low plasma concentrations of free cyanide dicobalt edetate itself can be toxic.' A second approach is to use sodium nitrite, which converts haemoglobin to methaemoglobin, though in a patient whose oxygen delivery is already compromised by a high carboxyhaemoglobin concentration a further decrease in the haemoglobin available for oxygen transport can be dangerous. We therefore recommend use of the safer intravenous antidote sodium thiosulphate,3 whose distribution is enhanced by the vasodilator amyl nitrite.4 R M LANGFORD
University College Hospital, London WC1E 6AU C J VESEY
St Bartholomew's Hospital, London ECIA 7BE I Robertson C, Fenton 0. Management of severe burns. Br MedJ 1990;301:282-6. (4 August.) 2 Home Office. Fire statistics. United Kingdom. London: HMSO,
1988. 3 Marrs TC. The choice of cyanide antidotes. In: Ballantyne B, Marrs T, eds. Clinical and experimental toxicology of cvanides. Bristol: Wright, 1987:383-401. 4 van Heiist ANP, Meredith TJ. Antidotes for cyanide poisoning. In: Volans GN, Sims J, Sullivan FM, Turner P, eds. Basic science in toxicology, 5th international congress of toxicology. London: Taylor and Francis, 1990:560.
Whiplash injury SIR,-Dr P K Newman fails to come clean over the "thorny problem of the late whiplash syndrome."' Opinion should be separated from fact.
Fact (1) No study has been published with an adequate control group-that is, a series of injuries occurring in people not claiming compensation. (2) No radiographic technique or laboratory test exists to confirm or refute the symptoms. (3) Relative sparing of the young and the over 60s and poor correlation with radiographic evidence of spondylosis indicate that symptoms are mainly independent of degenerative changes in the cervical spine. (4) Most subjects recover quickly, two thirds being free of pain after three months and three quarters returning to work after one month.2 The striking resemblance to strains of other muscles and ligaments is apparent. (5) There is a high association with anxiety and depression.2' Spurious non-anatomical physical signs are common and reflect exaggeration or simulation of illness. Analgesics and collars fail to relieve symptoms of late whiplash. Settlement of litigation sometimes, but not always, results in resolution of complaints. (6) Maimaris has reported results of magnetic resonance imaging in four patients with moderate or severe persisting symptoms4 and Von Meydam et al have similarly examined 15 such patients.5 The results were normal in all 19 patients.
Opinion There is little evidence to suggest that whiplash injury is different from other muscular or ligamentous strains. It is much better termed neck sprain. By definition I would exclude all patients with neck injuries affecting vertebrae, intervertebral discs, or nerve roots, which indicate a more serious condition and a different natural course. Dr Newman and others fail to provide an organic explanation for the persistence of symptoms, and results of magnetic resonance imaging argue strongly against a mechanical source. Whether these symptoms are genuine or exag-
gerated in the interests of enhancing financial rewards is a subjective judgment. Dr Newman cites no support for his contention "it is usually the persistence .of symptoms that leads a patient to
610
litigation, and not vice versa." The available evidence argues to the contrary. Balla stated that "Socio-cultural factors may account for a number becoming chronic. It is difficult to separate the effects of seeking compensation from other factors. Whiplash injuries certainly lend themselves to fraud of which there have been a number of well documented cases seen at the Motor Accidents Board."'l Undoubtedly, disability may be prolonged by the lengthy delay in obtaining a legal settlement. Neurotic features can also be deliberately inflated and should be carefully weighed in relation to the circumstances, previous psychoneurotic illness, and current behaviour and observed reactions during examination. Most victims of whiplash injury have, however, sustained no more than a minor sprain to the soft tissues, and unusually severe or protracted complaints may demand explanations that lie outside the fields of organic and psychiatric illness. J M S PEARCE Hull Royal Infirmary, Hull HU3 2JZ
transferase activity was 1033 IU/l (normal range 13-51 IU/1). His creatine kinase activity was 28 218 IU/I (24-195 IU/1), and it later reached 73 000 IU/l before returning to normal on discharge. Investigations failed to find a cause of his rhabdomyolysis, and we concluded that it was caused by his falciparum malaria. Severe malaria can cause muscle injury in children and correlates with severity of illness.3 There has been only one other case of acute rhabdomyolysis and acute renal failure induced by malaria, and this occurred in a Sri Lankan man with severe disease and high parasite index.4 We agree with Dr Coakley and colleagues that in all cases of acute renal failure the possibility of muscle damage should be borne in mind and suggest that creatine kinase concentration be measured in all patients with falciparum malaria. There are many mechanisms of pathogenesis of malarial acute renal failure,5 and more research is needed to evaluate fully the nephrotoxic potential of skeletal muscle damage in this condition. W R J TAYLOR D I PROSSER
I Newman PK. WC'hiplash injurv. Br Med J7 1990;301:395. (I September.) 2 Pearce JMS. Whiplash injury: a reappraisal. J Neurol Neurosurg
Psvchiatry 1989;52:1329-31. 3 Balla JI. Report of the Motor Accidents Board of Victoria on whiplash injuries, 1984. In: Hopkins A, ed. Headache and cervical disorders. London: Saunders, 1988:256-69. 4 Maimaris C. Neck sprains after car accidents. Br Med J 1989;299: 123. 5 Van Meydam K, Sehlen S, Schlenkhoff D, Kiricuta JC, Beyer HK. Kernspintomographische Befunde beim Halswir-
belsaulentrauma. FortschrRoengenstr 1986;145:657-60.
AUTHOR'S REPLY,-Dr J M S Pearce has instructively expanded aspects of the late whiplash syndrome that I could only sketch in my editorial. Perhaps our only difference is that I am a few points lower than he on the hawk-dove rating scale of medicolegal necks. Lead swingers abound in our medicolegal practices, but so does genuine disability, and each case requires careful individual assessment. Unfortunately, many of the published "facts" about the late whiplash syndrome are subjective and have been extracted retrospectively from personal medicolegal series. Such material often has dubious validity, and I hope that a large, long term, prospective study will eventually emerge to illuminate this dusky corner of clinical practice. Finally, may I caution against undue reliance on negative results on magnetic resonance imaging. Recent experience in cervical degenerative disease suggests that this technique may be less accurate than myelography in a large proportion of cases. P K NEWMAN
Middlesbrough General Hospital, Middlesbrough, Cleveland TS5 5AZ
Occult ischaemic necrosis of skeletal muscle SIR,-Dr J H Coakley and colleagues report that ischaemic muscle necrosis may be associated with acute renal failure.' We would like to draw attention to another unusual cause of acute renal failure-namely, acute rhabdomyolysis. An 18 year old Gambian man who developed acute falciparum malaria and a parasite index of 1 1% went on to develop acute hypercatabolic renal failure, which required dialysis and which is usually associated with a high parasite index.2 He complained of general malaise and fever and displayed no remarkable physical signs, and in common with the patients described by Dr Coakley and colleagues he had no muscle symptoms or signs. We were alerted to the possibility of acute rhabdomyolysis because his aspartate amino-
Kent and Canterbury Hospital.
Canterbury CTI 3NG 1 Coaklev JH, Edwards RHT, McClelland P, Bone JM, Helliwell TR. Occult ischaemic necrosis of skeletal muscle associated with renal failure. Br Medj 1990;301:370. (18-25 August.) 2 Anonymous. Renal lesions in human malaria [Editoriall. Br MedJ7 1976;ii: 132. 3 Miller KD, White NJ, Lott JA, Roberts JM, Greenwood BM. Biochemical evidence of muscle in'jury in African children with severe malaria. J InJect Dis 1989;159: l39-42. 4 DeSilva HJ, Goonetilleke AKE, Senaratna N, et al. Skeletal muscle necrosis in severe falciparum malaria. Br Med J 1988;296: 1039. 5 Sitprija V. Nephropathy in falciparum malaria. Kidney Int 1988;34:868-77.
Terminal cancer care and patients' preference for place of death SIR,-MS Joy Townsend and colleagues found that 67% of patients dying of cancer, given "more favourable circumstances," would prefer to die at home, but only 29% did so. 'Twenty seven per cent of patients with cancer in England and Wales died at home in the same period.2 Although comparing home care teams is difficult because of the different ways in which they function, recent reports from hospice teams in England and abroad have shown that up to 71% of patients were enabled to die at home (table). Indeed, some Proportion of patients with cancer enabled to die at home according to place of care °/, Dying at home
North London Hospice 1985' St Mary's Hospice, Birmingham 1986' West Cumbria 1987' St Joseph's Hospice, London 1988' Tunbridge Wells Hospice at Home 1989* South Auckland Hospice, New Zealand 1988-9t Bologna, Italy 1985-88'
58 55 53 61 71 59 60
*Tunbridge Wells Hospice at Home Annual Review 1989.
tSouth Auckland Hospice Care Report 1989.
care teams are aiming higher.' Enabling more than two thirds of patients to die at home may be limited both by the wishes of patients and carers and by the community facilities available-for example, district nursing, Macmillan nurses, hospice home care services, medical services, and 24 hour care. BRENDAN AMESBURY
Horfield, Bristol BS7 8QZ I Townsend J, Frank AO, Fermont D, et al. 'Terminal cancer care and patients' preference for place of death: a prospective studv. Br MedJ 1990;301:415-7. (I September.)
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2 Office of Population Censuses and Surveys. Mlortality statistics for 1987. England and Wlales. London: HMSO, 1989. 3 Copperman H. Domiciliars hospice care: a survey of general practitioners. 7 R Coll Gen Pract 1988;38:411-3. 4 Rees WD. Changes in prescribing for terminal care patients in general practice, hospital and hospice over a five year period. J R Coll Gen Pract 1987;37:504-6. S Herd EB. Terminal care in a semi-rural area. British Journal of General Practice 1990;40:248-51. 6 Dunphy KP, Amesburv BDW. A comparison of hospice and home care patients: patterns of referral, patient characteristics and predictors of place of death. Palliative Medicine 1990;4: 105-11. 7 Pannuti F. Home care for advanced and very advanced cancer patients: the Bologna experience. Journal of Palliative Care 1988;4:54-7.
Precautions taken by orthopaedic surgeons to avoid infection with HIV and hepatitis B virus SIR,- Drs T C and S M M O'Dowd are concerned about the uptake of immunisation against hepatitis B virus among surgeons.' We believe that the immunisation rate among primary health care staff is also of concern. Despite optimistic data from Wessex region2 we and other groups'4 have found a low uptake of immunisation among health workers. We undertook a telephone survey of 149 Belgian general practitioners and 126 dental practitioners to assess vaccination state, prevalence of hepatitis B virus, and attitude and knowledge tow*ds the hepatitis B vaccines. We achieved a participation rate of 91%. A tenth of the doctors had been infected with hepatitis B virus, and one admitted to being a carrier; 9% of the dentists admitted to having had hepatitis B. As hepatitis B vaccine has been available for nearly a decade these prevalence data are hardly encouraging. They show that members of primary health care teams are at a great risk of infection and suggest that this risk is still underestimated. Only 66 of the doctors and 90 of the dentists had been immunised. Half the doctors and three quarters of the dentists who had not been immunised said that they would be willing to have a vaccination. The reasons given for not having been immunised were similar to those found by Porteous.' Seven people thought that the vaccine was not safe, of whom four were afraid of AIDS; 10 thought the vaccine too expensive; 29 had neglected to be immunised; and 24 did not think that they were at risk. The high proportion of doctors who had neglected to be immunised or thought immunisation unnecessary is disappointing, especially as almost a quarter of the participating doctors admitted having at least one needle accident a month and about a third still recapped needles. The lack of immunisation is clearly due to a failure in preventive medicine, and the most important reason is the lack of general awareness about hepatitis B virus among health staff.4 This raises the question whether doctors who fail to immunise themselves are the right people to educate, inform, or vaccinate their high risk patients. Further reduction of the prevalence of hepatitis B virus and increase in the acceptance of vaccine require that more information and a greater sense of responsibility are conveyed during medical education. PIERRE VAN DAMME MYRJAM CRAMM University of Antwerp, 2610 Antwerp,
GUIDO DE COCK WILLY EYLENBOSCH
Belgiusm I O'Dowd TC, O'Dowd SMM. Precautions taken by orthopaedic surgeons to avoid infection with HIV and hepatitis B virus. Br MedJ 1990;301:440-1. (I September.)
2 Williams JR, Flowerdew ADS. Uptake of immunisation against hepatitis B among surgeons in Wessex Regional Health Authority. BrMedJ 1990;301:154. (21 July.) 3 Kinnersley P. Attitudes of general practitioners towards their
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vaccination against hepatitis B. Br Med J 1990;300:238. (27 January.) 4 Scapa E, Karpuch J, Waron M, Eschar J. Attitude of hospital personnel towards hepatitis B vaccination. Am J Gastroenterol
1989;84:400-2. 5 Porteous MJLeF. Operating practices of and precautions taken by orthopaedic surgeons to avoid infection with HIV and hepatitis B virus during surgery. Br Med J 1990;301:167-9. (21 July.)
SIR,-We agree with Drs T C and S M M O'Dowd that surgeons and all health care workers at risk should be offered and should accept vaccination against hepatitis B virus. It is the health authority's duty to protect its employees against risks to their health and safety, but it is also the duty of employees to care for the health and safety of themselves and of the staff and patients who may be affected by their actions at work. We would not, however, support a policy of compulsory vaccination and a requirement for evidence of seroconversion before surgeons be allowed to operate. Such a policy could not take account of the fact that after the standard course of three injections only 75% achieve protective seroconversion (titre of antibodies to hepatitis B virus > 100 IU) and only a further 9% convert after a fourth injection.' The seroconversion rate falls with age, especially after the age of 40, and titres of antibodies to hepatitis B virus tend to fall with time, necessitating booster doses at intervals that have not been clearly determined. As vaccination cannot guarantee seroconversion the introduction of a policy requiring seroconversion might exclude experienced surgeons from practice, perhaps indefinitely, even if they had done all they could to protect themselves and their patients against infection with hepatitis B virus. We believe that our policy provides an effective and workable alternative to mandatory vaccination. We offer vaccination to health care staff, giving priority to those working with high risk patients. Those who fail to respond to vaccination and any who might have contracted hepatitis B during the course of their work are asked to submit serum for determination of carrier state. Carriers who work where there is a risk of infecting patients are advised of the potential risks and of their legal and moral responsibilities. Although it is the policy of the Department of Health to redeploy carriers (renal unit staff excepted) only if they are known to be responsible for the transmission of hepatitis B virus to patients,5 we also, with its consent, discuss redeployment with the appropriate manager as it would be morally and legally indefensible for a surgeon to continue to operate knowing or suspecting that he or she might be a carrier. COLIN D PAYTON D A SCARISBRICK Leicester Royal Infirmary, Leicester LEI 5WW I O'Dowd TC, O'Dowd SMM. Precautions taken by orthopaedic surgeons to avoid infection with HIV and hepatitis B virus.
BrMedj 1990;301:440-1. (1 September.) 2 Jachuck SJ, Jones C, Nicholls A, Bartlett M. Resource needs of an occupational health service to accommodate a hepatitis B vaccination programme. J Soc Occup Med 1990;40:89-91. 3 Department of Health. Chief medical officer's letter. London: DoH, 1972. (CMO 25/72.)
Vocational training in general practice SIR,-The plight of the trainee described by Mr D G Nasmyth is unfortunately all too common.' A study of hospital training for general practice in the North Western region has highlighted availability of study leave as an important deficiency.2 Study leave was applied for by trainees in only 37% of the 441 posts surveyed, and one fifth of these applications were refused. The most
common reasons given to trainees for these refusals were that the topic for study was not related to the current post or that leave was not being used to attend a course or sit an examination. Trainees appeared reluctant to apply for study leave despite this being a contractual right. This raises the question whether trainees, and junior doctors in general, no longer perceive study leave as a right but rather as a privilege bestowed on them by benevolent consultants. The situation is unfortunately likely to deteriorate. Lack of staff to provide cover for study leave is recognised as one of the biggest hindrances to solving this problem.' Given the increasingly profit motivated ethos behind health care, any application for extra senior health officers to cover study leave will come a poor second behind requests for staff for clinical developments likely to attract patients and therefore much needed cash. Mr Nasmyth suggests that if study leave is refused the suitability of the post for training must be questioned. This is true. It is important, however, not to view the issue of study leave in isolation. It is only one of several indicators that basic specialist training, for both general practice and other specialties, takes place in hospital posts in which, for the most part, the balance between service and training is seriously distorted.2 Unless this underlying deficiency is addressed, and several possible solutions have been proposed,34 the outlook for change must be bleak. HUGH REEVE Rusholme Health Centre, Manchester M14 5NP I Nasmyth DG. Vocational training for general practice. BrMedj 1990;301:389-90. (18-25 August.) 2 Reeve HA, Bowman A. Hospital training for general practice: views of trainees in the North Western region. Br Med J 1989;298: 1432-4. 3 Council for Postgraduate Medical Education in England and Wales. The problems of the senior house officer. London: CPME, 1987. 4 General MedicalCouncil EducationCommittee. Recommendations on the training of specialists. London: GMC, 1987.
Eosinophilia myalgia syndrome SIR,-It is difficult to share Minerva's optimism that the mystery of the eosinophilia myalgia syndrome is now solved.' Though the probable chemical contaminant in tryptophan has been identified,2 there are many unanswered questions. What is the mechanism by which this chemical induces the syndrome? What is the role of the eosinophils? Why does the inflammatory condition have a predilection for fascial surfaces? Why have only a few of the people who have taken tryptophan developed the syndrome? And most importantly, what lessons can this "natural experiment" teach us about similar idiopathic multisystem disorders? In Spain in 1981 an analogous problem was identified. The toxicoil syndrome, clinically similar to the eosinophilia myalgia syndrome, was induced by denatured rape seed oil sold as cooking oil.3 Despite identifying the responsible chemical the specific cause and pathophysiology have not been elucidated. Early enthusiasm that this syndrome might provide clues to conditions such as systemic sclerosis has so far been unfounded. Therefore, identification of the responsible chemical in the eosinophilia myalgia syndrome hardly justifies the statement that "the mystery illness is a mystery no longer." C M DEIGHTON
Sunderland Royal Infirmary, Sunderland SR2 7JE 1 Anonymous. Views. BrMed_' 1990;301:450. (1 September.) 2 Belongia EA, Hedberg CW, Gleich GJ, et al. An investigation of the cause of the eosinophilia-myalgia syndrome associated with tryptophan use. N EnglJ Med 1990;323:357-65. 3 Kilbourne EM, Rigau-Perez JG, Heath CW, et al. Clinical epidemiology of toxic-oil syndrome: manifestations of a new illness. N Engl3 Med 1983;309:1408-14.
611
University College Hospital, London WC1E 6AU C J VESEY
St Bartholomew's Hospital, London ECIA 7BE I Robertson C, Fenton 0. Management of severe burns. Br MedJ 1990;301:282-6. (4 August.) 2 Home Office. Fire statistics. United Kingdom. London: HMSO,
1988. 3 Marrs TC. The choice of cyanide antidotes. In: Ballantyne B, Marrs T, eds. Clinical and experimental toxicology of cvanides. Bristol: Wright, 1987:383-401. 4 van Heiist ANP, Meredith TJ. Antidotes for cyanide poisoning. In: Volans GN, Sims J, Sullivan FM, Turner P, eds. Basic science in toxicology, 5th international congress of toxicology. London: Taylor and Francis, 1990:560.
Whiplash injury SIR,-Dr P K Newman fails to come clean over the "thorny problem of the late whiplash syndrome."' Opinion should be separated from fact.
Fact (1) No study has been published with an adequate control group-that is, a series of injuries occurring in people not claiming compensation. (2) No radiographic technique or laboratory test exists to confirm or refute the symptoms. (3) Relative sparing of the young and the over 60s and poor correlation with radiographic evidence of spondylosis indicate that symptoms are mainly independent of degenerative changes in the cervical spine. (4) Most subjects recover quickly, two thirds being free of pain after three months and three quarters returning to work after one month.2 The striking resemblance to strains of other muscles and ligaments is apparent. (5) There is a high association with anxiety and depression.2' Spurious non-anatomical physical signs are common and reflect exaggeration or simulation of illness. Analgesics and collars fail to relieve symptoms of late whiplash. Settlement of litigation sometimes, but not always, results in resolution of complaints. (6) Maimaris has reported results of magnetic resonance imaging in four patients with moderate or severe persisting symptoms4 and Von Meydam et al have similarly examined 15 such patients.5 The results were normal in all 19 patients.
Opinion There is little evidence to suggest that whiplash injury is different from other muscular or ligamentous strains. It is much better termed neck sprain. By definition I would exclude all patients with neck injuries affecting vertebrae, intervertebral discs, or nerve roots, which indicate a more serious condition and a different natural course. Dr Newman and others fail to provide an organic explanation for the persistence of symptoms, and results of magnetic resonance imaging argue strongly against a mechanical source. Whether these symptoms are genuine or exag-
gerated in the interests of enhancing financial rewards is a subjective judgment. Dr Newman cites no support for his contention "it is usually the persistence .of symptoms that leads a patient to
610
litigation, and not vice versa." The available evidence argues to the contrary. Balla stated that "Socio-cultural factors may account for a number becoming chronic. It is difficult to separate the effects of seeking compensation from other factors. Whiplash injuries certainly lend themselves to fraud of which there have been a number of well documented cases seen at the Motor Accidents Board."'l Undoubtedly, disability may be prolonged by the lengthy delay in obtaining a legal settlement. Neurotic features can also be deliberately inflated and should be carefully weighed in relation to the circumstances, previous psychoneurotic illness, and current behaviour and observed reactions during examination. Most victims of whiplash injury have, however, sustained no more than a minor sprain to the soft tissues, and unusually severe or protracted complaints may demand explanations that lie outside the fields of organic and psychiatric illness. J M S PEARCE Hull Royal Infirmary, Hull HU3 2JZ
transferase activity was 1033 IU/l (normal range 13-51 IU/1). His creatine kinase activity was 28 218 IU/I (24-195 IU/1), and it later reached 73 000 IU/l before returning to normal on discharge. Investigations failed to find a cause of his rhabdomyolysis, and we concluded that it was caused by his falciparum malaria. Severe malaria can cause muscle injury in children and correlates with severity of illness.3 There has been only one other case of acute rhabdomyolysis and acute renal failure induced by malaria, and this occurred in a Sri Lankan man with severe disease and high parasite index.4 We agree with Dr Coakley and colleagues that in all cases of acute renal failure the possibility of muscle damage should be borne in mind and suggest that creatine kinase concentration be measured in all patients with falciparum malaria. There are many mechanisms of pathogenesis of malarial acute renal failure,5 and more research is needed to evaluate fully the nephrotoxic potential of skeletal muscle damage in this condition. W R J TAYLOR D I PROSSER
I Newman PK. WC'hiplash injurv. Br Med J7 1990;301:395. (I September.) 2 Pearce JMS. Whiplash injury: a reappraisal. J Neurol Neurosurg
Psvchiatry 1989;52:1329-31. 3 Balla JI. Report of the Motor Accidents Board of Victoria on whiplash injuries, 1984. In: Hopkins A, ed. Headache and cervical disorders. London: Saunders, 1988:256-69. 4 Maimaris C. Neck sprains after car accidents. Br Med J 1989;299: 123. 5 Van Meydam K, Sehlen S, Schlenkhoff D, Kiricuta JC, Beyer HK. Kernspintomographische Befunde beim Halswir-
belsaulentrauma. FortschrRoengenstr 1986;145:657-60.
AUTHOR'S REPLY,-Dr J M S Pearce has instructively expanded aspects of the late whiplash syndrome that I could only sketch in my editorial. Perhaps our only difference is that I am a few points lower than he on the hawk-dove rating scale of medicolegal necks. Lead swingers abound in our medicolegal practices, but so does genuine disability, and each case requires careful individual assessment. Unfortunately, many of the published "facts" about the late whiplash syndrome are subjective and have been extracted retrospectively from personal medicolegal series. Such material often has dubious validity, and I hope that a large, long term, prospective study will eventually emerge to illuminate this dusky corner of clinical practice. Finally, may I caution against undue reliance on negative results on magnetic resonance imaging. Recent experience in cervical degenerative disease suggests that this technique may be less accurate than myelography in a large proportion of cases. P K NEWMAN
Middlesbrough General Hospital, Middlesbrough, Cleveland TS5 5AZ
Occult ischaemic necrosis of skeletal muscle SIR,-Dr J H Coakley and colleagues report that ischaemic muscle necrosis may be associated with acute renal failure.' We would like to draw attention to another unusual cause of acute renal failure-namely, acute rhabdomyolysis. An 18 year old Gambian man who developed acute falciparum malaria and a parasite index of 1 1% went on to develop acute hypercatabolic renal failure, which required dialysis and which is usually associated with a high parasite index.2 He complained of general malaise and fever and displayed no remarkable physical signs, and in common with the patients described by Dr Coakley and colleagues he had no muscle symptoms or signs. We were alerted to the possibility of acute rhabdomyolysis because his aspartate amino-
Kent and Canterbury Hospital.
Canterbury CTI 3NG 1 Coaklev JH, Edwards RHT, McClelland P, Bone JM, Helliwell TR. Occult ischaemic necrosis of skeletal muscle associated with renal failure. Br Medj 1990;301:370. (18-25 August.) 2 Anonymous. Renal lesions in human malaria [Editoriall. Br MedJ7 1976;ii: 132. 3 Miller KD, White NJ, Lott JA, Roberts JM, Greenwood BM. Biochemical evidence of muscle in'jury in African children with severe malaria. J InJect Dis 1989;159: l39-42. 4 DeSilva HJ, Goonetilleke AKE, Senaratna N, et al. Skeletal muscle necrosis in severe falciparum malaria. Br Med J 1988;296: 1039. 5 Sitprija V. Nephropathy in falciparum malaria. Kidney Int 1988;34:868-77.
Terminal cancer care and patients' preference for place of death SIR,-MS Joy Townsend and colleagues found that 67% of patients dying of cancer, given "more favourable circumstances," would prefer to die at home, but only 29% did so. 'Twenty seven per cent of patients with cancer in England and Wales died at home in the same period.2 Although comparing home care teams is difficult because of the different ways in which they function, recent reports from hospice teams in England and abroad have shown that up to 71% of patients were enabled to die at home (table). Indeed, some Proportion of patients with cancer enabled to die at home according to place of care °/, Dying at home
North London Hospice 1985' St Mary's Hospice, Birmingham 1986' West Cumbria 1987' St Joseph's Hospice, London 1988' Tunbridge Wells Hospice at Home 1989* South Auckland Hospice, New Zealand 1988-9t Bologna, Italy 1985-88'
58 55 53 61 71 59 60
*Tunbridge Wells Hospice at Home Annual Review 1989.
tSouth Auckland Hospice Care Report 1989.
care teams are aiming higher.' Enabling more than two thirds of patients to die at home may be limited both by the wishes of patients and carers and by the community facilities available-for example, district nursing, Macmillan nurses, hospice home care services, medical services, and 24 hour care. BRENDAN AMESBURY
Horfield, Bristol BS7 8QZ I Townsend J, Frank AO, Fermont D, et al. 'Terminal cancer care and patients' preference for place of death: a prospective studv. Br MedJ 1990;301:415-7. (I September.)
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2 Office of Population Censuses and Surveys. Mlortality statistics for 1987. England and Wlales. London: HMSO, 1989. 3 Copperman H. Domiciliars hospice care: a survey of general practitioners. 7 R Coll Gen Pract 1988;38:411-3. 4 Rees WD. Changes in prescribing for terminal care patients in general practice, hospital and hospice over a five year period. J R Coll Gen Pract 1987;37:504-6. S Herd EB. Terminal care in a semi-rural area. British Journal of General Practice 1990;40:248-51. 6 Dunphy KP, Amesburv BDW. A comparison of hospice and home care patients: patterns of referral, patient characteristics and predictors of place of death. Palliative Medicine 1990;4: 105-11. 7 Pannuti F. Home care for advanced and very advanced cancer patients: the Bologna experience. Journal of Palliative Care 1988;4:54-7.
Precautions taken by orthopaedic surgeons to avoid infection with HIV and hepatitis B virus SIR,- Drs T C and S M M O'Dowd are concerned about the uptake of immunisation against hepatitis B virus among surgeons.' We believe that the immunisation rate among primary health care staff is also of concern. Despite optimistic data from Wessex region2 we and other groups'4 have found a low uptake of immunisation among health workers. We undertook a telephone survey of 149 Belgian general practitioners and 126 dental practitioners to assess vaccination state, prevalence of hepatitis B virus, and attitude and knowledge tow*ds the hepatitis B vaccines. We achieved a participation rate of 91%. A tenth of the doctors had been infected with hepatitis B virus, and one admitted to being a carrier; 9% of the dentists admitted to having had hepatitis B. As hepatitis B vaccine has been available for nearly a decade these prevalence data are hardly encouraging. They show that members of primary health care teams are at a great risk of infection and suggest that this risk is still underestimated. Only 66 of the doctors and 90 of the dentists had been immunised. Half the doctors and three quarters of the dentists who had not been immunised said that they would be willing to have a vaccination. The reasons given for not having been immunised were similar to those found by Porteous.' Seven people thought that the vaccine was not safe, of whom four were afraid of AIDS; 10 thought the vaccine too expensive; 29 had neglected to be immunised; and 24 did not think that they were at risk. The high proportion of doctors who had neglected to be immunised or thought immunisation unnecessary is disappointing, especially as almost a quarter of the participating doctors admitted having at least one needle accident a month and about a third still recapped needles. The lack of immunisation is clearly due to a failure in preventive medicine, and the most important reason is the lack of general awareness about hepatitis B virus among health staff.4 This raises the question whether doctors who fail to immunise themselves are the right people to educate, inform, or vaccinate their high risk patients. Further reduction of the prevalence of hepatitis B virus and increase in the acceptance of vaccine require that more information and a greater sense of responsibility are conveyed during medical education. PIERRE VAN DAMME MYRJAM CRAMM University of Antwerp, 2610 Antwerp,
GUIDO DE COCK WILLY EYLENBOSCH
Belgiusm I O'Dowd TC, O'Dowd SMM. Precautions taken by orthopaedic surgeons to avoid infection with HIV and hepatitis B virus. Br MedJ 1990;301:440-1. (I September.)
2 Williams JR, Flowerdew ADS. Uptake of immunisation against hepatitis B among surgeons in Wessex Regional Health Authority. BrMedJ 1990;301:154. (21 July.) 3 Kinnersley P. Attitudes of general practitioners towards their
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vaccination against hepatitis B. Br Med J 1990;300:238. (27 January.) 4 Scapa E, Karpuch J, Waron M, Eschar J. Attitude of hospital personnel towards hepatitis B vaccination. Am J Gastroenterol
1989;84:400-2. 5 Porteous MJLeF. Operating practices of and precautions taken by orthopaedic surgeons to avoid infection with HIV and hepatitis B virus during surgery. Br Med J 1990;301:167-9. (21 July.)
SIR,-We agree with Drs T C and S M M O'Dowd that surgeons and all health care workers at risk should be offered and should accept vaccination against hepatitis B virus. It is the health authority's duty to protect its employees against risks to their health and safety, but it is also the duty of employees to care for the health and safety of themselves and of the staff and patients who may be affected by their actions at work. We would not, however, support a policy of compulsory vaccination and a requirement for evidence of seroconversion before surgeons be allowed to operate. Such a policy could not take account of the fact that after the standard course of three injections only 75% achieve protective seroconversion (titre of antibodies to hepatitis B virus > 100 IU) and only a further 9% convert after a fourth injection.' The seroconversion rate falls with age, especially after the age of 40, and titres of antibodies to hepatitis B virus tend to fall with time, necessitating booster doses at intervals that have not been clearly determined. As vaccination cannot guarantee seroconversion the introduction of a policy requiring seroconversion might exclude experienced surgeons from practice, perhaps indefinitely, even if they had done all they could to protect themselves and their patients against infection with hepatitis B virus. We believe that our policy provides an effective and workable alternative to mandatory vaccination. We offer vaccination to health care staff, giving priority to those working with high risk patients. Those who fail to respond to vaccination and any who might have contracted hepatitis B during the course of their work are asked to submit serum for determination of carrier state. Carriers who work where there is a risk of infecting patients are advised of the potential risks and of their legal and moral responsibilities. Although it is the policy of the Department of Health to redeploy carriers (renal unit staff excepted) only if they are known to be responsible for the transmission of hepatitis B virus to patients,5 we also, with its consent, discuss redeployment with the appropriate manager as it would be morally and legally indefensible for a surgeon to continue to operate knowing or suspecting that he or she might be a carrier. COLIN D PAYTON D A SCARISBRICK Leicester Royal Infirmary, Leicester LEI 5WW I O'Dowd TC, O'Dowd SMM. Precautions taken by orthopaedic surgeons to avoid infection with HIV and hepatitis B virus.
BrMedj 1990;301:440-1. (1 September.) 2 Jachuck SJ, Jones C, Nicholls A, Bartlett M. Resource needs of an occupational health service to accommodate a hepatitis B vaccination programme. J Soc Occup Med 1990;40:89-91. 3 Department of Health. Chief medical officer's letter. London: DoH, 1972. (CMO 25/72.)
Vocational training in general practice SIR,-The plight of the trainee described by Mr D G Nasmyth is unfortunately all too common.' A study of hospital training for general practice in the North Western region has highlighted availability of study leave as an important deficiency.2 Study leave was applied for by trainees in only 37% of the 441 posts surveyed, and one fifth of these applications were refused. The most
common reasons given to trainees for these refusals were that the topic for study was not related to the current post or that leave was not being used to attend a course or sit an examination. Trainees appeared reluctant to apply for study leave despite this being a contractual right. This raises the question whether trainees, and junior doctors in general, no longer perceive study leave as a right but rather as a privilege bestowed on them by benevolent consultants. The situation is unfortunately likely to deteriorate. Lack of staff to provide cover for study leave is recognised as one of the biggest hindrances to solving this problem.' Given the increasingly profit motivated ethos behind health care, any application for extra senior health officers to cover study leave will come a poor second behind requests for staff for clinical developments likely to attract patients and therefore much needed cash. Mr Nasmyth suggests that if study leave is refused the suitability of the post for training must be questioned. This is true. It is important, however, not to view the issue of study leave in isolation. It is only one of several indicators that basic specialist training, for both general practice and other specialties, takes place in hospital posts in which, for the most part, the balance between service and training is seriously distorted.2 Unless this underlying deficiency is addressed, and several possible solutions have been proposed,34 the outlook for change must be bleak. HUGH REEVE Rusholme Health Centre, Manchester M14 5NP I Nasmyth DG. Vocational training for general practice. BrMedj 1990;301:389-90. (18-25 August.) 2 Reeve HA, Bowman A. Hospital training for general practice: views of trainees in the North Western region. Br Med J 1989;298: 1432-4. 3 Council for Postgraduate Medical Education in England and Wales. The problems of the senior house officer. London: CPME, 1987. 4 General MedicalCouncil EducationCommittee. Recommendations on the training of specialists. London: GMC, 1987.
Eosinophilia myalgia syndrome SIR,-It is difficult to share Minerva's optimism that the mystery of the eosinophilia myalgia syndrome is now solved.' Though the probable chemical contaminant in tryptophan has been identified,2 there are many unanswered questions. What is the mechanism by which this chemical induces the syndrome? What is the role of the eosinophils? Why does the inflammatory condition have a predilection for fascial surfaces? Why have only a few of the people who have taken tryptophan developed the syndrome? And most importantly, what lessons can this "natural experiment" teach us about similar idiopathic multisystem disorders? In Spain in 1981 an analogous problem was identified. The toxicoil syndrome, clinically similar to the eosinophilia myalgia syndrome, was induced by denatured rape seed oil sold as cooking oil.3 Despite identifying the responsible chemical the specific cause and pathophysiology have not been elucidated. Early enthusiasm that this syndrome might provide clues to conditions such as systemic sclerosis has so far been unfounded. Therefore, identification of the responsible chemical in the eosinophilia myalgia syndrome hardly justifies the statement that "the mystery illness is a mystery no longer." C M DEIGHTON
Sunderland Royal Infirmary, Sunderland SR2 7JE 1 Anonymous. Views. BrMed_' 1990;301:450. (1 September.) 2 Belongia EA, Hedberg CW, Gleich GJ, et al. An investigation of the cause of the eosinophilia-myalgia syndrome associated with tryptophan use. N EnglJ Med 1990;323:357-65. 3 Kilbourne EM, Rigau-Perez JG, Heath CW, et al. Clinical epidemiology of toxic-oil syndrome: manifestations of a new illness. N Engl3 Med 1983;309:1408-14.
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