nursing staff who give dialysis to a patient who is HIV positive? Although Ms Edwards's letter states that nurses who follow the standard guidelines "'will be protected from the risk of transmission of HIV," some of the expert advice we have received is that the possibility of a needlestick injury remains and, given the size of the needles and the blood volumes involved, the chances of such an injury from an HIV positive patient causing infection in the nurse may be significant. It might also seem sensible that HIV positive patients regularly receiving haemodialysis should be given dialysis in a separate facility, as is done for hepatitis B positive patients, and this obviously will require that these issues have been fully discussed with all members of the nursing staff. I understand that the Department of Health will soon be issuing some further guidelines about HIV testing, but it seems that these will be rather neutral and, once again, not of much help to the clinicians actually having to deal with the issue. Similarly, ex cathedra statements from the Royal College ofNursing about this complex and sensitive topic are unlikely to be of much practical guidance unless they provide the stimulus for the wide ranging debate about these issues which is required. M A MANSELL
St Peter's Hospitals, London WC2A 2EX 1 Edwards P. HIV testing of patients with end stage renal failure.
BMJ 1991;303:308. (3 August.)
Calcium and soya milk SIR,-Professor B A Wharton and B J Clark gave a very helpful answer to the question of the calcium intake of a healthy child who is avoiding dairy products and taking soya milk.' Milk contains 120 mg of calcium per 100 ml, and children receiving the specifically designed soya based feeds (Formula S, Ostersoy, Wysoy, etc) are unlikely to become calcium deficient as these fortified products contain 52-67 mg per 100 ml. Children (and adults) who use unfortified, plain soya milk, however, are at considerable risk of calcium deficiency as this contains only 13 mg per 100 ml. In addition, many transfer from the specially designed feeds to plain soya milk and are unaware of this risk. K SHIELS
D CLEMENTS
University Hospital of Wales, Cardiff CF4 4XW 1 Wharton BA, Clark BJ. Any questions. BMJ 1991;303:177.
(20 July.)
Use of thalidomide in leprosy SIR,- Dr Colin Crawford' is right to draw attention to the important side effect of peripheral neuropathy induced by thalidomide,2 a condition of which leoprologists are well aware. But he is guilty of special pleading when he quotes the high incidence of this neuropathy encountered in nodular prurigo,' a disease in which there is cutaneous nerve proliferation.4 He should not be amazed that doctors have failed to detect the neuropathy in patients with lepromatous leprosy treated with thalidomide to control severe erythema nodosum leprosum. The incidence of thalidomide in most conditions is not scientifically known. By the end of 1960 it was suggested that a million people in West Germany alone were taking thalidomide nightly.5 One estimate was that 0 5% of those who took the drug for two months or more developed the neuropathy, and there is some evidence of a relation with total dosage.' At the Leprosy Research Unit, Sungai Buluh, Malaysia, between 1967 and
470
1981 and subsequently in London my colleagues and I treated around 400 cases of erythema nodosum leprosum with thalidomide. Most of these patients were already suffering from lepromatous peripheral neuropathy, which might well have masked the side effects of thalidomide on the sensory system. To date, though, none has developed new signs or symptoms suggestive of thalidomide neuropathy or been found to develop loss of ankle jerks, which sometimes occurs in the neuropathy but not in leprosy. Some patients, after erythema nodosum leprosum neuritis has been controlled, have shown dramatic improvement in motor nerve function. In medicine generally the selection of treatment implies careful weighing of risk against benefit. In the past severe erythema nodosum leprosum could cause death in the acute phase, years of chronic ill health, ' and, if poorly controlled, secondary amyloidosis and death by renal failure.' Experienced leprologists have seen every form of steroid toxicity in this condition. Unfortunately clofazimine, so useful in mild erythema nodosum leprosum, is less powerful, acts slowly, and in high dosage has an effect on skin colour that many patients find socially unacceptable. Therefore the main alternative to corticosteroids is thalidomide, a drug reported to suppress T helper cells9 and to inhibit production of tumour necrosis factor alpha. '0 Control of severe erythema nodosum leprosum is at least as easy to obtain with thalidomide as with corticosteroids; the incidence of toxic side effects is much less; the quality of life is greatly improved; and the careful use of thalidomide in men and postmenopausal women can on occasion be life saving.8
disease in the over 64 age group. Gastric cancer is essentially a disease of that age group, with a median age at presentation >65 years in major European series (68 1 years in our own series).4 Indeed, one of the points that we sought to make was that doctors should be responsive to increased expectations about health care in this age group. To use truncated incidences is to ignore incidence in that age group. The cancer registration rates for all ages quoted by Drs Forman and Kinlen confirm that in Scotland between 1962-5 and 1978-82 there was a marginal decline (3%) in the standardised cancer registration' rate for all ages. Our study confirmed that there was no significant decline in age standardised cancer registration rates in Scotland in the more recent period 1978-87. Nor was there a significant decline in age standardised cancer registration rates in any of the age bands studied (35 years to 84 years by 10 year increments), with the exception of women aged 65 and over. It is clear that in Scotland over the past 30 years the incidence, as gauged by age standardised cancer registration rates, has declined but marginally. As the title of our paper suggests, our study and conclusions were confined to Scotland. We have shown that there is no evidence of a significant decline in age corrected incidence of this disease in Scotland during the past decade. Drs Forman and Kinlen have confirmed the lack of a significant decline in age corrected incidence in the two decades to 1982. The clinical workload is not declining and, as Drs Forman and Kinlen suggest, may even be increasing. In the face of this evidence our conclusions that gastric cancer can no longer be regarded as a disease in decline seems entirely justified.
M F R WATERS
D M SEDGWICK I M C MACINTYRE
Hospital for Tropical Diseases, London NW I OPE 1 Crawford CL. Use of thalidomide in leprosy. BMJ 1991;302: 1603-4. (29 June.) 2 Fullerton PM, O'Sullivan DJ. Thalidonmide neuropathy: a clinical, electrophysiological and histological follow-up study. J Neurol Neurosurg Psychiatry 1968;31:543-5 1. 3 Wulff CH, Hoyer H, Asboel-Hansen G, Brodthagen H. Development of polyneuropathy during thalidomide therapy. Br3rDermatol 1985;112:475-80. 4 Runne U, Orfanos CE. Cutaneous neural proliferation in highly pruritic lesions of chronic prurigo. Arch Dermnatol 1977;113: 787-91. 5 Insight Team of the Sunday Times. Suffer the children: the story of thalidomide. London: Andre Deutsch, 1979:36-8. 6 Water MFR, Ridley DS. Necrotising reactions in lepromatous leprosy: a clinical and histologic study. Intj Lepr 1963;31: 418-36. 7 Karat ABA, Karat S, Job CK, Sundarsanam D. Acute necrotising lepromatous lymphadenitis: an erythema-nodosumleprosum-like reaction in lymph nodes. BMJ 1968;iv:223-4. 8 Waters MFR, Philalithis PE, Lucas S. The long term prognosis of proven renal amyloidosis in leprosy. Int J Lepr 1989;57: 412. 9 Gas SM, Shannon EJ, Krotoski WA, Hastings RC. Thalidomide induces imbalance in T-lymphocyte subpopulations in the circulating blood of health males. Lepr Rev 1985;56:35-9. 10 Sampaio EP, Sarno EN, Galilly R, Cohn ZA, Kaplan G. Thalidomide selectively inhibits tumor necrosis factor alpha production by stimulated human monocytes. J Exp Med 1991;173:699-703.
Unchanging workload in gastric cancer SIR,-There can be no question, as we showed in our recent article,' that mortality from gastric carcinoma continues to decline. It is inappropriate to suggest that this is merely a manifestation of a disappearing disease when there is evidence to suggest that improvements in surgical care may well have contributed to this decline in mortality. We have recently shown a significant decline in operative mortality in series reported in English language publications over the past three decades.2 Drs David Forman and Leo Kinlen suggest that it is useful to examine age adjusted truncated incidences rather than incidences for all ages.3 As clinicians we think that it is less valuable to use truncated incidences as they completely ignore the
Western General Hospital, Edinburgh EH4 2XU I Sedgwick DM, Akoh JA, Macintyre IMC. Gastric cancer in Scotland: changing epidemiology, unchanging workload.
BMJ 1991;302:1305-7. (1 June.) 2 Macintyre IMC, Akoh JA. Improving survival in gastric cancer: a review of operative mortality in English language publications
from 1970. BrJ Surg 1991;78:773-8. 3 Forman D, Kinlen L. Declining incidence of
gastric
cancer.
BMJ 1991;303:248-9. (27 July.) 4 Akoh JA, Sedgwick DM, Macintvre IMC. Improving results gastric cancer-an II year audit. BrJ7 Surg 1991;78:349-5 1.
in
Managing violence in psychiatric hospitals SIR,-In their editorial Drs J A Schipperheijn and Francis J Dunne conclude that violence in psychiatric hospitals is common and difficult to predict.' They focus on the use of drug treatment and empathic communication as means of reducing violent incidents. Unfortunately, they make little comment on physical safety arrangements other than to say that, in an ideal world, all wards should have alarm buzzers and staff should avoid interviewing patients in unsafe situations. Junior psychiatrists, sadly, do not work in such an environment. We recently undertook a survey of junior doctors' experience of violence while working in psychiatry. The volume of comments returned with our questionnaire indicated the strength of doctors' anxieties about safety. One of the main concerns was the general lack of security in psychiatric hospitals. Interview rooms were often cramped and isolated, making it difficult to leave the room or to obtain help in an emergency. Even when a patient had been identified as being potentially dangerous, staffing levels made it difficult to find a nurse to accompany doctors to the interview.
Despite the tendency to focus on dangerous clinical situations our respondents reported feeling in danger at other times. Women doctors in particular found it daunting to travel between wards at night in large, poorly lit psychiatric
BMJ
VOLUME 303
24 AUGUST 1991
hospitals. Security guards were rarely available, and nurse escorts could often not be arranged. The safety of on call rooms was also of great concern. Simple practical measures were reassuring: improved lighting and a spyhole and chain fitted to the door of an on call room had greatly reduced doctors' anxieties at one hospital. It is encouraging to see the prominence that Drs Schipperheijn and Dunne give to education in managing aggression. We believe, however, that it is essential not to allow educational approaches to overshadow the practical steps that hospitals can take to provide all staff with a safer working environment. CAMERON STARK
Department of Puiblic Health, Argyll and Clyde Health Board, Paisley PAl l)D BRIAN KIDD
Departntent of Psychiatry, Southerrn (eneral Hospital, Glasgoss (5 1 4TF Schipperheiin JA, Dunne FJ. Managing violence in psychiatric hospitals. BMJ 1991;303:71-2. (13 July.)
Review of neonatal screening programme for phenylketonuria SIR,-The review by Dr Isabel Smith and colleagues' was particularly timely as we have just reviewed the procedures for neonatal biochemical screening in Wandsworth. For 5'% of babies born in the first eight months of 1990 we found that results were not readily available. After contacting all the relevant agencies, including the hospitals of birth, many screening laboratories, and the health visitors, we were still unable to find results for 2% of infants. We can only assume that these children have not been tested. Dr Smith suggests that the national coverage "approaches 100%." This may well be true, but national averages can obscure large individual differences. She touches on this when mentioning Hunter et al's study of the apparent low uptake in Riverside. It is essential that someone monitors local screening services. In the increasingly fragmented health service, how is this to be done? As in many aspects of community child health, there are many people involved-the midwife who takes the sample, the laboratory that performs the test, the administrative staff who receive and pass on the result, the health visitor who is usually the professional receiving the result, the general practitioner or local clinic undertaking child health surveillance on the child, the district health authority responsible for the health of its residents, and the senior doctor in community child health. No one solution will be appropriate for all districts, but we suggest the following as a framework. (1) When the test is performed, it should be fully explained to the parent. In this way the parent is likely to request the result if it seems overdue. The result should be recorded in the parent held record at the earliest opportunity. (2) All results, including negatives, should be reported. This is still not universal practice. (3) The health visitor should be responsible for seeing that a result has been received for every child on her case load. This is not the same as checking that a sample has been taken. (4) If a result has not been received by the time a child is 1 month old at the latest a result should be sought, and if it cannot be found a sample should be taken without delay. (5) Depending on the sophistication of the local information system, either constant monitoring or regular spot checks should be made to ensure the system is working properly. (6) Someone needs to take overall responsibility for ensuring the system is working. In some
BMJ VOLUME 303
24 AUGUST 1991
districts this would fall to community paediatricians and in others to the departments of public health medicine. We would be interested to know the coverage figures for other districts. DAVID ELLIMAN JUNE GARNER
St George's Hospital, London SW 17 OQTF I Smith I, Cook I, Beasley M. Review of neonatal screening programme for phenylketonuria. BMJ 1991;303:333-5. (10 August.)
What now for IPPNW? SIR,-Having attended the 10th anniversary congress of International Physicians for the Prevention of Nuclear War (IPPNW), I was interested in Dr Richard Smith's editorial on the future of IPPNW.' Some points might be questioned: the total membership of the affiliated organisations is well over 200 000 but not quite 40 times the world's population, and, more seriously, not all would agree that IPPNW's tendency to elitism has been beneficial. With the ending of the cold war, in which IPPNW might indeed claim a share, the organisation's mission certainly needs to be redefined and extended beyond the prevention of nuclear war. As Dr Smith notes, doctors may find themselves on opposite sides in conventional war. The Gulf war shows that this is not necessarily so; at IPPNW's meeting in Stockholm influential speakers from Israel, Iraq, Palestine, Jordan, Egypt, and Turkey were agreed on the need for a zone free of nuclear, chemical, and biological weapons in the Middle East. Many of us support Haines's call for IPPNW and its affiliates to address the wider issues of global security.2 The affiliates in the United Kingdom, the Medical Campaign Against Nuclear Weapons and the Medical Association for Prevention of War, are working towards amalgamation and a relaunch with these issues in mind while continuing to press for a comprehensive ban on nuclear testing as a key step in eradicating nuclear weapons. Meanwhile, in Stockholm IPPNW's international council voted nem con to devote its resources (a) to preventing war, especially that using weapons of mass destruction, (b) to redirecting world resources from producing arms to promoting human wellbeing, and (c) to protecting the environment from preparations for war as well as from war itself. Environmental effects of military activity include radioactive and toxic pollution, some of it ozone depleting, and wastage of resources. The fuel burnt by the army worldwide in peacetime and used in producing arms contributes up to 6% of global emissions of carbon dioxide annually, adding appreciably to global warming through the greenhouse effect.' DOUGLAS HOLDSTOCK Medical Campaign Against Nuclear Weapons, London N 19 4DJ I Smith R. What now for IPPNW?
B.MJ 1991;303:145-6. (20
two years previously, the awesome aftermath of the Persian Gulf war, and considerable ferment within the organisation about how it could best address environmental questions-the 10th congress was certainly a critical juncture for the federation. IPPNW seemed more in robust health than in crisis. Eight new affiliates joined the federation in Stockholm, bringing the number of countries represented to 76, with over 200000 physician members worldwide. IPPNW has been growing most rapidly in the Third World, and more physicians from Third World countries were present in Stockholm than at any preceding IPPNW congress. A real global maturity and willingness to critically review and refine the organisation's direction were in evidence. Complacency about the nuclear threat is far from justified. Thus far no superpower nuclear warheads have been dismantled, and the recently concluded START treaty will merely bring strategic nuclear weapons back to numbers which exceed their levels a decade ago when the START negotiations began. Global nuclear military infrastructures, nuclear weapon and missile proliferation, growing disparities between rich and poor, and growing environmental threats to security combine with a continued qualitative arms race to maintain a nuclear risk that is largely unabated. And given the increasingly destructive power of modern weaponry, non-nuclear war is effectively a weapon of mass destruction. In Stockholm, IPPNW defined clear and bold new directions. The organisation will broaden its concern to include all forms of war and their prevention. IPPNW's central task remains the prevention of war. In this, as a medical organisation, it stands alone, and this task is as vital as ever. There are many credible and effective organisations in many countries addressing a range of environmental issues. Delegates in Stockholm agreed that the unique mission, the "ecological niche" of IPPNW, apart from working for the prevention of war, was to address the effects of war and militarism on the environment, an area which hardly any other major international organisation is addressing. Much of IPPNW's strength and effectiveness derives from its ability to unite diverse physicians from around the world on a highly focused and critically important agenda. As the organisation continues to flourish and consolidate the richness and diversity of its membership, it still needs a carefully crafted and sharp edge. Two specific projects now bearing fruit are the IPPNW global commission on the health and environmental effects of nuclear weapons production, which has just released the first comprehensive global assessment of nuclear weapons testing, and the Satelife project, a satellite communications project enabling physicians around the world, especially in poor and remote areas, to communicate rapidly and cheaply. The direction and challenges set in Stockholm will ensure that the organisation continues to make a vital contribution to safeguarding the life and health of our planet and its inhabitants. TILMAN RUFF International Physicians for the Prevention of Nuclear War, Cambridge, Massachusetts 02142-1096,
USA
July.) 2 Haines A. Global security: a role for health professionals. PSR Quarterly 1991;1:89-95. 3 Renner M. Assessing the military's war on the environment. In: Brown LR, ed. State of the world 1991. New York: W W Norton, 1991:132-52.
1 Smith R. What now for IPPNW? BMJ 1991;303:145-6. (20 July.)
Better mental health services SIR,-The recent editorial regarding the recent 10th anniversary world congress of International Physicians for the Prevention of Nuclear War,' however, demands response. It describes the organisation as being now in crisis, the victim of its own success. I must disagree. Given the tremendous changes in Europe and the US-Soviet relations since the ninth congress
SIR,-Ms Ros Hepplewhite of MIND takes exception' to-my recommendation that mentally ill patients would benefit from a "personal physician" and that an increased number of consultant psychiatrists is needed to serve them.2 She then proceeds to give several reasons to support my case. She quotes the report by MIND, People First,' which says that many patients do not find
471
St Peter's Hospitals, London WC2A 2EX 1 Edwards P. HIV testing of patients with end stage renal failure.
BMJ 1991;303:308. (3 August.)
Calcium and soya milk SIR,-Professor B A Wharton and B J Clark gave a very helpful answer to the question of the calcium intake of a healthy child who is avoiding dairy products and taking soya milk.' Milk contains 120 mg of calcium per 100 ml, and children receiving the specifically designed soya based feeds (Formula S, Ostersoy, Wysoy, etc) are unlikely to become calcium deficient as these fortified products contain 52-67 mg per 100 ml. Children (and adults) who use unfortified, plain soya milk, however, are at considerable risk of calcium deficiency as this contains only 13 mg per 100 ml. In addition, many transfer from the specially designed feeds to plain soya milk and are unaware of this risk. K SHIELS
D CLEMENTS
University Hospital of Wales, Cardiff CF4 4XW 1 Wharton BA, Clark BJ. Any questions. BMJ 1991;303:177.
(20 July.)
Use of thalidomide in leprosy SIR,- Dr Colin Crawford' is right to draw attention to the important side effect of peripheral neuropathy induced by thalidomide,2 a condition of which leoprologists are well aware. But he is guilty of special pleading when he quotes the high incidence of this neuropathy encountered in nodular prurigo,' a disease in which there is cutaneous nerve proliferation.4 He should not be amazed that doctors have failed to detect the neuropathy in patients with lepromatous leprosy treated with thalidomide to control severe erythema nodosum leprosum. The incidence of thalidomide in most conditions is not scientifically known. By the end of 1960 it was suggested that a million people in West Germany alone were taking thalidomide nightly.5 One estimate was that 0 5% of those who took the drug for two months or more developed the neuropathy, and there is some evidence of a relation with total dosage.' At the Leprosy Research Unit, Sungai Buluh, Malaysia, between 1967 and
470
1981 and subsequently in London my colleagues and I treated around 400 cases of erythema nodosum leprosum with thalidomide. Most of these patients were already suffering from lepromatous peripheral neuropathy, which might well have masked the side effects of thalidomide on the sensory system. To date, though, none has developed new signs or symptoms suggestive of thalidomide neuropathy or been found to develop loss of ankle jerks, which sometimes occurs in the neuropathy but not in leprosy. Some patients, after erythema nodosum leprosum neuritis has been controlled, have shown dramatic improvement in motor nerve function. In medicine generally the selection of treatment implies careful weighing of risk against benefit. In the past severe erythema nodosum leprosum could cause death in the acute phase, years of chronic ill health, ' and, if poorly controlled, secondary amyloidosis and death by renal failure.' Experienced leprologists have seen every form of steroid toxicity in this condition. Unfortunately clofazimine, so useful in mild erythema nodosum leprosum, is less powerful, acts slowly, and in high dosage has an effect on skin colour that many patients find socially unacceptable. Therefore the main alternative to corticosteroids is thalidomide, a drug reported to suppress T helper cells9 and to inhibit production of tumour necrosis factor alpha. '0 Control of severe erythema nodosum leprosum is at least as easy to obtain with thalidomide as with corticosteroids; the incidence of toxic side effects is much less; the quality of life is greatly improved; and the careful use of thalidomide in men and postmenopausal women can on occasion be life saving.8
disease in the over 64 age group. Gastric cancer is essentially a disease of that age group, with a median age at presentation >65 years in major European series (68 1 years in our own series).4 Indeed, one of the points that we sought to make was that doctors should be responsive to increased expectations about health care in this age group. To use truncated incidences is to ignore incidence in that age group. The cancer registration rates for all ages quoted by Drs Forman and Kinlen confirm that in Scotland between 1962-5 and 1978-82 there was a marginal decline (3%) in the standardised cancer registration' rate for all ages. Our study confirmed that there was no significant decline in age standardised cancer registration rates in Scotland in the more recent period 1978-87. Nor was there a significant decline in age standardised cancer registration rates in any of the age bands studied (35 years to 84 years by 10 year increments), with the exception of women aged 65 and over. It is clear that in Scotland over the past 30 years the incidence, as gauged by age standardised cancer registration rates, has declined but marginally. As the title of our paper suggests, our study and conclusions were confined to Scotland. We have shown that there is no evidence of a significant decline in age corrected incidence of this disease in Scotland during the past decade. Drs Forman and Kinlen have confirmed the lack of a significant decline in age corrected incidence in the two decades to 1982. The clinical workload is not declining and, as Drs Forman and Kinlen suggest, may even be increasing. In the face of this evidence our conclusions that gastric cancer can no longer be regarded as a disease in decline seems entirely justified.
M F R WATERS
D M SEDGWICK I M C MACINTYRE
Hospital for Tropical Diseases, London NW I OPE 1 Crawford CL. Use of thalidomide in leprosy. BMJ 1991;302: 1603-4. (29 June.) 2 Fullerton PM, O'Sullivan DJ. Thalidonmide neuropathy: a clinical, electrophysiological and histological follow-up study. J Neurol Neurosurg Psychiatry 1968;31:543-5 1. 3 Wulff CH, Hoyer H, Asboel-Hansen G, Brodthagen H. Development of polyneuropathy during thalidomide therapy. Br3rDermatol 1985;112:475-80. 4 Runne U, Orfanos CE. Cutaneous neural proliferation in highly pruritic lesions of chronic prurigo. Arch Dermnatol 1977;113: 787-91. 5 Insight Team of the Sunday Times. Suffer the children: the story of thalidomide. London: Andre Deutsch, 1979:36-8. 6 Water MFR, Ridley DS. Necrotising reactions in lepromatous leprosy: a clinical and histologic study. Intj Lepr 1963;31: 418-36. 7 Karat ABA, Karat S, Job CK, Sundarsanam D. Acute necrotising lepromatous lymphadenitis: an erythema-nodosumleprosum-like reaction in lymph nodes. BMJ 1968;iv:223-4. 8 Waters MFR, Philalithis PE, Lucas S. The long term prognosis of proven renal amyloidosis in leprosy. Int J Lepr 1989;57: 412. 9 Gas SM, Shannon EJ, Krotoski WA, Hastings RC. Thalidomide induces imbalance in T-lymphocyte subpopulations in the circulating blood of health males. Lepr Rev 1985;56:35-9. 10 Sampaio EP, Sarno EN, Galilly R, Cohn ZA, Kaplan G. Thalidomide selectively inhibits tumor necrosis factor alpha production by stimulated human monocytes. J Exp Med 1991;173:699-703.
Unchanging workload in gastric cancer SIR,-There can be no question, as we showed in our recent article,' that mortality from gastric carcinoma continues to decline. It is inappropriate to suggest that this is merely a manifestation of a disappearing disease when there is evidence to suggest that improvements in surgical care may well have contributed to this decline in mortality. We have recently shown a significant decline in operative mortality in series reported in English language publications over the past three decades.2 Drs David Forman and Leo Kinlen suggest that it is useful to examine age adjusted truncated incidences rather than incidences for all ages.3 As clinicians we think that it is less valuable to use truncated incidences as they completely ignore the
Western General Hospital, Edinburgh EH4 2XU I Sedgwick DM, Akoh JA, Macintyre IMC. Gastric cancer in Scotland: changing epidemiology, unchanging workload.
BMJ 1991;302:1305-7. (1 June.) 2 Macintyre IMC, Akoh JA. Improving survival in gastric cancer: a review of operative mortality in English language publications
from 1970. BrJ Surg 1991;78:773-8. 3 Forman D, Kinlen L. Declining incidence of
gastric
cancer.
BMJ 1991;303:248-9. (27 July.) 4 Akoh JA, Sedgwick DM, Macintvre IMC. Improving results gastric cancer-an II year audit. BrJ7 Surg 1991;78:349-5 1.
in
Managing violence in psychiatric hospitals SIR,-In their editorial Drs J A Schipperheijn and Francis J Dunne conclude that violence in psychiatric hospitals is common and difficult to predict.' They focus on the use of drug treatment and empathic communication as means of reducing violent incidents. Unfortunately, they make little comment on physical safety arrangements other than to say that, in an ideal world, all wards should have alarm buzzers and staff should avoid interviewing patients in unsafe situations. Junior psychiatrists, sadly, do not work in such an environment. We recently undertook a survey of junior doctors' experience of violence while working in psychiatry. The volume of comments returned with our questionnaire indicated the strength of doctors' anxieties about safety. One of the main concerns was the general lack of security in psychiatric hospitals. Interview rooms were often cramped and isolated, making it difficult to leave the room or to obtain help in an emergency. Even when a patient had been identified as being potentially dangerous, staffing levels made it difficult to find a nurse to accompany doctors to the interview.
Despite the tendency to focus on dangerous clinical situations our respondents reported feeling in danger at other times. Women doctors in particular found it daunting to travel between wards at night in large, poorly lit psychiatric
BMJ
VOLUME 303
24 AUGUST 1991
hospitals. Security guards were rarely available, and nurse escorts could often not be arranged. The safety of on call rooms was also of great concern. Simple practical measures were reassuring: improved lighting and a spyhole and chain fitted to the door of an on call room had greatly reduced doctors' anxieties at one hospital. It is encouraging to see the prominence that Drs Schipperheijn and Dunne give to education in managing aggression. We believe, however, that it is essential not to allow educational approaches to overshadow the practical steps that hospitals can take to provide all staff with a safer working environment. CAMERON STARK
Department of Puiblic Health, Argyll and Clyde Health Board, Paisley PAl l)D BRIAN KIDD
Departntent of Psychiatry, Southerrn (eneral Hospital, Glasgoss (5 1 4TF Schipperheiin JA, Dunne FJ. Managing violence in psychiatric hospitals. BMJ 1991;303:71-2. (13 July.)
Review of neonatal screening programme for phenylketonuria SIR,-The review by Dr Isabel Smith and colleagues' was particularly timely as we have just reviewed the procedures for neonatal biochemical screening in Wandsworth. For 5'% of babies born in the first eight months of 1990 we found that results were not readily available. After contacting all the relevant agencies, including the hospitals of birth, many screening laboratories, and the health visitors, we were still unable to find results for 2% of infants. We can only assume that these children have not been tested. Dr Smith suggests that the national coverage "approaches 100%." This may well be true, but national averages can obscure large individual differences. She touches on this when mentioning Hunter et al's study of the apparent low uptake in Riverside. It is essential that someone monitors local screening services. In the increasingly fragmented health service, how is this to be done? As in many aspects of community child health, there are many people involved-the midwife who takes the sample, the laboratory that performs the test, the administrative staff who receive and pass on the result, the health visitor who is usually the professional receiving the result, the general practitioner or local clinic undertaking child health surveillance on the child, the district health authority responsible for the health of its residents, and the senior doctor in community child health. No one solution will be appropriate for all districts, but we suggest the following as a framework. (1) When the test is performed, it should be fully explained to the parent. In this way the parent is likely to request the result if it seems overdue. The result should be recorded in the parent held record at the earliest opportunity. (2) All results, including negatives, should be reported. This is still not universal practice. (3) The health visitor should be responsible for seeing that a result has been received for every child on her case load. This is not the same as checking that a sample has been taken. (4) If a result has not been received by the time a child is 1 month old at the latest a result should be sought, and if it cannot be found a sample should be taken without delay. (5) Depending on the sophistication of the local information system, either constant monitoring or regular spot checks should be made to ensure the system is working properly. (6) Someone needs to take overall responsibility for ensuring the system is working. In some
BMJ VOLUME 303
24 AUGUST 1991
districts this would fall to community paediatricians and in others to the departments of public health medicine. We would be interested to know the coverage figures for other districts. DAVID ELLIMAN JUNE GARNER
St George's Hospital, London SW 17 OQTF I Smith I, Cook I, Beasley M. Review of neonatal screening programme for phenylketonuria. BMJ 1991;303:333-5. (10 August.)
What now for IPPNW? SIR,-Having attended the 10th anniversary congress of International Physicians for the Prevention of Nuclear War (IPPNW), I was interested in Dr Richard Smith's editorial on the future of IPPNW.' Some points might be questioned: the total membership of the affiliated organisations is well over 200 000 but not quite 40 times the world's population, and, more seriously, not all would agree that IPPNW's tendency to elitism has been beneficial. With the ending of the cold war, in which IPPNW might indeed claim a share, the organisation's mission certainly needs to be redefined and extended beyond the prevention of nuclear war. As Dr Smith notes, doctors may find themselves on opposite sides in conventional war. The Gulf war shows that this is not necessarily so; at IPPNW's meeting in Stockholm influential speakers from Israel, Iraq, Palestine, Jordan, Egypt, and Turkey were agreed on the need for a zone free of nuclear, chemical, and biological weapons in the Middle East. Many of us support Haines's call for IPPNW and its affiliates to address the wider issues of global security.2 The affiliates in the United Kingdom, the Medical Campaign Against Nuclear Weapons and the Medical Association for Prevention of War, are working towards amalgamation and a relaunch with these issues in mind while continuing to press for a comprehensive ban on nuclear testing as a key step in eradicating nuclear weapons. Meanwhile, in Stockholm IPPNW's international council voted nem con to devote its resources (a) to preventing war, especially that using weapons of mass destruction, (b) to redirecting world resources from producing arms to promoting human wellbeing, and (c) to protecting the environment from preparations for war as well as from war itself. Environmental effects of military activity include radioactive and toxic pollution, some of it ozone depleting, and wastage of resources. The fuel burnt by the army worldwide in peacetime and used in producing arms contributes up to 6% of global emissions of carbon dioxide annually, adding appreciably to global warming through the greenhouse effect.' DOUGLAS HOLDSTOCK Medical Campaign Against Nuclear Weapons, London N 19 4DJ I Smith R. What now for IPPNW?
B.MJ 1991;303:145-6. (20
two years previously, the awesome aftermath of the Persian Gulf war, and considerable ferment within the organisation about how it could best address environmental questions-the 10th congress was certainly a critical juncture for the federation. IPPNW seemed more in robust health than in crisis. Eight new affiliates joined the federation in Stockholm, bringing the number of countries represented to 76, with over 200000 physician members worldwide. IPPNW has been growing most rapidly in the Third World, and more physicians from Third World countries were present in Stockholm than at any preceding IPPNW congress. A real global maturity and willingness to critically review and refine the organisation's direction were in evidence. Complacency about the nuclear threat is far from justified. Thus far no superpower nuclear warheads have been dismantled, and the recently concluded START treaty will merely bring strategic nuclear weapons back to numbers which exceed their levels a decade ago when the START negotiations began. Global nuclear military infrastructures, nuclear weapon and missile proliferation, growing disparities between rich and poor, and growing environmental threats to security combine with a continued qualitative arms race to maintain a nuclear risk that is largely unabated. And given the increasingly destructive power of modern weaponry, non-nuclear war is effectively a weapon of mass destruction. In Stockholm, IPPNW defined clear and bold new directions. The organisation will broaden its concern to include all forms of war and their prevention. IPPNW's central task remains the prevention of war. In this, as a medical organisation, it stands alone, and this task is as vital as ever. There are many credible and effective organisations in many countries addressing a range of environmental issues. Delegates in Stockholm agreed that the unique mission, the "ecological niche" of IPPNW, apart from working for the prevention of war, was to address the effects of war and militarism on the environment, an area which hardly any other major international organisation is addressing. Much of IPPNW's strength and effectiveness derives from its ability to unite diverse physicians from around the world on a highly focused and critically important agenda. As the organisation continues to flourish and consolidate the richness and diversity of its membership, it still needs a carefully crafted and sharp edge. Two specific projects now bearing fruit are the IPPNW global commission on the health and environmental effects of nuclear weapons production, which has just released the first comprehensive global assessment of nuclear weapons testing, and the Satelife project, a satellite communications project enabling physicians around the world, especially in poor and remote areas, to communicate rapidly and cheaply. The direction and challenges set in Stockholm will ensure that the organisation continues to make a vital contribution to safeguarding the life and health of our planet and its inhabitants. TILMAN RUFF International Physicians for the Prevention of Nuclear War, Cambridge, Massachusetts 02142-1096,
USA
July.) 2 Haines A. Global security: a role for health professionals. PSR Quarterly 1991;1:89-95. 3 Renner M. Assessing the military's war on the environment. In: Brown LR, ed. State of the world 1991. New York: W W Norton, 1991:132-52.
1 Smith R. What now for IPPNW? BMJ 1991;303:145-6. (20 July.)
Better mental health services SIR,-The recent editorial regarding the recent 10th anniversary world congress of International Physicians for the Prevention of Nuclear War,' however, demands response. It describes the organisation as being now in crisis, the victim of its own success. I must disagree. Given the tremendous changes in Europe and the US-Soviet relations since the ninth congress
SIR,-Ms Ros Hepplewhite of MIND takes exception' to-my recommendation that mentally ill patients would benefit from a "personal physician" and that an increased number of consultant psychiatrists is needed to serve them.2 She then proceeds to give several reasons to support my case. She quotes the report by MIND, People First,' which says that many patients do not find
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