CORRESPONDENCE * All letters must be typed with double spacing and signed by all authors. * No letter should be more than 400 words. * For letters on scientific subjects we normally reserve our correspondence columns for those relating to issues discussed recently (within six weeks) in the BMI. * We do not routinely acknowledge letters. Please send a stamped addressed envelope ifyou would.like an acknowledgment. * Because we receive many more letters than we can publish we may shorten those we do print, particularly when we receive several on the same subject.

Dog bites to children SIR,-Dog bites to children continue to receive media attention, and there have been recent changes in legislation intended to control particular breeds.' To detail the size and nature of the problem we analysed data from the Department of Trade and Industry's home and leisure accident surveillance systems (HASS and LASS)2 for the calendar year November 1987 to November 1988. These systems record relevant accidents presenting to accident and emergency departments in a representative sample of 22 hospitals throughout the United Kingdom. HASS incidents occur in the home and its surrounds; LASS incidents occur outside the home but exclude work and vehicle accidents. Case listings and cross tabulations were obtained for dog bites to children under 16 years old. Over 2000 cases were recorded at the 22 hospitals; a breakdown by age and sex is presented in the table. With the department's own multiplier, this implies that in the United Kingdom as a whole there were about 25000 dog bites in the home and 33000 in "leisure" situations-that is, a total of over 55 000 dog bites to children presented to hospital in the 12 months studied. There may have been other incidents treated at home or by general

practitioners. Most home accidents (21%) took place in the living and dining areas; most leisure, accidents (38%) took place in the street. Children were commonly playing (HASS 45%, LASS 29%). Home accidents commonly involved the head and face (45%) whereas leisure accidents most often involved the legs and buttocks (42%). Puncture wounds were the most common injury (HASS 42%, LASS 44%). Referral was usually to home (HASS 73%, LASS 63%), and referral rates to outpatient clinics and to general practitioners were considerably lower than those for children's accidents overall. Only three children required admission to hospital for more than six days. The breed of dog was recorded in 487 (36%) of Ages and sexes of children bitten by dogs 0-4 years

5-15 years

All children

Girls Not known

253 203 I

479 417 1

732 620 2

Total

457

897

1354

95 48 0

478 255 2

573

143

735

878

HASS: Boys

LASS: Boys Girls Not known Total

303 2

HASS=Home Accident Surveillance System; LASS= Leisure Accident Surveillance System.

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HASS incidents. The three commonest were mongrel (114), German shepherd (66), and Jack Russell (49). Dobermanns were mentioned 22 times and Rottweilers 13 times. Pit bull terriers were not mentioned. LASS incidents recorded breeds in 237 (27%) cases, the three commonest being mongrel (63), German shepherd (52), and Jack Russell (17). There were 13 incidents involving Dobermanns, eight Rottweilers, and one pit bull terrier. This information is of limited value as the populations of various breeds of dog are not known and some breeds are more readily identified and recorded than others. These figures show that dog bites to children are common but rarely serious, and that many incidents take place in the home. They suggest that measures to control particular breeds in public places offer at best a partial solution. SARA LEVENE

Child Accident Prevention Trust, London WIN 4DE I Dangerous Dogs Act 1991. London: HA\SO, 1991. 2 Consumer Safety Unit. Home and leisure accident research (1988 data). London: Department of Trade and Industry, 1990.

Inner city psychiatry SIR,-Although the summer holiday is traditionally a quiet period for hospital admissions, you may like to know that "the game of pass the parcel" as delineated by Dr Jeremy Coid continues ever more furiously.' At present the 20 bed acute psychiatry ward for which I am responsible as consultant has 14 patients under Mental Health Act orders, of whom six are under section 37 (transferred from the courts, usually via prison). At least three others await such transfer arrangements. The City and Hackney Health District, in which I work, has neighbours who seem equally pressured. Within the last week we have had two patients simply sent direct from Wandsworth in an ambulance, under section, despite no bed being available. An attempt to refer an Islington patient met with the reply that he would be seventh on the "waiting list." Another nearby district has refused to accept a transfer by dint of denying the diagnosis made by four other consultant psychiatrists. Arguments over catchment areas abound, duty doctors act merely as gatekeepers, families and general practitioners are undermined and appalled. The admirable experiment of shortcircuiting the system by placing psychiatrists in magistrates' courts so as to avoid prison remand2 forgot one key factor: the lack of available beds. Without the judicial "holding pattern" the system is being swamped. A major incident is overdue. T H TURNER

Department of Psychological Medicine, St Bartholomew's Hospital, London ECIA 7BE

1 Coid JW. "Difficult to placc" psychiatric paticnts. BMJ 1991;302:603-4. (16 Mlarch.) 2 James DN', Hamilton LW. The Clerkenwell schcme: assessing efficacy and cost ot a psychiatric liaison service to a magistrates' court. BAIJ 1991;303:282-5. (3 August.)

Zidovudine after occupational exposure to HIV SIR,-The current approach to dealing with individuals who have been exposed to HIV raises many difficult questions. One of these questions relates to the most appropriate way of dealing with health care workers who may have been exposed to the virus. Currently when individuals have a potential exposure to HIV part of our approach is to offer them advice and counselling about minimising the possible spread to others (for example, by practising "safe sex") until it is established that they are HIV negative. The time required to establish this is usually considered to be about six months with current serological testing; this period is commonly referred to as the "window" period. Testing for HIV antigen at present seems insufficiently sensitive to reduce the window period in the vast majority of cases. We may also offer these individuals zidovudine, although the efficacy of this treatment for prophylaxis is uncertain.' Consider the case of a health care worker in this situation whose job regularly puts him or her in contact with patients' blood. Surgeons constitute the most relevant group in this context. A recent survey of New York surgeons found that the incidence of needlestick injury in the preceding year in the group was 86%.2 The risk of a surgeon passing on HIV to a patient (or colleague) is probably very low (ranging from one in 100 000 to one in a million operations), but it is an issue that has to be considered in order to avoid the "collective denial" of the past.' It is known that a dentist has passed on the virus,a and it is only a matter of time before we see this type of transmission in surgeons. How should we counsel the potentially infected surgeon? Should we suggest that he or she carries on operating without restriction? Should we suggest avoiding high risk procedures such as vaginal hysterectomy, oral surgery, and major pelvic and cardiac surgery?5 Should we suggest that infected surgeons inform all their patients of the potential risk? Or should we be consistent with our advice with regard to known modes of transmission of the virus and suggest that they stop operating altogether until the window period is over? This option would have serious implications for individuals, compensation systems, and health care services-implications which are either unrecognised or ignored in many quarters. As

BMJ VOLUME 303

24 AUGUST 1991

occupational health practitioners we will meet this problem and would value the advice of others on how best to approach this delicate issue. LEON LE LEtT E MICHAEL SHANAHAN

Occupational Health Unit, Roval Adelaide Hospital, Adelaide, South Australia 1 Jeffries DJ. Zidovudine after occtupational exposure to HIV. BMJ 1991;302:1349. (8 Junie. 2 Lowenfels AB, Wormser GP, Jain R. Frequency of puncture injuries in surgeons anid estimated risk of HIV infection. Arch

Surg 1989;124:1284-6. 3 Rhame FS. The HIVr-infected sturgcon. JAMA 1990;264:507-8. 4 Centers for Disease Control. Update: transmission of HIV infection during an invasive dental procedure. IfMWR

1991;40:22-7. 5 Rhame FS, Pitt H.l, Tapper NL, et al. Position paper: the HIV infected healthcare worker. Infect Control Hosp Epidemiol 1990;11:647-56.

SIR,-In March 1990 the national committee against AIDS of the Italian Ministry of Health issued guidelines on zidovudine prophylaxis in exposed health care workers, recommending that treatment should be started as soon as possible after exposure, preferably within four hours. Our unit is in charge of the Italian programme on occupational exposure to HIV. It is located at the Lazzaro Spallanzani Hospital, a 100 bed major referral centre for infectious diseases in Rome, where more than 50% of patients admitted in 1990 were HIV infected. To overcome the difficulties of counselling exposed health care workers soon after the accident without delaying treatment we adopted the following policy for our hospital. (1) A series of workshops based on lectures reviewing the current knowledge on zidovudine prophylaxis, open discussion, and study of case histories were held by expert physicians and psychologists; these have been attended by nearly all health care workers in the hospital. (2) A copy of the national protocol is available for all health care workers. (3) To ensure a rapid deliveny of prophylaxis the drug is available throughout the day to be dispensed by the physicians on duty. (4) At the time of the accident the exposed worker is first of all strongly advised to take a 250 mg tablet of zidovudine; stressing the need for early treatment is emphasised and the worker is reassured that adverse effects are extremely unlikely with this single dose. Soon after the worker will be given individual medical and psychological counselling decide whether or not to continue treatment. We believe that in this way virtually all health care workers have been informed and can form their own opinion before a possible accident. We suggest that this policy should be adopted particularly in health care settings with a high prevalence of HIV infected patients, and we believe that it can reduce stress among health care workers and allow the timely starting of prophylaxis in most cases. The effectiveness of the programme is presently being evaluated; the research is supported by a grant from the Italian Ministry of Health AIDS project.

considered to be a risk factor for osteoporosis. 'Fheir findings may be due, at least in part, to inadequate matching of the treated subjects and the controls for all of the relevant risk factors. The users of DMPA for long term contraception tend to be high parity women from low socioeconomic groups; often they are higher than average users of cigarettes and alcohol and have poorer quality diets than their more affluent peers. Indeed, the investigators identified a discordance in cigarette smoking between the groups but do not provide information about other known risk factors for osteoporosis such as alcohol and caffeine intake, calcium intake, and levels of exercise-all of which might reasonably be expected to be less satisfactory among the DMPA users than among non-users. Similarly, if the group treated with DMPA contained a significant proportion of high parity women who had breast fed their infants a long time (as it well could have done, because one of the reasons for using DMPA is that it provides good contraception without interfering with lactation) then it could reasonably be concluded that their calcium reserves and hence their bone density might be less than those of the controls. No information was provided concerning the contraceptive methods being used by the premenopausal controls, specifically how many of them were taking oral contraceptives containing oestrogen. Their serum oestradiol concentrations were not measured; the figure used for comparison with the group treated with DMPA was the laboratory normal value. As the age range of this control group was 25 to 52 years and the mean age was 42 5 years the use of oral contraceptives by members of this group could have had a beneficial effect on the mean bone density values. The fact that the difference in bone density between the DMPA users and the premenopausal controls was greatest among women with high body mass indexes also suggests that oestrogen deficiency may not be the sole cause of the finding, because it is known that women with a low body mass have a higher risk of postmenopausal osteoporosis than those who are heavier. The study does not provide conclusive evidence that the use of DMPA as a long term contraceptive is a significant risk factor for osteoporosis and that a prospective study of populations more closely matched for relevant parameters is required. HAZEI, HINCHLEY

Donihcad St Andrew, Shaftesburv SP7 9EF I Cundv T, Evans M, Roberts H, WVattie D, Ames R, Reid IR. Bonc density in women receiving depot medroxv,progesteronc acetate for contraception. HB.A 1991;303:13-6. (6 Julv.

DMPA and bone density

SIR, - Depot medroxyprogesterone acetate (DMPA) has provided safe and effective contraception to millions of women world wide. The welfare of current and potential users is best served when reports of possible adverse effects are clear and balanced. Dr Tim Cundy and colleagues report a slight reduction in bone density in long term users of DMPA.' They do not, however, consider four possible confounders: (a) DMPA users included four times as many smokers as the premenopausal controls; (b) the authors provided no information about past or current contraceptive use of the controls; (c) the bone density before treatment of all three study groups is unknown; (d) the median exposure to DMPA was not given. Moreover, two important characteristics of the study group and results need highlighting -namely, that the study is concerned with amenorrhoeic DMPA users only, and that the reduction of bone density in the femoral neck was

SIR,-Dr Tim Cundy and colleagues state that the use of depot medroxyprogesterone acetate (DMPA) for long term contraception should be

not statistically significant. The conclusion that DMPA should be considered "a potential risk" for osteoporosis should be addressed in a controlled prospective trial,

VINCENZO PURO ENRICO GIRARDI GIUSEPPE IPPOIATO Unita' Sanitaria Locale RM/10 AIDS Unit, L Spallanzani Hospital, 0(0149 Rome, Italv

BMJ VOLUME 303

24 AUGUST 1991

preferably encompassing other contraceptives of free oestrogen which cause amenorrhoea. A KUBBA

Famnilh Planning and Reproductive Hcalth Services, West lIambeth Hcalth Authority, St Thomas's Hospital, london SE I 7EH I Cttndv T, Evans M, Robcrts H, Wattie l), Amcs R, Reid IR. Bone dcnsity in women rccciving depot mcdroxyprogesterone acetate ftor contracepti(oni B.11Y 1991303:13-6. l6 July.)

SIR,-The effect of prolonged amenorrhoea in users of all progestogen only methods of contraception is an important issue. This has not yet been resolved by Dr Tim Cundy and colleagues, who suggest that amenorrhoeic long term users of depot medroxyprogesterone acetate (DMPA) may be at increased risk of osteoporosis.' However, the study design, comprising measurements at one point in time in different populations of users and controls, makes it difficult to judge their comparisons since no measurement of bone density was made before starting taking DMPA. When such small numbers are involved (only 21 users after removal of pairs not matchable for smoking habit) it is possible that the DMPA volunteers for the study simply started with a lower mean bone density than the controls. Indeed, this would tend to be supported by the authors' own observation that there was no difference in biochemical indices of bone turnover. Although the authors controlled for current smoking habit, there is no mention of whether duration of smoking or amount smoked were taken into account, both of which may be important. We agree that it is important to match the body mass index because this is related to bone density, but here it is possible that overmatching may have occurred. Weight gain is a recognised side effect of DMPA, but whether this artificial increase promotes bone density is not known. Thus, matching women who would inherently have a lower body mass index without DMPA with those who have a naturally higher body mass index may have inadvertently biased the bone density results. It should not be forgotten that DMPA has previously been shown to protect against osteoporosis' and has in fact been used in its treatment.4 In the present study the apparent effects of DMPA seemed to be least in the underweight (more at risk) women. Overall, the observed reduction in bone density was not such as to suggest that any DMPA users are at current risk of symptomatic osteoporosis.' However, women who reach the menopause with a low bone density are at a disadvantage. If further studies were to confirm that DMPA lowers bone density in current users it would be important to ascertain whether the effect is reversed when the method is stopped. Until this issue is resolved it may be that we should advise long term amenorrhoeic DMPA users to have their bone density measured when they reach the menopause. If it is found to be low, then they, like so many other women, would benefit from hormone replacement therapy. What is now needed is a much larger, prospective controlled study. Meanwhile, DMPA remains for many women a highly effective contraceptive option whose known benefits vastly outweigh its known or suggested risks. ANNE SZAREWSKI JOHN GUILLEBAUD

Miargaret Pyke Centre, Lottdon W'l V 5'1'TX ELPHIS CHRISTOIPHER

Haringey Health Authoritv, lIondon N22 Ctindv T, Evans M, Roberts H. Wattie 1), Ames R, Rcid IR. Bone densitv in womeni receis'ing depot medroxyprogesterolle acetate lor contraception. MI_7 1991;303:13-6. 6 July. 2 Loho RA, McCormick W, Singer F. Roy S. D)epomedroxvprogesterone acctate compared with con jugatcd estrogcis for the treatment of postmenopausal womnen. Obhstw (;Ynec(ol 1984;63: 1-5.

467

Zidovudine after occupational exposure to HIV.

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