SERVING TWO MASTERS

287 ask of death of 60% or more on admission or of 30% or more on referral for TPN. If the estimated probabilities of death are reliable, such a decision will lead to the refusal of TPN to some patients with a probability of survival greater than 60%. So the predictive value posinve result of 100% obtained by Chang and colleagues in 8 patients may be a chance result and they should calculate confidence mtervals for all their estimates. We can never be sure to be right when predicting survival-but if we do not treat severely ill padents, we can be almost certain to be right in predicting death. We hope that the years to come will not see extensive misuse of statistical techniques and severity scoring systems in intensive care. INSERM Unit 169, 94807 Villejuif, France

A. ALPEROVITCH

Hôpital Saint-Louis, Pans Hôpital Foch, Suresnes

J. R. LE GALL P. LOIRAT

ELECTRONIC PUBLICATIONS FOR UPDATING CONTROLLED TRIAL REVIEWS

SiR,—Many of your readers will have welcomed your decision to allow the results of the ISIS trial (July 12, p 57) to be presented within the context of a formal overview of all previously reported trials of early beta-blockade in acute myocardial infarction. Other reports of trials published by The Lancet1 would have been much strengthened had they included data derived from such overviews.2 It is clear from a comment in your editorial accompanying the ISIS paper that you feel ambivalent about your decision to allow the inclusion of a "lengthy tailpiece". Your ambivalence probably reflects a concern that such reviews could take up an unacceptable amount of space in the journal. I can well understand that you might be reluctant to publish an overview as detailed as that in the ISIS paper next time you print a report of a trial of early beta-blockade in acute myocardial infarction. Even so I hope that you would accept a less lengthy tailpiece, showing how the results of the latest trial influenced the estimates of treatment effects derived from the ISIS overview. The updating of trial overviews as new information becomes available may be a task for which electronic publishing has something to offer. Next year the Oxford Database of Perinatal Trials3 will be published by Oxford University Press in electronic form. Besides registers of published4 and unpublished trials and trials in progress or planned, the data base will include a library of trial overviews which will be updated when new data become available. Oxford Database of Perinatal Trials, National Perinatal Epidemiology Unit, Radcliffe Infirmary, Oxford 0X2 6HE

IAIN CHALMERS

1. Leveno KJ, Klein VR, Guzick DS, Young DC, Hankins GDV, Williams ML. Single-centre randomised trial of ritodrine hydrochloride for preterm labour. Lancet 1986; i: 1293-96. 2 King JF, Keirse MJNC, Grant A, Chalmers I. Tocolysis—the case for and against. In: Beard RW, Sharp F, eds. Preterm labour and its consequences. Proceedings of the 13th Study Group of the RCOG. London: Royal College of Obstetricians and

Gynaecologists, 1985: 199-208. 3. Chalmers I, HetheringtonJ, Newdick

M,etal. The Oxforddatabase of perinatal trials:

Developing a register of published reports of controlled trials. ControlledClin Trials 4

in press). National Perinatal Epidemiology Unit. A classified bibliography of controlled trials in perinatal medicine 1940-1984. Oxford: Oxford University Press, 1986.

SERVING TWO MASTERS

StR;—No life assurance company or underwriter will argue with Dr Toon and Dr Jones’ view (May 24, 1196) of the function of p general practitioners, but many will disagree with their views on disclosure to interested third parties, especially life assurance companies. One responsibility of a life underwriting department and the company’s medical officer is to underwrite a proposal for life asurmce

as

fairly as possible, not only

to

the

applicant

but also

to those who already have policies with the company. To do this the underwriter may need a detailed medical history. The notion, widely held, that an independent medical assessment is the answer to all problems is fallacious. An independent assessment is a "snapshot" of an applicant on a particular day and is at its most often useful when answering possible queries thrown up once a detailed history is known. It cannot replace the medical history of the

applicant. All companies

seek the applicant’s authority to approach any doctor who has been consulted about the applicant’s physical or mental health, and the format has been agreed with the British Medical Association. Toon and Jones mention four cases: it is unlikely that any of them would have been refused life assurance outright by this company. In case 1, because of the advice given, the GP probably deprived his patient of life cover that would have been helpful to the patient’s family in the event of the man’s early death. I recognise that there are ethical problems for doctors in disclosing information. However, the guidelines proposed, especially guideline 2, could work to the detriment of the patient/applicant. No life assurance underwriter would advise an applicant about his medical treatment. Do GPs have the knowledge necessary to advise their patients about life insurance? The GP’s function is to benefit his patient in respect of that patient’s mental and physical health: it is the function of a life assurance company to benefit the patient’s family in the event of early death and to protect their future. To do this, and to be fair to all, life companies need the help and cooperation of doctors. M&G Life Assurance Co Ltd, M&G House, Victoria Road, Chelmsford CM1 1FB

ERIC PURDY

** Dr Toon and Dr Jones reply as follows.-ED. L. SIR,--Our paper was intended to stimulate debate so we welcome Mr Purdy’s response. Our principal concern is with the quality of the consent obtained for medical reports. That the authority has been agreed with the British Medical Association is no comfort; it is the inadequacy of accepted medical practice in this area which led us to write our article. If companies were to implement a protocol for their officials on explaining the meaning of their authorities to applicants, then it might do much to make our "guidelines" redundant. As general practitioners our job is to provide a medical service to our patients. Life underwriters have different aims, one of which is to provide a fair and useful service to policy holders and would-be policy holders. But they also have a profit motive: life assurance companies provide a socially useful service but their relationship with their clients is that of buyer and seller, not doctor and patient. The aims of the company and the doctor will often be compatible, but sometimes they will conflict and when they do doctors need to be clear where their loyalties lie. We recommend an independent medical assessment because, whilst that may be less valuable to the company, it avoids a conflict of loyalties. We are not saying that GPs should give advice about life assurance. We do suggest that doctors should encourage patients to consider the matter carefully and point out the implications. A GP may lack the financial knowledge to advise on choice of life cover, but he does have the inestimable advantage of being free of any financial interest in the decision made. Denying life assurance companies access to GP records may make it harder for them to provide a cheap and fair service, though we wonder how companies manage in countries where patients do not register with one doctor and where there is not the continuity of care that enables such reports to be given. However, the practice of passing to companies reports prepared from GPs’ notes does harm medical care. It has, for example, been suggested that positive human immunodeficiency virus antibody tests should not be communicated to GPs because this fact might then be passed on to life assurance companies. Withholding this information from GPs

288 prevent it being passed on to third parties serves neither standards of medical care nor, ultimately, the companies themselves.

to

Academic Department of General Practice and Primary Care, Medical Colleges of St Bartholomew’s and The London Hospitals, Charterhouse Square, London EC1

immunodeficiency syndrome (AIDS): Findings m 53 homosexual men with Kaposi’s sarcoma. Oral Surg 1983; 565: 491-94. 3. Greenspan D, Greenspan J, Conant M, Peterson V, Silverman S Jr, DeSouza Y Oral "hairy" leukoplakia in male homosexuals: Evidence of association with both papillomavirus and a herpes group virus. Lancet 1984; u: 831-34. 4. Klein R, Harris C, Small C, Moll B, Lesser M, Friedland G. Oral candidiasis in high risk patients as the initial manifestation of the acquired immunodeficiency syndrome. N Engl J Med 1984; 311: 351-57.

PETER TOON

ERICA JONES VERTICAL TRANSMISSION OF HIV IN 15-WEEK FETUS

ORAL MANIFESTATIONS IN INPATIENTS WITH AIDS OR AIDS-RELATED COMPLEX

SIR,—Manifestations of immunosuppression in the oral cavity of patients with AIDS and AIDS-related complex (ARC) are well described, and include candidiasis, oral malignancies1 and hairy leukoplakia.1-3 Klein and his group’ followed the development of AIDS in two high-risk groups and noted that in the one group with oral candidiasis, 86% (19/22) acquired AIDS within 3 months while none in the other group had AIDS after being followed up for median of 12 months. We have looked for differences in the oral manifestations of AIDS and ARC in patients categorised as male homosexuals or as male intravenous drug abusers. The percentage of drug abusers in people with AIDS in New York State is 33 % and homosexuals comprise only 55%, compared with Centers for Disease Control figures of 73% homosexuals and 17% intravenous drug abusers. 122 male patients were studied. 64 were homosexual or bisexual with AIDS, but were not intravenous drug abusers; 16 intravenous drug abusers with AIDS denied homosexuality or bisexuality; 25 homosexuals or bisexuals had ARC but were not intravenous drug abusers; and 17 intravenous drug abusers had ARC but denied homosexuality or bisexuality. Hospital records were searched and patients were throughly examined for evidence of oral manifestations. All patients had antibodies to human immunodeficiency virus (HIV) and met all other criteria for AIDS or ARC. Candidiasis was prevalent in all groups, Kaposi’s sarcoma was much more frequent in homosexual/bisexual groups with AIDS or ARC than it was in drug abusers. A history of syphilis, gonorrhoea, genital herpes, and parasitic disease was also more common in the homosexual/bisexual groups than in the drug abuser groups. A history of hepatitis was more frequent in the drug abusers. No patient had oral hairy leukoplakia as defmed clinically (table). a

SIR,-Different observations suggest transplacental transmission of human immunodeficiency virus (HIV)l,2 early in pregnancy. At the request of the patient we terminated a 15-week pregnancy in a woman with stage IV AIDS who had generalised Kaposi sarcoma. HIV antigenic activity was demonstrated in amniotic fluid and fetal tissues. After ultrasonographic localisation of a posteriorly inserted placenta, an intra-amniotic catheter was inserted and used to collect 40 ml of clear amniotic fluid and to inject 40 mg prostaglandin F 2a(’Dinolytic’; Upjohn). Later a dead fetus of 250 g was expelled in the membranes. To avoid contamination with maternal blood, the fetus was washed with 70% isopropanol. The placenta was normotrophic with no suggestion of an inflammatory process. HIV antigens were sought by co-culture of maternal peripheral blood lymphocytes, amniotic fluid, amniotic cells, and fetal lung, brain, and spleen with adult anti-HIV negative blood lymphocytes. After 11 days supernatants were collected, filtered, and added to MT-2 and HUT-78 cells.3 To demonstrate virus-specific antigens, monoclonal antibodies directed to p155 (H311 and 8A6, prepared by J. Cogniaux-Le-Clerc) were used. On day 8 and then twice weekly PRESENCE OF HIV MARKERS IN HUT-78 CELLS INOCULATED WITH SUPERNATANTS OF CO-CULTURES FROM FETAL ORGANS WITH ADULT PERIPHERAL BLOOD LYMPHOCYTES

*On 9 ml of supernatant culture. Results

synthetic template-primers

as

ratio of enzymatic

activity obtained on both 2-3, + + 3-5, + - -

(dT12-18rA)/(dT12-18dA).5+=ratio

5-7, + + + + 8-10. tlndex of antibody bindmg 3-4 ( + +),4-5 ( + + + ), 5-6 ( + + + +). 3,4 Results as ratio

ORAL MANIFESTATIONS IN AIDS AND ARC PATIENTS

of bound cells.

cells

mouse

were

Ig labelled with iodine-125 on infected cells compared with uninfected

harvested and

processed for solid-phase radioimmuno-

assay based on binding of mouse Ig labelled with iodine-125. These experiments were done over 11 weeks.

H/B=homosexual/bisexual.

IVDA=intravenous

drugs abuser.

The major finding was that almost all homosexual/bisexual men with AIDS had oral manifestations. Department of Dentistry, Beth Israel Medical Center,

CHARLES E. BARR

and Mount Sinai School of Medicine, New York NY 10003, USA

1.

JAMES P.

TOROSIAN

Lozada F, Silverman S Jr, Conant M. New outbreak of oral tumors, malignancies, and infectious diseases strikes young male homosexuals. J Calif Dent Assoc 1982; 10:

39-42. 2. Lozada F, Silverman S Jr, manifestations of tumor

Miglioratti C, Conant M, Volberding and

The HUT-78 cells that had been inoculated with the filtered supernatants from the co-cultures were antigen positive after 8-15 days. At this time, a strong cytopathic effect necessitated additions of non-infected HUT-78 cells to keep the culture growing. The MT-2 cells treated in the same way were negative. Particle reverse transcriptase (RT) activity5 was demonstrated in the supernatants of HUT-78 cells positive for the viral antigens. These results suggest that vertical transplacental transmission of HIV occurs as early as the 15th week of gestation. They stress the importance of screening high-risk groups in the antenatal clinic anè of the need for medical surveillance of such pregnancies and the resulting babies.

opportunistic

infections

in

P. Oral

acquired

Institut Pasteur du Brabant, B-1180 Brussels, Belgium; and Hôpital Universitaire Saint-Pierre, Brussels

1.

Jovaisas E, Koch MA, Schafer A, Stauber M, Lowenthal 20-week fetus. Lancet 1985; ii: 1129.

S. SPRECHER G. SOUMENKOFF F. PUISSANT M. DEGUELDRE D. LAVHTLV-III in