- Email: [email protected]
Hysteria over doctors with HIV
764
An inability to make any moral distinction between natural death from the passage of time, the advance of disease, and the invasion of micro-organisms ("letting nature take its course") and the deliberate action of a human being is entirely at variance with common sense.
Department of Medicine for the Elderly, Addenbrookes Hospital, Cambridge CB2 2QQ, UK
N. K. CONI
SIR,-With respect to Malcolm Dean’s comments about euthanasia, I should like to make it quite clear that the report "Born too Soon", published by the Office of Health Economics (January, 1993), does not in any way suggest "that very premature babies should be left to die because of the large numbers who grow up handicapped and incapable of an independent life". It is regrettable that Dean seems to have based his account on the inaccurate reports in some of the more "imaginative" of the tabloid newspapers, rather than his own research. Perhaps if had read the report itself or your note of Jan 30, which accurately reflects the arguments, he would have realised that the report does not call for very preterm babies to be left to die. Instead it outlines the causes of premature births, the neonatal consequences, and the largely unsatisfactory treatments for trying to prevent its occurrence. The main thrust of the report, and indeed its conclusion, is that "the difficulties of eradicating social inequality underline the importance of more research to establish the causes of preterm birth, and in
understanding the causes to work towards reducing the incidence". It takes a tremendous intellectual leap to call this euthanasia. Office of Health Economics, 12 Whitehall, London SW1 2DY, UK
JANE GRIFFIN
AIDS: donors dictate third-world strategy SIR,-Your discussions (Dec 19/26, p 1533, Jan 23, p 234) on AIDS fall short of providing new perspective for your readership in developing countries. Despite the fact that poverty is identified as a key factor in the AIDS pandemic, research has not been directed to the understanding of poverty, labour migration, and prostitution. The lack of critical inquiry makes these social problems seem to come out of nowhere, and to be perpetuated by no one. For example, instead of seeking ways to change the political conditions that subjugate women to the degradation of prostitution, the Indian Government’s AIDS campaign unwittingly provides for healthier
prostitutes. In developing countries, there are numerous health hazards that often go unnoticed. For example, the use of unsterile needles, which is not uncommon, has the real potential to spread HIV infection through immunisation programmes. The gravity of such a tragedy with respect to infant mortality and child survival rates is beyond imagination. Against such realities, where easily curable health problems go untreated, a cure for AIDS will be meaningless to the populations of most developing countries. The World Bank conditional assistance
to
India’s AIDS
programme-ie, that 40% and 19% of the fund will go to intermediary and foreign consultancies-does not reflect the spirit of so-called extraordinary co-operation. The research emphasis on vaccine and drug development clearly shows that reliance of these programmes on the wisdom of donor countries continues to shape the third-world perception about their health-care strategy and research priorities. Department of Surgery, All India Institute of Medical Sciences, New Delhi 110 029, India
Hysteria
over
L. R. MURMU
doctors with HIV
SiR,—The hysterical media reaction in the UK to the discovery of health care workers infected with HIV has not been helped by the response from the Department of Health or the health authorities concerned. The risk to patients is minute and theoretical, since there have been no reported cases of surgeons infecting patients and only 1 one case of a dentist who might have infected a patient. The latest media orgy has involved the naming of the unfortunate gynaecologist, reporting of his lifestyle, sexual orientation, and even
choice ofties.2 This constitutes a grave invasion of privacy. There is logical reason for contacting the patients treated by this person other than political expediency. Doctors are far more likely to contact HIV from their patients than vice versa. Some surgical personnel, particularly in the USA, may be facing a 2% per year risk of seroconversion.3 Over a professional lifetime of 35 years, more than half such surgeons would contract HIV. The suggestion that all doctors should be coerced into having an HIV test2 is a dangerous nonsense. The General Medical Council’s suggestion that doctors who discover that a colleague is HIVpositive should report the result to the authorities is a breech of patient confidentiality. Doctors’ civil liberties are endangered. Policies should be based on the known risks of transmission and not on the fantasies of the media. no
Green College, Oxford OX2 6HG, UK
SIMON J. ELLIS
1. Possible transmission of human immunodeficiency virus to a patient invasive dental procedure. MMWR 1990; 39: 489-93. 2. The Sun. 1993; March 8: 5-6. 3. Emanuel EJ. Do physicians have an obligation to treat patients with AIDS? Med 1988; 318: 1686-90.
during
an
N Engl J
Cervicocephalic artery dissections due to chiropractic manipulations SiR,—Chiropractic manipulations are a common therapy for head and neck pain. Frisoni et all discusssed vertebrobasilar ischaemia due to vertebral artery dissections as a complication of chiropractic manoeuvres. The symptoms vary from neck pain and occipital headache2 to Wallenberg’s syndromeand lethal stroke, and may even mimic myocardial infarction.4 The risk is considered as low as 1 case per million treatments. 5 Over 6 months, we observed 4 patients with such complications among a population of 1 million (table). None of the patients had a history of other causes leading to cervicocephalic artery dissections, such as trauma,6 sport injuries,1,1,8 and abnormal head positions.8 The close time correlation of the initial symptoms was evidence against the possibility of spontaneous dissection. Stretching injury of the endothelium between the atlas and the axis is thought to explain the pathophysiology of vertebral artery dissection.2,6,7 Predisposing factors include diseases of the vessel wall, such as cystic media necrosis, Marfan’s syndrome, Ehler Danlos’ syndrome, and fibromuscular dysplasia.1,2,6,9 Subtle changes of the renal arteries on arteriography indicated fibromuscular dysplasia in only 1 of our patients. The role of cervical spine degeneration, atherosclerosis, hypertension, migraine, and oral contraception as potential predisposing factors is unclear ;1,2,6 these factors were absent in our patients. The first symptoms were unspecific and occurred during or immediately after the chiropractic treatment. There was no relation between the severity of symptoms and the violence of the neck manipulation and our patients had been treated by experienced chiropracters. The delay between the first symptoms and the onset of neurological deficit varied from 2 h to 2 days; there are longer delays reported.2 Thromboembolism from the site of the endothelial damage is the main source of stroke, and rapid institution of anticoagulation followed by platelet aggregation inhibition is effective.2,9 In 1 of our patients we did emergency intraarterial fibrinolysis, but this cannot be generally recommended.2 Ultrasound may show a dissection; however, arteriography is still necessary to prove the diagnosis. Magnetic resonance imaging (MRI) is the method of choice to verify brainstem and cerebellar ischaemia, whereas computed tomography (CT) is of limited value during the acute stage. The role of magnetic resonance angiography for the verification of dissections remains to be determined.’" The true frequency of cervicocephalic dissections induced by chiropractic manoeuvres is not sufficiently documented. Our and other investigations1,9 indicate a higher incidence than suspected previously. Prospective studies are warranted because this complication may lead to severe disability and even death. The individual risk of a dissection cannot be predicted in most patients.
An inability to make any moral distinction between natural death from the passage of time, the advance of disease, and the invasion of micro-organisms ("letting nature take its course") and the deliberate action of a human being is entirely at variance with common sense.
Department of Medicine for the Elderly, Addenbrookes Hospital, Cambridge CB2 2QQ, UK
N. K. CONI
SIR,-With respect to Malcolm Dean’s comments about euthanasia, I should like to make it quite clear that the report "Born too Soon", published by the Office of Health Economics (January, 1993), does not in any way suggest "that very premature babies should be left to die because of the large numbers who grow up handicapped and incapable of an independent life". It is regrettable that Dean seems to have based his account on the inaccurate reports in some of the more "imaginative" of the tabloid newspapers, rather than his own research. Perhaps if had read the report itself or your note of Jan 30, which accurately reflects the arguments, he would have realised that the report does not call for very preterm babies to be left to die. Instead it outlines the causes of premature births, the neonatal consequences, and the largely unsatisfactory treatments for trying to prevent its occurrence. The main thrust of the report, and indeed its conclusion, is that "the difficulties of eradicating social inequality underline the importance of more research to establish the causes of preterm birth, and in
understanding the causes to work towards reducing the incidence". It takes a tremendous intellectual leap to call this euthanasia. Office of Health Economics, 12 Whitehall, London SW1 2DY, UK
JANE GRIFFIN
AIDS: donors dictate third-world strategy SIR,-Your discussions (Dec 19/26, p 1533, Jan 23, p 234) on AIDS fall short of providing new perspective for your readership in developing countries. Despite the fact that poverty is identified as a key factor in the AIDS pandemic, research has not been directed to the understanding of poverty, labour migration, and prostitution. The lack of critical inquiry makes these social problems seem to come out of nowhere, and to be perpetuated by no one. For example, instead of seeking ways to change the political conditions that subjugate women to the degradation of prostitution, the Indian Government’s AIDS campaign unwittingly provides for healthier
prostitutes. In developing countries, there are numerous health hazards that often go unnoticed. For example, the use of unsterile needles, which is not uncommon, has the real potential to spread HIV infection through immunisation programmes. The gravity of such a tragedy with respect to infant mortality and child survival rates is beyond imagination. Against such realities, where easily curable health problems go untreated, a cure for AIDS will be meaningless to the populations of most developing countries. The World Bank conditional assistance
to
India’s AIDS
programme-ie, that 40% and 19% of the fund will go to intermediary and foreign consultancies-does not reflect the spirit of so-called extraordinary co-operation. The research emphasis on vaccine and drug development clearly shows that reliance of these programmes on the wisdom of donor countries continues to shape the third-world perception about their health-care strategy and research priorities. Department of Surgery, All India Institute of Medical Sciences, New Delhi 110 029, India
Hysteria
over
L. R. MURMU
doctors with HIV
SiR,—The hysterical media reaction in the UK to the discovery of health care workers infected with HIV has not been helped by the response from the Department of Health or the health authorities concerned. The risk to patients is minute and theoretical, since there have been no reported cases of surgeons infecting patients and only 1 one case of a dentist who might have infected a patient. The latest media orgy has involved the naming of the unfortunate gynaecologist, reporting of his lifestyle, sexual orientation, and even
choice ofties.2 This constitutes a grave invasion of privacy. There is logical reason for contacting the patients treated by this person other than political expediency. Doctors are far more likely to contact HIV from their patients than vice versa. Some surgical personnel, particularly in the USA, may be facing a 2% per year risk of seroconversion.3 Over a professional lifetime of 35 years, more than half such surgeons would contract HIV. The suggestion that all doctors should be coerced into having an HIV test2 is a dangerous nonsense. The General Medical Council’s suggestion that doctors who discover that a colleague is HIVpositive should report the result to the authorities is a breech of patient confidentiality. Doctors’ civil liberties are endangered. Policies should be based on the known risks of transmission and not on the fantasies of the media. no
Green College, Oxford OX2 6HG, UK
SIMON J. ELLIS
1. Possible transmission of human immunodeficiency virus to a patient invasive dental procedure. MMWR 1990; 39: 489-93. 2. The Sun. 1993; March 8: 5-6. 3. Emanuel EJ. Do physicians have an obligation to treat patients with AIDS? Med 1988; 318: 1686-90.
during
an
N Engl J
Cervicocephalic artery dissections due to chiropractic manipulations SiR,—Chiropractic manipulations are a common therapy for head and neck pain. Frisoni et all discusssed vertebrobasilar ischaemia due to vertebral artery dissections as a complication of chiropractic manoeuvres. The symptoms vary from neck pain and occipital headache2 to Wallenberg’s syndromeand lethal stroke, and may even mimic myocardial infarction.4 The risk is considered as low as 1 case per million treatments. 5 Over 6 months, we observed 4 patients with such complications among a population of 1 million (table). None of the patients had a history of other causes leading to cervicocephalic artery dissections, such as trauma,6 sport injuries,1,1,8 and abnormal head positions.8 The close time correlation of the initial symptoms was evidence against the possibility of spontaneous dissection. Stretching injury of the endothelium between the atlas and the axis is thought to explain the pathophysiology of vertebral artery dissection.2,6,7 Predisposing factors include diseases of the vessel wall, such as cystic media necrosis, Marfan’s syndrome, Ehler Danlos’ syndrome, and fibromuscular dysplasia.1,2,6,9 Subtle changes of the renal arteries on arteriography indicated fibromuscular dysplasia in only 1 of our patients. The role of cervical spine degeneration, atherosclerosis, hypertension, migraine, and oral contraception as potential predisposing factors is unclear ;1,2,6 these factors were absent in our patients. The first symptoms were unspecific and occurred during or immediately after the chiropractic treatment. There was no relation between the severity of symptoms and the violence of the neck manipulation and our patients had been treated by experienced chiropracters. The delay between the first symptoms and the onset of neurological deficit varied from 2 h to 2 days; there are longer delays reported.2 Thromboembolism from the site of the endothelial damage is the main source of stroke, and rapid institution of anticoagulation followed by platelet aggregation inhibition is effective.2,9 In 1 of our patients we did emergency intraarterial fibrinolysis, but this cannot be generally recommended.2 Ultrasound may show a dissection; however, arteriography is still necessary to prove the diagnosis. Magnetic resonance imaging (MRI) is the method of choice to verify brainstem and cerebellar ischaemia, whereas computed tomography (CT) is of limited value during the acute stage. The role of magnetic resonance angiography for the verification of dissections remains to be determined.’" The true frequency of cervicocephalic dissections induced by chiropractic manoeuvres is not sufficiently documented. Our and other investigations1,9 indicate a higher incidence than suspected previously. Prospective studies are warranted because this complication may lead to severe disability and even death. The individual risk of a dissection cannot be predicted in most patients.