- Email: [email protected]
Access to food safety data
432
Noticeboard Doctors with HIV Should patients worry about contracting HIV infection from their doctors? In 1985 Sacksl described a US doctor who had been diagnosed as HIV positive in 1981 and who died in 1983. He had taken part in 400 invasive medical procedures while he was known to have been infected. Close follow-up of these patients has failed to identify any case of HIV seroconversion. Another study focused on patients treated by a UK surgeon who died in March, 1988, he had probably coontracted the virus while working in Africa from 1983 to 1986. 339 patients whom he had operated on were traced, and of 76 who volunteered for an antibody test, none was found to be HIV
positive. This apparent low risk has now been challenged by a report of a young woman who became HIV positive with progression to AIDS but in whom no known risk factor was identified.3 She recalled a dental appointment 2 years previously. The dentist had been diagnosed as HIV positive 3 months earlier. During the procedure (extraction of 2 teeth under a local anaesthetic) he wore gloves and a mask, and the woman could not remember any needlestick injury. Viral DNA analysis of both the woman and dentist suggested a similarity between the strains of HIV causing their infection. One physician has now stated that there is "little difference between the HIV-infected homosexual or intravenous drug abuser who continues to have unrestrained sexual activity and the surgeon who is infected and continues to practise surgery"." More reassuring news about risk comes from a study of 2160 patients treated by a surgeon who died of AIDS in January, 1989. 264 of his patients had died, but no case of AIDS has been recorded in 1652 of those contacted. 616 of these (37%) were tested for HIV and only one intravenous drug user was positive-he probably had HIV at the time of his surgery (for cervical lymphadenopathy with a subsequent diagnosis of tuberculosis). This is the most comprehensive retrospective study of the contacts of one HIVpositive surgeon reported so far, and the results support previous data showing that risk to patients from their seropositive doctors is small. Although it is estimated that about 1000 practising US doctors are HIV positive, Rhame argues that there is no case for mandatory testing.6 If a surgeon has a known risk factor, however, HIV testing would be appropriate. If confirmed to be HIV positive, he or she should not "engage in any activity that creates a risk of transmission of the disease to others" (guidelines of the American Medical Association, 1988). 1. Sacks JJ. AIDS in a surgeon. N Engl J Med 1985; 313: 1017-18. 2. Porter JD, Cruickshank JG, Gentle PH, Robinson RG, Gill ON. Management of patients treated by a surgeon with HIV infection. Lancet 1990; 335: 113-14. 3. Centers for Disease Control. Possible transmission of HIV to a patient during an invasive dental procedure. MMWR 1990; 39: 489-93. 4. Smith DD. Physicians and the acquired immunodeficiency syndrome. JAMA 1990; 264: 452. 5. Mishu B, Schaffner W, Horan JM, Wood LH, Hutcheson RH, McNabb PC. A surgeon with AIDS: lack of evidence of transmission to patients. JAMA 1990; 264: 467-70 6. Rhame FS. The HIV-infected surgeon JAMA 1990; 264: 507-08.
Contaminated L-tryptophan The latest
epidemiological inquiry into eosinophilia-myalgia throws a little light on the pathogenesis.! In the (EMS) syndrome second of their case-control studies from Minnesota, Belongia and his colleagues identified 30 cases of EMS in which the manufacturer of the L-tryptophan they had taken was known. In 29 the source was the Japanese company Showa Denko KK; furthermore the dates of manufacture of the suspect material clustered in early 1989. Three things happened at about that time--a switch to a new strain of Bacillus amyloliquefaciens, which is used in the fermentation process;
a
reduction in the
amount
of activated carbon used in the
purification of the product; and, for about nine months, the failure of some of the product to pass through a filtration step that removes molecules above 1 kD. Showa Denko’s tryptophan is usually 99-6% pure (exceeding US Pharmacopeia requirements), which suggests that the contaminant responsible for EMS is very potent.
High-performance liquid chromatography revealed, but did not identify, the presence of a contaminant that was associated with retail lots of L-tryptophan consumed by patients with EMSindeed so confident are Belongia et al about this "signature" that they suggest that the 30th case also ingested the Showa Denko product. Laboratory studies pointed to a 5-fold increase in eosinophil major basic protein in the serum of cases and an I 1-fold increase in eosinophil-derived neurotoxin, but serum IgE was usually normal. 1.
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.
Cannabinoid
receptor(s)
Clinicians need not get too excited by the news that a receptor for A9-tetrahydrocannabinol, the psychoactive ingredient in cannabis, has at last been identified.! That there ought to be receptors for cannabinoids in the central nervous system had been realised for a long time but, as Snyder points out/ progress in this area did not mimic that with opioid receptors. What Matsuda and colleagues have provided is a tool, in the form of a cloned cannabinoid receptor, but the properties of cannabis derivatives suggest that we are dealing with a family of receptor subtypes and, presumably, as yet unknown endogenous ligands. Without that heterogeneity the cannabinoids are unlikely to rise from their lowly place in the
pharmacopoeia. 1. Matsuda LA, Lolait SJ, Browostein MJ, Young AC, Bonner TI. Structure of the cannabinoid receptor and functional expression of the cloned cDNA. Nature 1990, 346: 561-64. 2 Snyder SH. Planning for serendipity. Nature 1990; 346: 508.
Catheters out! Catheter care in both medical and surgical patients can be fraught with difficulties, most commonly traumatic passage, infection, and paraphimosis. Catheter removal is not thought of as a contentious issue, but it is recognised that a delayed return to normal frequency and voiding volumes may ensue after withdrawal. A group from London, UK,l now report on 86 patients who had their catheters removed at either midnight or 6 am (usual ward practice). They found that those patients who had night-time removal produced significantly greater volumes of urine at the time of their first void, and they were also discharged earlier from hospital. They recommend that catheter removal at midnight is a way to achieve a faster physiological voiding pattern. 1. Noble JG, Menzies D, Cox PJ, Edwards L. Midnight removal: an improved approach to removal of catheters. Br J Urol 1990; 65: 615-17
Access to food
safety data
Genetically modified bakers’ yeast, the alleged induction of polyploidy by irradiated wheat, a code of practice on tasting beers by genetically manipulated yeasts, a chymosin enzyme (for cheese manufacture) from a genetically manipulated source organism, fructose syrup containing dextrans, and a novel fat replacer were the topics on which the Advisory Committee on Novel Foods and Processes completed its deliberations in the first year of its existence.’ This committee, reconstituted from the Advisory Committee
on
Irradiated and Novel Foods
to
reflect the
rapid
development in food biotechnology, saw no safety reason against the use of genetically manipulated yeast in food, but it recommended that manufacturers should carry out regular checks to detect genetic drift in the yeast genome in use. Its report has been forwarded to Ministers, as has that on dextrans, which the Committee also judges as safe for use in fructose syrup. The advice or chymosin enzyme is being considered by the Food Advisory Committee, and neither the raw materials (egg and milk proteins) nor the production process (microparticulation) for the fat replacer was thought to be novel,
433
although its use was. In the Committee’s opinion animal feeding studies indicated that irradiated wheat was unlikely to cause
polyploidy.
its decisions, the Committee’s report To give the public to Ministers will be made available on request. In addition, the Committee is making arrangements to deposit with the British Library the data that it examines. access to
1. Department of Health and Ministry of Agricultural Fishenes and Food Advisory Committee on Novel Foods and Processes Annual Report 1989. 1990. Pp 27. Available from Department of Health, Room 617 Eileen House, Newington Causeway, London SE1 6EF.
Mapping the visual areas of the brain The easiest way
spot a friend in a crowd is to look out for a feature-a red hat, for instance. This principle, specific, striking combined with positron emission tomography (PET), has been used to locate the parts of the brain that process shape, colour, and velocity. Corbetta et all first confirmed that subjects were able to detect a change in a visual stimulus more accurately when they concentrated on one attribute than when they divided their attention between attributes. On the assumption that good discrimination might mean enhanced neuronal activity, they repeated the experiment, this time with PET, to detect variation in neuronal activity between different parts of the brain during periods of divided attention or selective attention to a visual stimulus. Shape, colour, and velocity activated different parts of the brain, though not necessarily one part each, and activity tended to be
International Nutrition Foundation
prize
The topic for the 1991 competition of the International Nutrition Foundation (ISFE) is "Nutritional Aspects of Hypertension". Entrants should send, by May 1991, four copies of reprints of relevant publications over the past five years, unpublished manuscripts, a brief statement of the significance of the contribution, a short curriculum vitae, and a list of major publications to Prof Dr D. Hotzel, Institut fur Emahrungswissenschaft, Rhein Friedrich- Wilhelms- Universitat, D-5300 Bonn 1, West Germany.
In
England Now
to
asymmetrical. 1. Corbetta M, Miezin FM, Dobmeyer S, Schulman GL, Petersen SE. Attentional modulation of neural processing of shape, colour, and velocity in humans. Science
1990, 248: 1556-58.
As sceptical as any other member of the medical profession when I hear of seemingly miraculous cures achieved with "alternative" remedies, I listened in silent disbelief as a friend told me how comfrey (widely believed to be almost in a class of its own as a curative) had came to his rescue. He had tried to separate two fighting dogs and in the process had received a painful bite on his hand. He glanced at the wound and saw, to his horror, a large area of raw flesh between the thumb and first finger, and rapidly averted his eyes. His companion, however, knew what to do and applied a comfrey leaf to the wound and bound it up. In the evening the patient was brave enough to remove the comfrey leaf, and was astonished to see that apart from a trivial puncture wound the hand looked normal. Naturally he became an immediate convert to the magic powers of comfrey. It was fortunate, I thought, that I had made no comment, for the comfrey had indeed produced a magic cure. But my scepticism was not misplaced, after all. Later, the patient had happened to look at the discarded leaf: on it lay a substantial piece of severed canine lip.
Anaesthetic safety checks Airline pilots
use standard lists to check equipment, so do service engineers. Why not anaesthetists as well? Actually various checklists exist. These and procedures recommended by manufacturers of
various anaesthetic machines have formed the basis of a listl compiled by the Association of Anaesthetists of Great Britain and Ireland and designed to take only a few minutes without being too superficial to be of doubtful value. The approach is based on use of oxygen analysers and should detect misfilling of oxygen cylinders and contamination of liquid oxygen reservoirs, which are not detected by checks for "crossover" (of pipelines). The booklet also gives outline checks for breathing systems, lung ventilators, and suction equipment. 1. Checklist for anaesthetic machines. Association of Anaesthetists of Great Britain and
Ireland, 9 Bedford Square, London WC1B 3RA. 1990. Pp 11. £1.50 for members, £300 for non-members.
International Diary A conference entitled The People’s Health-Who’s in Charge? is to take place in Glasgow on Saturday, Sept 1: Public Health Alliance, Room 204, Snow Hill House, 10-15 Livery Street, Birmingham B3 2PE, UK (021-235
4044). A short course on Transplantation Statistics organised by the Medical Research Council Biostatistics Unit will take place at Clare College, Cambridge, on Sept 23-26: Sheila M. Gore, MRC Biostatistics Unit, 5 Shaftsbury Road, Cambridge CB2 2BW, UK (0223 324022).
A
symposium on AIDS and the Epidemics of History will take place in London, on Wednesday, Oct 17: Royal Society of Medicine, 1 Wimpole Street, London W1M 8AE, UK (071-408 2119).
Deaf but not dumb with hearing impairment find that doctors do not make much effort to communicate. Deaf people are often unnecessarily embarrassed during medical consultations, and they-not just the doctor--can find the experience extremely frustrating. A little thought and a little extra time can go a long way to reduce these difficulties, as discussed in an article in Saundbarrier,l the newsletter of the Royal National Institute for the Deaf. The author, a person with hearing impairment, gives some good advice. Don’t sit in front of a window or light, or use subdued lighting, otherwise lip-reading will be impossible. Never bypass the patient to talk mainly with a partner or carer. Speak clearly and not too quickly-but don’t shout or use unusual emphasis, because normal lip and mouth movements will be distorted. And if you do have to resort to writing down information, at least make sure that the writing is legible.
Many people
1 Pat Robins. Painful doctors—the
remedy Soundbarrier March, 1990.
2nd international conference on Oral Chelation is to take place in Bombay on Nov 2-3: Dr M. B. Agarwal, Organising Secretary, 303 Doctors Centre,
Kemps Comer, 135 August Kranti Marg, Bombay 400 036, India (8115504). meeting of the North American Society for Pediatric Gastroenterology and Nutrition will be held in Chicago, Illinois on Nov 2-3: NASPGN Registration Manager, c/o SLACK Inc, 6900 Grove Road, Thorofare, NJ 08086, USA (609-848 1000).
Annual
Annual postgraduate course followed by 41st annual meeting of the American Association for the Study of Liver Diseases is to take place in Chicago, Illinois, on November 3-6: Registration Manager, SLACK Incorporated, 6900 Grove Road, Thorofare, New Jersey 08086, USA
(609-848 1000).
symposium on Cardiopulmonary Urgencies and will take place in Rotterdam on Nov 26-29: Dr Omar Prakash, Thorax Centre, Erasmus University, 3000 DR Rotterdam, Netherlands (31 10 463 5230).
6th international
Emergencies
Noticeboard Doctors with HIV Should patients worry about contracting HIV infection from their doctors? In 1985 Sacksl described a US doctor who had been diagnosed as HIV positive in 1981 and who died in 1983. He had taken part in 400 invasive medical procedures while he was known to have been infected. Close follow-up of these patients has failed to identify any case of HIV seroconversion. Another study focused on patients treated by a UK surgeon who died in March, 1988, he had probably coontracted the virus while working in Africa from 1983 to 1986. 339 patients whom he had operated on were traced, and of 76 who volunteered for an antibody test, none was found to be HIV
positive. This apparent low risk has now been challenged by a report of a young woman who became HIV positive with progression to AIDS but in whom no known risk factor was identified.3 She recalled a dental appointment 2 years previously. The dentist had been diagnosed as HIV positive 3 months earlier. During the procedure (extraction of 2 teeth under a local anaesthetic) he wore gloves and a mask, and the woman could not remember any needlestick injury. Viral DNA analysis of both the woman and dentist suggested a similarity between the strains of HIV causing their infection. One physician has now stated that there is "little difference between the HIV-infected homosexual or intravenous drug abuser who continues to have unrestrained sexual activity and the surgeon who is infected and continues to practise surgery"." More reassuring news about risk comes from a study of 2160 patients treated by a surgeon who died of AIDS in January, 1989. 264 of his patients had died, but no case of AIDS has been recorded in 1652 of those contacted. 616 of these (37%) were tested for HIV and only one intravenous drug user was positive-he probably had HIV at the time of his surgery (for cervical lymphadenopathy with a subsequent diagnosis of tuberculosis). This is the most comprehensive retrospective study of the contacts of one HIVpositive surgeon reported so far, and the results support previous data showing that risk to patients from their seropositive doctors is small. Although it is estimated that about 1000 practising US doctors are HIV positive, Rhame argues that there is no case for mandatory testing.6 If a surgeon has a known risk factor, however, HIV testing would be appropriate. If confirmed to be HIV positive, he or she should not "engage in any activity that creates a risk of transmission of the disease to others" (guidelines of the American Medical Association, 1988). 1. Sacks JJ. AIDS in a surgeon. N Engl J Med 1985; 313: 1017-18. 2. Porter JD, Cruickshank JG, Gentle PH, Robinson RG, Gill ON. Management of patients treated by a surgeon with HIV infection. Lancet 1990; 335: 113-14. 3. Centers for Disease Control. Possible transmission of HIV to a patient during an invasive dental procedure. MMWR 1990; 39: 489-93. 4. Smith DD. Physicians and the acquired immunodeficiency syndrome. JAMA 1990; 264: 452. 5. Mishu B, Schaffner W, Horan JM, Wood LH, Hutcheson RH, McNabb PC. A surgeon with AIDS: lack of evidence of transmission to patients. JAMA 1990; 264: 467-70 6. Rhame FS. The HIV-infected surgeon JAMA 1990; 264: 507-08.
Contaminated L-tryptophan The latest
epidemiological inquiry into eosinophilia-myalgia throws a little light on the pathogenesis.! In the (EMS) syndrome second of their case-control studies from Minnesota, Belongia and his colleagues identified 30 cases of EMS in which the manufacturer of the L-tryptophan they had taken was known. In 29 the source was the Japanese company Showa Denko KK; furthermore the dates of manufacture of the suspect material clustered in early 1989. Three things happened at about that time--a switch to a new strain of Bacillus amyloliquefaciens, which is used in the fermentation process;
a
reduction in the
amount
of activated carbon used in the
purification of the product; and, for about nine months, the failure of some of the product to pass through a filtration step that removes molecules above 1 kD. Showa Denko’s tryptophan is usually 99-6% pure (exceeding US Pharmacopeia requirements), which suggests that the contaminant responsible for EMS is very potent.
High-performance liquid chromatography revealed, but did not identify, the presence of a contaminant that was associated with retail lots of L-tryptophan consumed by patients with EMSindeed so confident are Belongia et al about this "signature" that they suggest that the 30th case also ingested the Showa Denko product. Laboratory studies pointed to a 5-fold increase in eosinophil major basic protein in the serum of cases and an I 1-fold increase in eosinophil-derived neurotoxin, but serum IgE was usually normal. 1.
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.
Cannabinoid
receptor(s)
Clinicians need not get too excited by the news that a receptor for A9-tetrahydrocannabinol, the psychoactive ingredient in cannabis, has at last been identified.! That there ought to be receptors for cannabinoids in the central nervous system had been realised for a long time but, as Snyder points out/ progress in this area did not mimic that with opioid receptors. What Matsuda and colleagues have provided is a tool, in the form of a cloned cannabinoid receptor, but the properties of cannabis derivatives suggest that we are dealing with a family of receptor subtypes and, presumably, as yet unknown endogenous ligands. Without that heterogeneity the cannabinoids are unlikely to rise from their lowly place in the
pharmacopoeia. 1. Matsuda LA, Lolait SJ, Browostein MJ, Young AC, Bonner TI. Structure of the cannabinoid receptor and functional expression of the cloned cDNA. Nature 1990, 346: 561-64. 2 Snyder SH. Planning for serendipity. Nature 1990; 346: 508.
Catheters out! Catheter care in both medical and surgical patients can be fraught with difficulties, most commonly traumatic passage, infection, and paraphimosis. Catheter removal is not thought of as a contentious issue, but it is recognised that a delayed return to normal frequency and voiding volumes may ensue after withdrawal. A group from London, UK,l now report on 86 patients who had their catheters removed at either midnight or 6 am (usual ward practice). They found that those patients who had night-time removal produced significantly greater volumes of urine at the time of their first void, and they were also discharged earlier from hospital. They recommend that catheter removal at midnight is a way to achieve a faster physiological voiding pattern. 1. Noble JG, Menzies D, Cox PJ, Edwards L. Midnight removal: an improved approach to removal of catheters. Br J Urol 1990; 65: 615-17
Access to food
safety data
Genetically modified bakers’ yeast, the alleged induction of polyploidy by irradiated wheat, a code of practice on tasting beers by genetically manipulated yeasts, a chymosin enzyme (for cheese manufacture) from a genetically manipulated source organism, fructose syrup containing dextrans, and a novel fat replacer were the topics on which the Advisory Committee on Novel Foods and Processes completed its deliberations in the first year of its existence.’ This committee, reconstituted from the Advisory Committee
on
Irradiated and Novel Foods
to
reflect the
rapid
development in food biotechnology, saw no safety reason against the use of genetically manipulated yeast in food, but it recommended that manufacturers should carry out regular checks to detect genetic drift in the yeast genome in use. Its report has been forwarded to Ministers, as has that on dextrans, which the Committee also judges as safe for use in fructose syrup. The advice or chymosin enzyme is being considered by the Food Advisory Committee, and neither the raw materials (egg and milk proteins) nor the production process (microparticulation) for the fat replacer was thought to be novel,
433
although its use was. In the Committee’s opinion animal feeding studies indicated that irradiated wheat was unlikely to cause
polyploidy.
its decisions, the Committee’s report To give the public to Ministers will be made available on request. In addition, the Committee is making arrangements to deposit with the British Library the data that it examines. access to
1. Department of Health and Ministry of Agricultural Fishenes and Food Advisory Committee on Novel Foods and Processes Annual Report 1989. 1990. Pp 27. Available from Department of Health, Room 617 Eileen House, Newington Causeway, London SE1 6EF.
Mapping the visual areas of the brain The easiest way
spot a friend in a crowd is to look out for a feature-a red hat, for instance. This principle, specific, striking combined with positron emission tomography (PET), has been used to locate the parts of the brain that process shape, colour, and velocity. Corbetta et all first confirmed that subjects were able to detect a change in a visual stimulus more accurately when they concentrated on one attribute than when they divided their attention between attributes. On the assumption that good discrimination might mean enhanced neuronal activity, they repeated the experiment, this time with PET, to detect variation in neuronal activity between different parts of the brain during periods of divided attention or selective attention to a visual stimulus. Shape, colour, and velocity activated different parts of the brain, though not necessarily one part each, and activity tended to be
International Nutrition Foundation
prize
The topic for the 1991 competition of the International Nutrition Foundation (ISFE) is "Nutritional Aspects of Hypertension". Entrants should send, by May 1991, four copies of reprints of relevant publications over the past five years, unpublished manuscripts, a brief statement of the significance of the contribution, a short curriculum vitae, and a list of major publications to Prof Dr D. Hotzel, Institut fur Emahrungswissenschaft, Rhein Friedrich- Wilhelms- Universitat, D-5300 Bonn 1, West Germany.
In
England Now
to
asymmetrical. 1. Corbetta M, Miezin FM, Dobmeyer S, Schulman GL, Petersen SE. Attentional modulation of neural processing of shape, colour, and velocity in humans. Science
1990, 248: 1556-58.
As sceptical as any other member of the medical profession when I hear of seemingly miraculous cures achieved with "alternative" remedies, I listened in silent disbelief as a friend told me how comfrey (widely believed to be almost in a class of its own as a curative) had came to his rescue. He had tried to separate two fighting dogs and in the process had received a painful bite on his hand. He glanced at the wound and saw, to his horror, a large area of raw flesh between the thumb and first finger, and rapidly averted his eyes. His companion, however, knew what to do and applied a comfrey leaf to the wound and bound it up. In the evening the patient was brave enough to remove the comfrey leaf, and was astonished to see that apart from a trivial puncture wound the hand looked normal. Naturally he became an immediate convert to the magic powers of comfrey. It was fortunate, I thought, that I had made no comment, for the comfrey had indeed produced a magic cure. But my scepticism was not misplaced, after all. Later, the patient had happened to look at the discarded leaf: on it lay a substantial piece of severed canine lip.
Anaesthetic safety checks Airline pilots
use standard lists to check equipment, so do service engineers. Why not anaesthetists as well? Actually various checklists exist. These and procedures recommended by manufacturers of
various anaesthetic machines have formed the basis of a listl compiled by the Association of Anaesthetists of Great Britain and Ireland and designed to take only a few minutes without being too superficial to be of doubtful value. The approach is based on use of oxygen analysers and should detect misfilling of oxygen cylinders and contamination of liquid oxygen reservoirs, which are not detected by checks for "crossover" (of pipelines). The booklet also gives outline checks for breathing systems, lung ventilators, and suction equipment. 1. Checklist for anaesthetic machines. Association of Anaesthetists of Great Britain and
Ireland, 9 Bedford Square, London WC1B 3RA. 1990. Pp 11. £1.50 for members, £300 for non-members.
International Diary A conference entitled The People’s Health-Who’s in Charge? is to take place in Glasgow on Saturday, Sept 1: Public Health Alliance, Room 204, Snow Hill House, 10-15 Livery Street, Birmingham B3 2PE, UK (021-235
4044). A short course on Transplantation Statistics organised by the Medical Research Council Biostatistics Unit will take place at Clare College, Cambridge, on Sept 23-26: Sheila M. Gore, MRC Biostatistics Unit, 5 Shaftsbury Road, Cambridge CB2 2BW, UK (0223 324022).
A
symposium on AIDS and the Epidemics of History will take place in London, on Wednesday, Oct 17: Royal Society of Medicine, 1 Wimpole Street, London W1M 8AE, UK (071-408 2119).
Deaf but not dumb with hearing impairment find that doctors do not make much effort to communicate. Deaf people are often unnecessarily embarrassed during medical consultations, and they-not just the doctor--can find the experience extremely frustrating. A little thought and a little extra time can go a long way to reduce these difficulties, as discussed in an article in Saundbarrier,l the newsletter of the Royal National Institute for the Deaf. The author, a person with hearing impairment, gives some good advice. Don’t sit in front of a window or light, or use subdued lighting, otherwise lip-reading will be impossible. Never bypass the patient to talk mainly with a partner or carer. Speak clearly and not too quickly-but don’t shout or use unusual emphasis, because normal lip and mouth movements will be distorted. And if you do have to resort to writing down information, at least make sure that the writing is legible.
Many people
1 Pat Robins. Painful doctors—the
remedy Soundbarrier March, 1990.
2nd international conference on Oral Chelation is to take place in Bombay on Nov 2-3: Dr M. B. Agarwal, Organising Secretary, 303 Doctors Centre,
Kemps Comer, 135 August Kranti Marg, Bombay 400 036, India (8115504). meeting of the North American Society for Pediatric Gastroenterology and Nutrition will be held in Chicago, Illinois on Nov 2-3: NASPGN Registration Manager, c/o SLACK Inc, 6900 Grove Road, Thorofare, NJ 08086, USA (609-848 1000).
Annual
Annual postgraduate course followed by 41st annual meeting of the American Association for the Study of Liver Diseases is to take place in Chicago, Illinois, on November 3-6: Registration Manager, SLACK Incorporated, 6900 Grove Road, Thorofare, New Jersey 08086, USA
(609-848 1000).
symposium on Cardiopulmonary Urgencies and will take place in Rotterdam on Nov 26-29: Dr Omar Prakash, Thorax Centre, Erasmus University, 3000 DR Rotterdam, Netherlands (31 10 463 5230).
6th international
Emergencies