the colour and a tell tale extension of pigment at one edge. As the checklist acknowledges, change in behaviour is the most important fact to emphasise in a public education campaign. But some patients are oblivious to change,' I and their melanoma is diagnosed incidentally by someone else. It is thus important that doctors, paramedics, and the public are exposed to as much visual material depicting melanomas as possible, either on television or in poster form. Those doctors who see patients with malignant melanoma should show the lesions to as many colleagues as possible.

Analysis ofyellow card reports of adverse drug reactions by number of times each doctor reported during 1972-80

ANTHONY DU VIVIER ELISABETH M HIGGINS

doctors using the scheme only once, but 42% came from doctors making six or more reports (table). Furthermore, six doctors reported on over 100 occasions, and they contributed nearly 1-5% of the total reports during 1972-80. Similar analyses of more recent data would not seem to be possible as the minister of health stated in 1989 that "we do not record the numbers of individual doctors and dentists who report adverse drug reactions to the CSM and this information would be provided only at disproportionate cost."3 The only comparable analysis by another national drug regulatory authority of frequency of reports of adverse drug reactions by individual doctors was supplied to me by Dr R Meyboom of The Netherlands Centre for Monitoring Adverse Drug Reactions for the year 1987. Only 2-16% of doctors on the Dutch medical register reported adverse reactions. About half of those reports came from doctors reporting only once and 7-7% came from doctors reporting on six or more occasions. The Committee on Safety of Medicines is keen to increase the value of the spontaneous adverse reaction reporting system. To do this it needs to encourage more widespread use of the system among doctors rather than to receive more reports from the same enthusiasts.

King's College Hospital, London SE5 9RS 1 MacKie RM. Clinical recognition of early invasive malignant melanoma. BM3' 1990;301:1005-6. (3 November.) 2 Keefe M, Dick DC, Wakeel RA. A study of the predictive value of the 7 point checklist in distinguishing benign pigmented lesions from melanoma. Clin Exp Dermatol 1990;15: 167-71. 3 Du Vivier A. Cutaneous malignant melanoma: a potentially curable disease. BrJ Hosp Med 1989;41:357-63. 4 Du Vivier AWP, Williams HC, Brett JV, Higgins EM. How do melanomas present and how does this correlate with the 7 point checklist? BrJ7 Dermatol 1990;123(suppl 37):39-40. 5 Monk BE, Clement M, Pembroke AC, du Vivier A. The incidental malignant melanoma. BM3 1983;287:485-6.

Aerobic work capacity in chronic fatigue syndrome SIR,-Dr Marshall S Riley and colleagues noted that the changes in indicators of aerobic work capacity in patients with the chronic fatigue syndrome resembled those observed in deconditioned subjects.' The chronic fatigue syndrome often develops after acute infectious disease, and its aetiology has therefore been related to infective agents. Over 120 years ago DaCosta described acute infection as one of the stressors that seemed to start a syndrome characterised by easy fatigability, weakness, and many symptoms referring to the cardiorespiratory and the gastrointestinal systems.2 Since then this syndrome has been described many times and under many names (for example, DaCosta's syndrome, the effort syndrome, neurocirculatory asthenia, and the mitral valve prolapse syndrome). DaCosta and many other investigators concluded that this syndrome was an unspecific reaction to overwhelming physical or psychlc stress, and low physical work capacity was regarded as a predisposing factor. When studying the aetiology of the chronic fatigue syndrome it would be worth referring to the many published reports on DaCosta's syndrome, even though they are published mainly by cardiologically oriented investigators. MATTI MANTYSAARI

Kuopio University Hospital, SF-70210 Kuopio, Finland 1 Riley MS, O'Brien CJ, McCluskey DR, Bell NP, Nicholls DP. Aerobic work capacity in patients with chronic fatigue syndrome. BMJ 1990;301:953-6. (27 October.) 2 DaCosta JM. On irritable heart: a clinical study of a form of functional cardiac disorder and its consequences. Aml Med Sci

1871;121:2-53.

The yellow card: mark II SIR,-Dr D H Lawson's editorial did not draw attention to the extremes of use or non-use of the yellow card system by doctors in the United Kingdom.' Speirs et al showed that only 16% of doctors working in the United Kingdom during 1972-80 reported adverse drug reactions to the Committee on Safety of Medicines using the yellow card system.2 Almost 20% of the reports came from 50

be readily identified by a straightforward questionnaire about symptoms.7 P J WHORWELL

No of doctors reporting (% of No of times doctor doctors working in NHS at any time during 1972-80) reported

No (%) of reports received

1 2 3 4 5 -_6

10 690 (8-6) 3 701 1 833 1011 694 1 820 (1-47)

10 690 (19-9) 7 402 (13-8) 5 499(10-2) 4044 (75) 3 470 (6-5) 22 580 (42-0)

Total

19 749(16-0)

53 685

J P GRIFFIN Association of the British Pharmaceutical Industry, London SWIA 2DY

1 Lawson DH. The yellow card: mark II. BMJ 1990;301:1234. (1 December.) 2 Speirs CJ, Griffin JP, Weber JCP, Bott MG, Twomey CCS. Demography of the UK adverse reactions register of spontaneous reports. Health Trends 1984;16:49-52. 3 Mellor D. Parliamentary written answer. House of Commons Official Report (Hansard) 1989 January 25;145:col 547. (No 35.)

University Hospital of South Manchester, Manchester M20 8LR 1 David A, Pelosi A, McDonald E, et al. Tired, weak, or iri need of rest. Fatigue among general practice attenders. BMJ 1990; 301:1199-202. (24 November.) 2 Whorwell PJ, McCallum M, Creed FH, Roberts CT. Non colonic features of irritable bowel syndrome. Gut 1986;27: 37-40. 3 Maxton DG, Morris JA, Whorwell PJ. Ranking of symptoms by patients with irritable bowel syndrome. BMJ 1989;299: 1138-9. 4 Maxton DG, Whorwell PJ. More accurate diagnosis of irritable bowel syndrome by the use of non-colonic symptomatology. Gut 1990;31:A1167. 5 Maxton DG, Whorwell PJ. More accurate diagnosis of irritable bowel syndome by the use of non-colonic symptomatology. Gut (in press.) 6 Thompson WG, Heaton KW. Functional bowel disorders in apparently healthy people. Gastroenterology 1980;79:283-8. 7 Manning AP, Thompson WG, Heaton KW, Morris AF. Towards positive diagnosis of the irritable bowel syndrome. BMJ 1978; ii:653-4.

Prediction of hip fracture in elderly women SIR,-Dr Albert M Van Hemerts' incorrectly states the sensitivity and specificity of the blood band ultrasonic attenuation (BUA) index in predicting hip fracture in our study.2 Our data did not allow such calculations to be made as no account had been taken of the many patients who had died (more than 300) before a hip fracture may have been sustained. Also the data were not presented in an ideal manner for such a calculation to be undertaken. Another study showed that the BUA index had a sensitivity of 81% and a specificity of 94% to discriminate between control women and women with osteoporotic fractures. The potential of ultrasonography to predict hip fracture in a normal population is considerably greater than it is in a group of women at high risk such as those we described (5 2% had a fracture in the two years). The BUA index and the Clifton assessment procedures for the elderly were able to predict those women at highest risk of sustaining

hip fracture. COLIN G MILLER

Norwich Eaton, Egham TW20 9NW RICHARD W PORTER Doncaster Royal Infirmary, Doncaster DN2 5LT

Fatigue among general practice attenders SIR, -Dr Anthony David and colleagues report a prevalence of fatigue of 10 5% but did not, as far as we can tell, record any gastrointestinal symptoms. ' We recently found that fatigue seemed to be strongly associated with the irritable bowel syndrome. It occurs in up to 96% of hospital outpatients with the disorder24 irrespective of the presence of psychopathology and also has diagnostic potential in helping to distinguish irritable bowel syndrome from other gastrointestinal diseases.5 It is not known whether fatigue is common in patients with the irritable bowel syndrome in the community, but even if it were less common than in patients attending gastroenterology clinics, the prevalence of the syndrome in the general population is so high (15%)6 that I would still expect to find many subjects with fatigue associated with the syndrome. It is therefore tempting to speculate that the syndrome may be accounting for a substantial number of cases of fatigue in the study by Dr David and colleagues. They state that they are assessing this cohort of patients further. We would strongly urge them to look for the irritable bowel syndrome, particularly as there is now good evidence that this disorder can

I Van Hemert AM. Prediction of hip fracture in elderly women.

BMJ 1990;301:1100. (10 November.) 2 Porter RW, Miller CG, Grainger D, Palmer SB. Prediction of hip fracture in elderly women: a prospective study. BMJ

1990;301:638-41. (29 September.) 3 McClockey EV, Murray SA, Miller C. Broadband ultrasound attentuation in the os calcis: relationship to bone mineral at

other sites. Clin Sci 1990;78:227-33.

HIV infection in women SIR,-Dr Stephen Norman and colleagues state that the question of pregnancy in the uninfected spouse of a man infected with HIV has not been examined.' This position is common to many partners of haemophiliac patients world wide and has been the subject of several studies since AIDS was first reported in haemophiliac patients in 1982. In the United Kingdom repeated advice about contraception has been issued by the Haemophilia Society since early 1985.2 The counselling of couples wanting to have children has also been described.3 We have reported the management of 12 children negative for HIV antibodies conceived when their fathers were positive for these antibodies (E Goldman et al, sixth world congress on AIDS, Montreal, 1989). Many haemophiliac patients seroconvert at a young age (in our cohort the median age at seroconversion was 24 years, range

BMJ

VOLUME

302

5 JANUARY 1991

The yellow card: mark II.

the colour and a tell tale extension of pigment at one edge. As the checklist acknowledges, change in behaviour is the most important fact to emphasis...
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