istic vaginal bleeding associated with cervical cancer. ' In our experience substantial antepartum haemorrhage rather than a bloody cervical smear is the usual presenting symptom when cervical cancer complicates pregnancy. In the National Maternity Hospital in Dublin between 1984 and 1990, 1479 women presented after 24 weeks' gestation with substantial antepartum haemorrhage. In four cases a histologically proved carcinoma of the cervix was found. The patients presented at 40 weeks, 34 weeks, 32 weeks, and 26 weeks of gestation, all with substantial haemorrhage. We believe that major antepartum haemorrhage is a common presenting symptom of cervical cancer in the second half of pregnancy. JOHN M STRONGE WILLIAM BOYD MICHAEL J RASMUSSEN National Maternity Hospital, Dublin 2 1 Chamberlain G. Antepartum haemorrhage. BMJ 1991;302:

1526-30. (22 June.)

Decompression sickness SIR,-The problem of decompression sickness in fish farm workers after multiple dives' has implications for diving practice. Dive profilesthat is, the curves relating depth and time-are normally planned so that the diver attains the maximum depth at the beginning of the dive and maintains this for a predetermined period before ascending at a rate determined by the appropriate dive table. Such profiles are therefore rectangular as opposed to the "saw tooth" configuration associated with multiple ascents. Dives entailing a single descent and ascent are governed by decompression tables, which have undergone progressive review and refinement.24 Formerly, multiple dives were planned on the assumption that the "bottom times" could be simply summated and the final ascent determined accordingly. This implied that the intermediate ascents could be disregarded. This approach, however, is no longer regarded as acceptable.5' Thus separate tables that take account of previous dives and surface intervals are now available.4 Applying these tables to the dive sequences described by Drs J D M Douglas and A H Milne suggests that decompression stops in the water would have been appropriate by the third dive to 18 m and the fourth dive to 15 m. Although diving can never be entirely free of risk, decompression sickness should be avoidable in both recreational and occupational diving.

Mean age at menopause, menarche, and visit for screening and body mass index and smoking habit in 157 women who had had natural menopause according to handedness

puerperal psychosis whereas others admitted mothers with a wider variety of diagnoses.

Right handed Left handed (n = 18) (n= 139)

DIANA M C CASSELL ROSALYN M COLEMAN Department of Child and Family Psychiatry, Charing Cross Hospital, London W6

Mean (range) age at menopause (years) Mean age at menarche (years) Mean age at visit (years) Mean body mass index Smoking habit (%): Non-smokers Ex-smokers Current smokers

49-5 (39-56) 49-1(39-55) 13-0 13-2 53 5 53 8 24-3 24-3 55 6 22-2 22-2

56 4 32-1 11-4

an earlier menopause than right handed women.2 The study he cites, by Leidy, examined two groups, Hispanic-American women and white and black American women.3 No difference in age at the menopause and handedness was observed in the white and black women. Leidy stated that in the Hispanic-American group 316 women aged 35-74 were selected as having had a natural menopause. Fourteen of 20 left handed women were then excluded, however, because they had had a hysterectomy, leaving only six in the sample. Almost half the right handed women had had a hysterectomy; the paper does not cite the number of right handed women who had undergone a true natural menopause in the final sample. We have examined data from white women attending for health screening. Of 157 women who had had a natural menopause (none had had a hysterectomy), 139 were right handed and 18 left handed. The table shows their mean ages at menarche, menopause, and the visit for screening; mean body mass index; and smoking habit. Mean values were compared by t tests and smoking habit by a X2 test. There were no significant differences between the groups in any of the factors examined. In particular, the age at the menopause and the range of ages at the menopause were not significantly different between the left handed and right handed groups. We conclude that there is no evidence of a relation between handedness and age at the menopause in a white population. SHARON ALLAWAY PATRICIA LAST ANN HALE BUPA Medical Research and Development Ltd, London WClX 8DU

1 Ginsberg J. What deLciiuones the age at the menopause? BMJ7 1991;302:1288-9. (1 June.) 2 McGarrv J. What determines the age at the menopause? BMJ 1991;302:1540. (22 June.) 3 Leidy LE. Early age at menopause among left handed women. Obstet Gynecol 1990;76:1111-4.

ANDREW H BARLTROP Thomas Guy Sub-Aqua Club,

Guy's Hospital, London SE1 9RT 1 Douglas JDM, Milne AH. Decompression sickness in fish farm workers: a new occupational hazard. BMJ 1991;302:1244-5. (25 May.) 2 Zanelli L, ed. The British Sub Aqua Club diving manual. 7th ed. London: British Sub Aqua Club, 1972:488-500. 3 British Sub Aqua Club. The British Sub Aqua Club diving manual. 10th ed. London: British Sub Aqua Club, 1978:546. 4 British Sub Aqua Club. The BS-AC '88 decoanpression tables. London: British SubAqua Club, 1988. S Cairns G. The navy's plan for safety. Diver 1989;34(9):29-30. 6 Busutilli M. Focus on the new tables. Diver 1988;33 (10):25-8. 7 Shaw D. Plan to survive. Diver 1988;33(l):17-8. 8 Ellerby D, Holbrook M, Longworth G, eds. Advanced sport diving, British Sub-Aqua Club. London: Stanley Paul, 1990: 27-3 1.

What determines the age at the menopause? SIR,-In reply to Dr Jean Ginsberg's editorial on what determines the age at the menopausel Mr John McGarry writes that left handed women have

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Care of women with postnatal mental illness SIR,-Drs R J Prettyman and T Friedman's survey of facilities for mentally ill mothers and their babies in England and Wales' draws attention to the lack of research regarding the various patterns of care and organisation of services for postnatal mental illness. Our smaller survey looked at some of these issues in greater depth; we also found that some districts had no designated mother and baby units.2 A dilemma faces those planning services with regard to smaller local versus larger regional units. Smaller units offer easier access for the patients and their families and for those referring patients, but several suffered problems over funding and staffing. The availability of other resources-for example, rooms for clinical family interviews, staff trained in infant care, and opportunities for some privacy during family visits -varied greatly. Some units concentrated on

1 Prettyman RJ, Friedman T. Care of women with puerperal psychiatric disorders in England and Wales. BMJ7 1991;302: 1245-6. (25 May.) 2 Cassell DMC, Coleman RM. Mother and baby admissions: survey of resources. Psychiatric Bulletin 1990;14:654-7.

Zidovudine after occupational exposure to HIV SIR,-In his editorial on giving zidovudine after occupational exposure to HIV Professor D 1 Jeffries makes several interesting points. He does not, however, mention recent relevant results in two animal models. One of these reports assessed the effect of zidovudine given to SCID-hu mice that had previously been infected with HIV.' As Professor Jeffries mentioned, such mice (immunodeficient mice engrafted with human fetal thymus and lymph node) can be infected with HIV." After intravenous inoculation with HIV the implanted human lymph nodes show signs of replication of HIV within two weeks.3 This reproducible model has been used to assess the effect of antiviral compounds alone and in combinations on HIV.4 To address the problem of treatment with zidovudine after exposure mice infected with HIV were given a parenteral bolus of zidovudine followed by oral treatment for two weeks.2 Zidovudine was started at various times after intravenous inoculation of HIV; two weeks later the human lymph node implants were analysed for signs of HIV infection by DNA polymerase chain reaction. If zidovudine was given within two hours after inoculation no animals had detectable HIV at two weeks. If treatment was delayed until 48 hours after inoculation none of the mice were protected. The study also showed that 20% of animals were protected when zidovudine was given 36 hours after exposure, which suggests that even late treatment may be useful. The route of administration of the drug could be important as the first dose was given parenterally; in contrast, in the two cases reported in which zidovudine given after exposure failed to prevent HIV infection the drug was first given orally.56 The advantage of this small animal model is that it uses human tissue and HIV as the retrovirus, and the timing, dose, and route of inoculation of HIV and of administration of drugs can be controlled. The effect of 2' ,3'-didexoyinosine on HIV infection has also been assessed in this model.4 In the second animal model the combination of zidovudine and interferon alfa prevented infection with Rauscher murine leukaemia virus in mice if given within four hours after exposure.7 Combination antiviral treatment may be essential in protecting against HIV infection, as described for the Rauscher murine leukaemia virus model. In vitro studies have shown synergistic inhibition of replication of HIV when the combination of zidovudine and 3'-fluoro-3'-deoxythymidine was used.8 In addition, such combination treatment may help overcome problems of resistance to zidovudine. The authors of one of the case reports in which treatment after exposure failed to prevent HIV infection suggest that the failure may have been due to virus resistant to zidovudine having been transmitted from the index patient, who had been receiving long term treatment with zidovudine.6 Although the exact concordance between the data from these mouse models and infected humans is unknown, the results strongly support the

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hypothesis that zidovudine given immediately, and in the first instance parenterally, will be beneficial. DOUGLAS NIXON

Virology Department, John Radcliffe Hospital, Oxford OX3 9DU I Jeffries DJ. Zidovudine after occupational exposure to HIV. BMJ 1991;302:1349-51. (8 June.) 2 Shih C-C, Kaneshima H, Rabin L, Namikawa R, Sager P, McGowan J, et al. Postexposure prophylaxis with zidovudine suppresses human immunodeficiency virus type 1 infection in SCID-hu mice in a time-dependent manner. J Infect Dis

1991;163:625-7. 3 Namikawa R, Kaneshima H, Leiberman M, Weissman IL, McCune JM. Infection of the SCID-hu mouse by HIV-1. Science 1988;242:1684-6. 4 McCune JM, Kaneshima H, Krowka J, Namikawa R, Outzon H, Peault B, et al. The SCID-hu mouse: a small animal model for HIV infection and pathogenesis. Annu Rev Immunol 1991;9: 399-430. 5 LargeJMA, BoucherCAB, Hollak CEM, Wiltink EHH, Reiss P, van Royen EA, et al. Failure of zidovudine prophylaxis after accidental exposure to HIV-1. N EnglJ Med 1990;322:1375-7. 6 Looke DFM, Grove DI. Failed prophylactic zidovudine after needlestick injury. Lancet 1990;335:1280. 7 Ruprecht RM, Chou TC, Chipty F, Sosa MG, Mullaney S, O'Brien L, et al. Interferon-alpha and 3'-azido-3'-deoxythymidine are highly synergistic in mice and prevent viremia after acute retrovirus exposure. J Acquir Immune Defic Syndr 1990;3:591-600. 8 Harmenberg J, Akesson-Johansson A, Vrang L, Cox S. Synergistic inhibition of human immunodeficiency virus replication in vitro by combinations of 3'-azido-3'-deoxythymidine and 3'-fluoro-3'-deoxythymidine. AIDS Res Hum Retroviruses 1990;6: 1197-202.

registration and subsequent professional training, and specialist status, in any country in the community. It is understandable that, in the present multicultural and nationalistic atmosphere of countries in the European Community these mutual bilateral agreements may be seen with fear by some, prompting a more or less open xenophobic response. We doubt whether doctors from the European Community constitute a serious threat to the British system as most of them want to, and do, go back to less fatiguing, and more rewarding and humane, jobs in their countries oforigin. This does not, however, imply that they should be treated differently from doctors who graduated in Britain. It would be against the European Community's regulations to create visiting registrar positions for doctors from the European Community3 as by definition these graduates are entitled to career posts, however much this may upset the professional structure carefully laid down, for graduates of British medical schools, by Achieving a Balance. A serious effort should be made to prompt real, not just legal, recognition of degrees, at both basic and postgraduate levels, to enable doctors from the European Community to gain further training to the top if they wish for this and deserve it. Training, not just qualifications, is already recognised across national borders, enabling the freedom of movement that up till now British doctors seem to have enjoyed more than their European counterparts.6 NICOLA MAFFULLI

individual people must not be forgotten when populations are considered. GEOFFREY WALKER

President, World Orthopaedic Concern, c/o British Council, PO Box 1043, Addis Ababa, Ethiopia 1 Groves T. Africa's health: hope at last? BMJ7 1991;302:1297. (1 June.)

Out of hours work in general practice SIR,-If there is one thing that will drive me to an early grave it is the stress of night calls from an increasingly demanding public. Unfortunately, many of my colleagues regard a working shift of 57 hours from 9 am on Saturday morning to 6 pm on Monday evening as quite normal and think that anyone who cannot thrive under this sort of pressure is a wimp. I have worked for 19 years in a rural area without a deputising service and am very attracted to Drs Steve Iliffe and Ursula Haug's ideas for a 17 hour working day.' This would be eminently practical if support from within the profession was forthcoming. I admit that I am human; I consider sleep to be a basic requirement for my continuing good health.

Doctors and the European Community

Department of Orthopaedics, Newham General Hospital, London E13 8RU

SIR,-The editorial on doctors and the European Community' prompts me to outline the six year pilot European credit transfer scheme of the ERASMUS (European action scheme for the mobility of students) bureau, which began in 198990. It enables students studying five subjects (history, mechanical engineering, chemistry, business studies, and medicine) to study for three to 12 months in another institution in the European Community with no lengthening of the course. This study is recognised to be of the same standard and cover as nearly as possible the same ground as that in the home university. Fourteen medical schools participate, including Bristol and Manchester from the United Kingdom. Nearly 300 medical students across the European Community will take part next academic year. Students benefit from studying in the language of, and living in, another country in the European Community, and a substantial body of knowledge of the various medical curriculums is being built up. This should lead to much greater understanding of the differences, and the experience and knowledge brought back by the student to the home institution will be a strong catalyst for change. An additional benefit is the network of contacts made and reinforced by regular meetings between the professional administrators and medical school academic staff working on the scheme.

Department of Obstetrics and Gynaecology, Eastbourne District Hospital, Eastbourne BN2 1 2UD

1 Iliffe S, Haug U. Out of hours work in general practice. BMJ

1 RichardsT. EdgingintoEurope.BM, 1991;302:1173. (18May.) 2 RichardsT. Euromigration. BMJ 1991;302:1296-7. (I June.) 3 Brearley S, Gentleman D. Doctors and the European Community. BMJ 1991;302:1221-2. (25 May.) 4 Cardillo MR. Doctors and the European Community. BMJ

Medical academics' concerns over pay

N B TURNBULL

BRUNO ARENA

T L JONES

University of Bristol, Bristol BS8 ITH 1 Brearley S, Gentleman D. Doctors and the European Community. BM7 1991;302:1221-2. (25 May.)

SIR,-The dispute over doctors from the European Community wishing to obtain training or to compete for consultant positions, or both, in the United Kingdom is far from over. 1-5 People from the European Community who qualify as doctors within the community have the right to complete recognition of their basic and postgraduate degrees in all the other countries in the community. They are thus entitled to full

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1991;303:59. (6July.) 5 Schwarzenberger J, Tyrone C. Doctors and the European

Community. BMJ 1991;303:59. (6 July.) 6 In Italy now. Lancet 1990;336:1502.

Africa's health SIR, -Dr Trish Groves's report of the comments of Dr Hiroshi Nakajima, the director general of the World Health Organisation, on health in Africa was interesting.' Though nobody can disagree that major efforts must be directed "where they are most needed-into primary care," it is important that perspectives and individual people are not forgotten. Though efforts to improve sanitation, water supplies, infant welfare, and population control are important, no one has yet explained what is the primary care of a patient presenting with a fresh, or not so fresh, compound fracture; with an acute abdomen; with a head injury with evidence of increasing cerebral compression; or in diabetic coma. The management of these fairly common surgical and medical emergencies may require a relatively large expenditure of health resources, but it is wrong that simple yet effective means of dealing with them locally may be overlooked when health services are being planned and provided. Appropriately trained staff as well as basic facilities and supplies are needed. These problems relate to the political decisions entailed in establishing priorities, both in training medical staff and in providing the necessary basic buildings and simple equipment. The fact that these may help only a fairly small proportion of the population does not mean that these sick and injured people should be left untreated. Politics is largely a question of priorities, and

Health Centre, Browne, Lincolnshire

1991;302:1584-6. (29 June.)

SIR,-I am a university lecturer (senior registrar grade), and the recent decision to break parity between academic and NHS pay causes me great concern.' In my "front line" specialty of anaesthesia I am required to be resident while on call (at the paltry rate of 30% of basic pay). The advent of disparity now means that I am paid less than my already underpaid NHS counterparts for similar work. For those of us at the bottom of the ladder considering an academic career the prospects look more bleak than ever. Medical academics are already denied most of the "jam" of private practice; now they are expected to work for less than the basic pay of their NHS counterparts. Where will it end? Surely this is one of British academic medicine's darkest hours-yet the silence of the profession is deafening. I scan the papers looking for letters signed by presidents of royal colleges and groups of professors, but there are none. Where are the "talking heads" on the news programmes bringing this grievance to the attention of the general public? Even the BMJ is reticent: I expected this crucial story to dominate the medicopolitical pages of the journal but found only a few column inches. This wrong will not be put right if we do nothing. The consequences of disparity must be carried into every corner of the land: British academic medicine is in imminent danger of death. I urge our professors, deans, and colleges to wake from their apparent slumber and get to work. There is no time to lose. J ROBERT SNEYD Department of Anaesthesia, University Hospital of South Manchester, Manchester M20 8LR 1 Beecham L. Medical academics' concerns over pay. BMJ

1991;302:1470. (15 June.)

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