to 1500 mg/day) have, in aggregate, actually shown appreciable protection against ischaemic heart disease.6 C H HENNEKENS J E BURING Department of Medicine and Preventive Medicine, Harvard Medical School and Brigham and Women's Hospital, Boston, MA 02115, United States P A G SANDERCOCK Department of Clinical Neurosciences, Western General Hospital, Edinburgh EH4 2XU R GRAY K WHEATLEY

R COLLINS R DOLL R PETO

Clinical Trial Service Unit, Radcliffe Infirmary, Oxford OX2 6HE I Paganini-Hill A, Chao A, Ross RK, Henderson BE. Aspirin use and chronic diseases: a cohort studv of the elderly. Br Med 3 1989;299:1247-50. (18 November.) 2 Ross RK, Paganini-Hill A, Landolph J, Gerkins V, Henderson BE. Analgesics, cigarette smoking, and other risk factors for cancer of the renal pelvis and ureter. Cancer Res 1989;49: 1045-8. 3 International Agency for Research on Cancer. Some pharmaceutical drugs. IARC Mlonographs on the Evaluation of the Carcinogenic Risk ofjChemicals of Humans 1980;24:135-61. 4 Steering Committee on the Physicians' Health Study Research Group. Final report on the aspirin component of the ongoing physicians' health study. N EnglJfMed 1989;321:129-35. 5 Peto R, Gray R, Collins R, et al. Randomised trial of prophylactic daily aspirin in British male doctors. BrMedJ7 1988;296:313-6. 6 Antiplatelet Trialists' Collaboration. Secondary prevention of sascular disease by prolonged antiplatelet treatment. Br Med]3

1988;2%:320-31. 7 Hennekens CH, Buring JE, Sandercock P, Collins R, Peto R. Aspirin and other antiplatelet agents in the secondary and primary prevention of cardiovascular disease. Circulation 1989;

80:749-56.

Terminal careless SIR,-I read with embarrassment the sad indictment of terminal care described by a doctor daughter concerning her father's final illness.' It raises a number of points that should be addressed. The return of symptoms some months after operation resulted in a "perfunctory" examination and the pronouncement of a clear clinical bill. Even with the assistance of modern investigations this cannot be guaranteed, and some effort by the clinician to communicate at this stage about the real possibility of emerging secondary spread will pave the way for understanding in the future. With the emphasis on curative medicine in our training we are all too keen to avoid discussing this possibility-a matter compounded by a lack of teaching of communication skills. It was pleasing to read that the hospital started oral morphine after inadequate attempts at home analgesia, and then progressed to a more appropriate subcutaneous infusion of opiate. Sadly, it is my experience on referral of terminal care patients that they are handled inadequately in hospital, little thought being given to route of administration or preparation. That trained nurses should have to call a junior houseman to refill a syringe pump is a reflection of the lengths to which nursing has allowed itself to be dominated. Milner et al reported the wide limitations that exist in the use of this excellent mode of opiate administration.2 In our district general hospital, the community around us, and the hospice trained nurses draw up, initiate, change, and monitor subcutaneous analgesia. They are trained; they are with the patients all the time; and they need the flexibility to respond to analgesic and other requirements of symptoms. Many advances have been achieved in recent years,' but it is important that these are aimed at improving pain management in the majority of patients rather than the small percentage who benefit from the sophisticated techniques that are costly in manpower and apparatus. Hospital teams, a regional terminal care approach,

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and audit for evaluation are needed. The Macmillan Service has extended into some hospitals and will continue to do so. Our hospital has a full time nurse specialist in chronic pain management whose job inevitably crosses the borders of managing cancer and non-cancer related chronic pain and entails appropriate liaison. The region has responded by setting up the Trent Region Palliative and Continuing Care Centre in 1989,4 a non-clinical facility for supporting, disseminating, educating, and helping coordinate research. It consists of a multidisciplinary team of experts, and we hope to report more fully in coming years. Audit of our work is planned, and already other excellent work in this area is in progress, financed by Help the Hospices.' Standards of pain control and terminal care obviously failed our colleague and her father, and for that reason alone we need to re-examine our systems of care delivery. Regrettably, however, it fails many others, as evidenced by the WHO report outlining that nearly 80% of patients reviewed in Britain, the United States, and Canada do not receive good pain relief in their terminal illness. With a few exceptions, the hospice movement and pain control clinics are still in their infancy; they provide ample evidence that we need to disseminate much more widely.

Unfortunately, I cannot reassure readers that they will receive even adequate pain control when they need it. A few years ago, after a craniotomy operation, I experienced quite devastating headache on waking. Although it was an established fact that quite a small dose of analgesic administered on waking relieved me of this agony, this had to be "authorised" by a ward doctor on each occasion. During the "waiting period" I was demoralisingly reduced to tears on several occasions. Eventually I persuaded my wife to raid my home emergency box for some pain killers, which we hid in my bedside locker. Quite soon I recovered, but the memory still leaves me furious at being made to suffer unnecessarily. When will we as a profession learn to generously and wisely prescribe the remedies at our disposal? Perhaps those who do not understand about pain control should fail their final or postgraduate examinations, as well as earning our universal and public censure. ERIC TRIMMER

Bembridge P035 5RY I Anonymous. Terminal careless. Br Med J 1989;299:1471. (9 December.)

R E ATKINSON

Trent Region Palliative and Continuing Care Centre, Sheffield Sll 9NE I Anonymous. Terminal careless. Br Med J 1989;299:1471.

(9 December.) 2 Milner PC, Harper R, Williams BT. What do palliative care workers think about portable syringe drivers? Palliative Medicine 1989;3: 141-50. 3 Atkinson RE. Cancer pain. Current Opinion in Anaesthesia 1989;2:653-7. 4 Anonymous. Tertninal care regional centre. Br MedJ3 1989;299: 63. (1 July.) 5 Higginson I, McCarthy M. Evaluation of palliative care: steps to quality assurance? Palliative Medicine 1989;3:267-74.

SIR,-The disturbing personal view on the terminal care that the author's father received' is a sad reflection on the patchy provision of terminal care services in the United Kingdom. Charities such as Cancer Relief have dramatically improved the community nursing services in this field, and their educational efforts, with those of the larger hospices, have, I believe, had an impact and improved the care of the dying. The writer correctly pleads for more hospital support teams, and too few districts seem to have responded meaningfully to the Department of Health's request in 1987 for them to look at NHS provision for the terminally ill in their areas. I have argued elsewhere the advantage of the district general hospital as the site for hospices, for here good care can be provided with easy access to investigative facilities, physiotherapy, and occupational therapy, and there can be easy medical cover.2 More importantly, this siting permits the easy spread of educational messages to the rest of the hospital. Such hospices can act as the base for hospital support teams and for the community teams. Good care for the dying is surely as essential a core service as good care of the diabetic or the patient with a myocardial infarction. MARTYN R PARTRIDGE Whipps Cross Hospital, London ElII NR

Rape and subsequent seroconversion to HIV SIR,-Drs Irene Foster and J G Bartlett have suggested that the topical application of virucidal agents-for example, nonoxvnol 9 or vinegar-in the form of a douche to the vagina after rape may be useful in preventing HIV transmission. ' Although nonoxynol 9 is known to counteract HIV in vitro, it has not been adequately evaluated in vivo. Indeed, Kreiss et al failed to show the efficacy of nonoxynol 9 in preventing heterosexual transmission of HIV when used in contraceptive sponges (fifth international conference on AIDS, Montreal, 1989). They also showed that the subjects using contraceptive sponges soaked with nonoxynol 9 had, in comparison with controls, an increased incidence of genital ulceration and of genital seroconversion to HIV associated with genital ulcer. As rape may also involve anal intercourse2 it would follow on these recommendations that the rectum also should be douched. The safety of nonoxynol 9 in rectal use, however, has not been established.3 We believe that at present there is inadequate evidence that douching with these agents after rape is beneficial; their use should not be recommended. S MURPHY P E MUNDAY D J JEFFRIES

Departments of Genitourinary Medicine and Virology, St Mary's Hospital, London W2 I NY I Foster I, Bartlett J. Rape and subsequent seroconversion to HIV. Br Medj 1989;299: 1282. (18 November.) 2 Murphy S, Kitchen V, Harris JRW, Forster SM. Rape and subsequent seroconversion to HIV. Br Med J 1989;299:718. (16 September.) 3 Reitmeijer CAM, Krebs J, Feorino P, Judson F. Condoms as physical and chemical barriers against HIV. JAMA 1988;259: 185 1-3.

1 Anonymous. rerminal careless. Br Med j 1989;299:1471. (9 December.) 2 Partridge MR. NHS provision for terminal care: one district's deliberations. Journal of Management in Medicine 1988;3: 362-71.

The cyclotron saga continues

SIR,-Your anonymous correspondent's horror story of the death of her father is quite the most awful indictment of our profession that I have ever read.' This example of man's inhumanity to man is ironically published in the same issue that proudly announced Cecily Saunders's well earned OM.

SIR,-The editorial by Dr J S Tobias' does no more than stir up the mud again. It contains no new information or references. A recent report of a large randomised trial in patients with head and neck cancer from five American centres showed no significant difference in survival or control overall between groups

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treated with neutrons and photons.2 Results were significantly better, however, for neutron than photon treatment in node positive patients, but worse in node negative patients with the suggestion that these were caused by inadequate planning because of the fixed neutron beams. No opposition was expressed to continued trials now under way. The discontinuation of funding suggested by Dr Tobias refers to that of new cyclotrons rather than of existing units. The arguments against neutrons have been well rehearsed. We still do not have clear cut answers. The proposed unit at St Thomas's would be for not only neutron therapy but also particle treatment of eye tumours and nuclide production for positron emission tomography. Cancer therapy depends on adequate planning of treatment obtainable only with the newer high energy neutrons. The earlier work at Hammersmith using fixed horizontal beams was a remarkable achievement, whatever the final value of neutron therapy. The real interest in this debate lies not only in the true role of neutron therapy but in the political machinations of the funding process. These have no long term significance. We await with interest the results of clinical trials and the evaluation of data obtained by positron emission tomography. KEITH HALNAN KAROL SIKORA

Department of Clinical Oncology, Roval Postgraduate Medical School, Hammersmith Hospital, London W12 OHS 1 Tobias JS. The cyclotron saga continucs. Br Med J 1989;299: 1294-5. (25 November.) 2 Griffin TW, Pajak TF. Mixed neutron/photon irradiation of unresectable squamous cell carcinoma of the head and neck: the final report of a randomised co-operative trial. Int 7 Radiat Oncol Biol Phts 1989;17:959-65.

Insertion of permanent pacemakers as a day case procedure SIR,-Dr Guy A Haywood and colleagues report that the insertion of permanent pacemakers as a day case procedure is as acceptable to patients as conventional admission and that the incidence of complications is comparable in these groups. I wish to draw their attention to a few facts. The incidence of lead displacement causing capture failure was reported to be 1/21 in the day case group and 1/19 among patients managed conventionally. Whether this was detected during the hospital stay or after discharge and the mode of presentation have not been mentioned by the authors. As only 37 patients received new permanent pacemakers (three having received only generators), the incidence of capture failure following lead dislodgement is 2/37-that is, more than 5%. Although there was no significant difference between the two groups, this is a significantly high rate of displacement considering the present lead designs. The rate has been reported to be as low as 04%,2 and this problem has not occurred in my latest 73 patients. This is an extremely important complication: for patients who depend on pacemakers capture failure could be fatal, especially if the patient has been discharged from the hospital. May I therefore suggest that the authors review and if necessary revise their method of lead implantation before taking to implanting permanent pacemakers on a day case basis? Also, the authors have mention,ed that "standard implantation procedures" were used but did not specify the exact number of procedures performed by subclavian puncture or cephalic vein cut down. It is important to note that the chances of haematoma formation are considerable with subclavian puncture.3 In cephalic venous cut down complete haemostasis is possible because the

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same is done under vision. Thus in patients undergoing permanent pacemaker implantation as a day case procedure cephalic venous cut down would be preferable to prevent the complication of haematoma formation and subsequent infection. BHARAT DALVI

Department of Cardiology, King Edward VII Miemorial Hospital, Bombay 400 012, India 1 Haywood GA, Camm AJ, Ward DE. Insertion of permanent pacemakers as a day case procedure. Br MedJ 1989;299: 1 139. (4 November.) 2 Mond H. The pacemaker lead. In: Mond H, ed. The cardiac pacemaker: function and malfunction. New York: Grune and Stratton, 1983:76. 3 Janchuck SJ, Gill BS, Petty AH. Permanent cardiac pacing through the subclavian vein. Brj Surg 1974;61:373-6.

AUTHORS' REPLY, -Two patients were affected by lead dislodgement. One was assumed to have a microdislodgement as he had a low threshold before discharge but at one month follow up was failing to pace. A chest radiograph showed no obvious displacement, and increasing the pulse amplitude resulted in recapture. The other patient was one of the three who were to receive new generators, but an insulation break was noted in the old lead and a revision of system was carried out. Pacing was satisfactory before discharge, but at follow up at one month the chest radiograph showed lead displacement. Assuming that the threshold rise in the first patient was due to a microdislodgement, the rate was 2/38 (5 3%) for the series, which is within the range for electrode displacement quoted in other series (0-12-5% for ventricular and 0-9-6% for atrial leads) but is higher than the mean reported in these series (1 -6% for ventricular and 3 2% for atrial leads).' The numbers are, however, small, and Dr Dalvi's suggestion that our displacement rate is significantly higher is statistically incorrect. The important question is whether travelling after implantation increases the risk of electrode dislodgement compared with the risk in patients who remain in hospital for one or more days after implantation. As we pointed out in the article, calculations of sample size show that 2500 patients would have to be studied for a 90% probability of showing a doubling of the frequency of electrode dislodgement using a one tailed test at the 5% level of significance. We thought that it would be impracticable to attempt a study of this size, and we draw Dr Dalvi's attention to the studies referenced in the introduction to our article, which attempted to assess safety. We agree that cephalic cut down is the method of choice for introduction of the pacing lead, and it was used in 20 of the 38 patients in our series. In the remainder the operator judged the cephalic vein to be unsuitable. We agree that this method is preferable for obtaining good haemostasis. It is our impression, however, that most haematomas form because of leakage from small vessels disrupted while the generator pocket is formed rather than from bleeding from the site of the subclavian vein puncture. GUY HAYWOOD

A JOHN CAMM DAVID WARD Department of Cardiological Sciences, St George's Hospital Medical School,

London SW 17 ORE 1 Ohm J, Breivik K. Pacing leads. In: Perez-Gomez F, ed. Cardiac pacing, electrophvsiology, tachyarrhvthmias. Madrid: Grouz, 1985:971.

Child health surveillance SIR,-Dr Leon Polnay's article highlights many important issues in child health surveillance.' I have recently researched the conditions and cir-

cumstances surrounding failure to thrive in children aged 12-24 months. The findings are particularly relevant to two of the issues raised-namely, the value of parental observations and the importance of growth monitoring. The study was based in the two electoral wards of Newcastle most affected by socioeconornic deprivation. Fifty two children (mean age 20 8 months) with mild failure to thrive were identified. Each was matched by age and gender with a control child, growing normally, from the same communities. Failure to thrive is often associated by professionals with neglectful or abusing parents, but I found that the parents of children who were failing to thrive were clearly aware of their child's predicament and were concerned about it. Analysis of responses to a questionnaire on attitudes showed that parental anxieties over their child's health, growth, and eating patterns were significantly different from those of parents in the control group. Most of these families were not, however, receiving any input from health care professionals. The mean number of weight measurements documented in the records of the children who were failing to thrive was 17, higher than for the controls (mean 12; p=0001). More frequent attendance may represent an indirect expression of these parental anxieties. Evidently, listening to parents talking about their concerns will aid the identification of vulnerable children. The article mentions the somewhat equivocal views in Health for All Children on the value of growth monitoring. My findings suggest, however, that growth charts represent a valuable tool for child health surveillance. Even in these deprived communities, where uptake of services is variable and often believed to be poor, 92% of all children had adequate growth charts (defined arbitrarily as those with at least six recorded weight measurements-that is, about every three months) held either by the health visitor or by the local authority clinic. The prevalence of mild failure to thrive was found to be 20 6%. The mean body mass index of these children was 16 1 kg/m2, significantly less than in the control group (17 4 kg/m2; p

The cyclotron saga continues.

to 1500 mg/day) have, in aggregate, actually shown appreciable protection against ischaemic heart disease.6 C H HENNEKENS J E BURING Department of Med...
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