the Department of Veterinary Pathology, Glasgow University. His isolation of the feline leukemia virus (FeLv) paved the way for the isolation of other horizontally transmitted retroviruses, including HIV. FeLv, like HIV, is incorporated into the host genome through reverse transcription. The mechanics of infection are similar in the two cases and involve cellular suspensions. The degree of infectivity increases with the density of cellular suspension. Although saliva is less infective than blood or semen it is, nevertheless, infective to some degree. By analogy, HIV could be expected to be transmitted in saliva. This is in keeping with horizontal transmission between young children3 and between a Florida dentist and three patients.4 The good news is that FeLv infection can be prevented with a vaccine that triggers the development of antibodies to feline oncornavirus membrane-associated antigen (FOCMA). Immunity is acquired not to the virus itself but, rather, to the "viral footprint" - the antigen. In 1986 I suggested a search for a human analogue to FOCMA in the AIDS situation; Professor Jarrett replied that this was the protein gpl20. He had prepared a subunit vaccine that had produced antibodies in primates. A high level of antigp120 antibodies in HIV-infected mothers has been associated with a diminished risk of newborn infection.5'6 Once again the veterinary pathologists have shown a certain flair for prophesy. What has all this to do with HIV antibody testing? The tragedy of the AIDS epidemic has been the endorsement of ignorance. JUNE 1, 1991
Emotional involvement by vocal self-interest groups has paradoxically presented a roadblock to investigation. Confusion of the disease with lifestyle and of medical issues with legal and ethical ones has served to promote obfuscation. If HIV infection follows the course of other known retrovirus models (e.g., FeLv), then many of the widely touted social programs (e.g., condom dispensers in high schools, free needles for drug abusers, promotion of safer sex and early sex education) will not stem the epidemic. These same social programs together with universal body fluid precautions are no substitute for the established principles of epidemic containment, the cornerstone of which is early and effective screening. This cannot be achieved without appropriate testing, which may be significantly impeded by a requirement for informed consent. James E. Parker, MA, MB, FRCPC 303-2151 McCallum Rd. Abbotsford, BC
References
that R. v. Dyment' does not deal with HIV seropositivity. He is also correct to say that operating a motor vehicle under the influence of alcohol is an offence, whereas being HIV positive is not. However, that was neither the issue nor the point of mentioning the Dyment case. Supreme Court decisions deal with matters of principle. The issue in the Dyment case was this: Is it permissible to use body fluids obtained in the course of providing health care for another purpose entirely and without the consent of the person from whom the fluid is taken? The decision of the court was No. This decision therefore applies whether we are dealing with testing for alcohol levels, HIV seropositivity or anything else. It therefore has important implications for nonconsensual testing in general. The case may not be quite as explicit as Parker would like it to be, but that is typical of Supreme Court cases; they deal with principles - that is precisely why they have such overriding
importance.
Eike-Henner Kiluge, PhD 1. R. v. Dyment, 2 SCR 417 (1988) 2. Parker JE: Cat leukemia and the cluster Director of ethics and legal affairs controversy. Can Med Assoc J 1978; Canadian Medical Association 118: 550-551 3. Wahn V, Kramer HH, Voit T et al: Horizontal transmission of HIV infection between two siblings [C]. Lancet 1986; 2: 694 4. Update: transmission of HIV infection during an invasive dental procedure Florida. JAMA 1991; 265: 563, 567568 5. Rossi P, Moschese V, Broliden PA et al: Presence of maternal antibodies to I n the first paragraph of the human immunodeficiency virus 1 envesection on contact-tracing of lope glycoprotein gpl2O epitopes correlates with the uninfected status of chilthis statement (Can Med dren born to seropositive mothers. Proc Assoc J 1991; 144: 997-1000), by Natl Acad Sci USA 1989; 86: 8055the Advisory Committee on Epi8058 6. Goedert JJ, Mendez H, Drummond JE demiology, the first sentence was et al: Mother-to-infant transmission of incorrect. It should have read as human immunodeficiency virus type 1: follows: "Measles is highly infecassociation with prematurity or low antious once any symptoms of the ti-gpl2O. Lancet 1989; 2: 1351-1354
Guidelines for measles control in Canada
Icorrection]
prodromal phase have appeared (usually within 3 to 5 [rather than [Dr. Kluge responds.] 15] days before onset of rash)." Dr. Parker is quite correct to say Ed. CAN MED ASSOC J 1991; 144 (I1)
1389
