with penicillin as part of treatment given in hospital ... Scottish Centre for Infection and Environmental Health, .... candidiasis (vaginal yeast infections, vaginal.
patients do ask for, and some doctors do provide, assistance in shortening life. For these patients and these doctors the law is clearly unsatisfactory, and furthernore restricts open discussion on both a professional and personal level. BARNEY WARD
Medical student PATTATE
General practitioner
East Barnwell Health Centre, Cambridge CB5 8SP 1 RodwayA. Euthanasia. BMJl994;309:52. (2 July.) 2 Ward BJ, Tate PA. Attitudes among NHS doctors to requests for euthanasia. BMJ 1994;308:1332-4. (21 May.) 3 Collins K, Gilhooly MLM, Murray K. Euthanasia. BMJ 1994;309:52. (2July.)
Achilles tendons. I had no alternative to walking home. It took three weeks for the wounds to heal. These high heel tabs, whatever their intended practical application, can and do cause injuries to the wearer. They seem to be no more than a fashion fad. Perhaps a couple of writs against the various manufacturers might cause them to mend their ways and produce more ergonomically sound footwear. Sperryn's photographs illustrate yet another sports hazard. If people wear such footwear without socks the environment within the shoe becomes a mixture of sweat, desquamated cells, sebum, bacteria, and fungi. In my experience (which is limited to Australia), tinea pedis is much more common and severe in those who do not wear socks when wearing enclosed shoes. KEN HAY
Sports medicine
Mandurah 6210,
Western Australia, Australia
Booster doses are not needed ED1TOR,-J C M Sharp's advice on tetanus immunisation' is contrary to that specified in the current
1 Sperryn PN. Overuse injury in sport. BMJ 1994;308:1430-2. (28 May.)
edition of the "green book." For immunised adults who have received five doses of tetanus vaccine, either as children or according to the recommended schedule of immunisation for those aged 10 years and over, booster doses are not recommended, other than at time of injury, since they have been shown to be unnecessary and can cause considerable local reactions.' Sharp's recommendation that people should have booster doses at 10 year intervals and that boosters should be considered at five year intervals for athletes is now out of date. FIONA SIM Clinical medical officer, community child health
Forth Valey Healthcare, Stirling Royal Infirmary, Siring FKC8 2AV
1 Sharp JCM. Infections in sport. BMJ 1994;305:1702-6. 2 Departnent of Health, Welsh Office, Scottish Home and Health Departmnent,
DHSS
(Northem
Ireland).
Immunisanon
against infectious disease. London: HMSO, 1992:37-43.
Author's reply ED1TOR,-The Departmnent of Health's recommendation limiting the number of doses of tetanus vaccine for prophylaxis in adults is well known and its validity generally accepted. My suggestion that rugby and soccer players should be considered for further occasional booster doses during their playing careers is based on the experience of a 26 year old Scottish rugby player: in 1988 he developed clinical tetanus after sustaining a deep stud wound despite having received tetanus vaccine with penicillin as part of treatment given in hospital on the occasion of his injury (unpublished case). He had reportedly received the full immunising course of five doses of vaccine before leaving school, his last booster dose having been in 1978, 10 years previously. J C M SHARP
Consultant epidemiologist Scottish Centre for Infection and Environmental Health, Ruchill Hospital, Glasgow G20 9NB
Heel tabs can cause injury EDrroR,-Peter N Sperryn made scant mention of equipment as a cause of overuse injury in sport yet included in his article two photographs of a glaring example of faulty equipment.' That same equipment recently caused bilateral injuries to my heels and ankles. I walk for 90 minutes most mornings, and recently replaced worn out jogging shoes. I made the grave error of buying new sports footwear with high heel tabs exactly as illustrated by Sperryn, although of a different brand. Halfway through my first walk in the new shoes I had blisters over both
474
Anaesthetist attends boxing contest ED1ToR,-I question the statement in Greg McLatchie and Bryan Jennett's article on head injury in sport regarding the management of the unconscious patient at the scene of injury. The authors suggest that the airway should be protected until arrival of paramedics, who would then institute suction and intubation. If in this situation the unconscious patient still had a gag reflex, any attempt to facilitate intubation without giving a general anaesthetic could potentiate an already severe injury, with catastrophic consequences. Following the injury received by the boxer Michael Watson, I sought the advice of local specialists with regard to ringside management of actute head injury in professional boxing. As a result there has been an anaesthetist present at all professional boxing contests in Wales since October 1991. Provision has been made for giving a neuroprotective general anaesthetic at the.scene, before transfer to hospital. All drugs and equipment are on site, and a basic protocol has been agreed. Only an anaesthetist following strict guidelines should attempt to intubate the unconscious head injured patient at a sporting venue. R M MONSELL Welsh area medical officer
British Boxing Board of Control, Cardiff CF2 7DS 1 McLatchie G, Jennett B. Head injury in sport. BMJ 1994;308: 1620-4. (18June.)
Syncope A good history is not enough ED1TOR,-The editorial on syncope by M C Petch invites comment.' The thrust is to oversimplify the diagnosis of syncope. We agree that this may be appropriate but depends on the history from patient and observer. However, in a substantial minority there are real difficulties. In this context Petch's definition of malignant vasovagal syncope does not match either the British or the North American definition.2 The British definition hinges on the lack of warning experienced, which results in injury in attacks, and the American definition emphasises the duration of asystole on tilt testing. For these patients testing is necessary, and until the mid-1980s there was no test that could, in the laboratory, reproduce vasovagal syncope. In 1986 Kenny et al first showed the clinical value of tilt testing and provided the basis for the British definition.' Since then tilt testing has spread worldwide, which reflects not only its clinical utility but also its economy.
We agree that many aspects of tilt testing remain to be fully evaluated, including use of drug challenge, reproducibility, and serial testing, but we underline the value of the test. After only eight years we are not surprised that scientific work in the field is incomplete. The consideration of a few patients for implantation of dual chamber pacemakers has not been lightly undertaken,4 and our recommendations now are that a patient with recurrent syncope, which meets the British definition of malignant vasovagal syncope, should undergo repeat tilt testing with temporary dual chamber pacing to show the benefit. Lastly, it must be stated that no therapy for vasovagal syncope has yet survived the rigours of a randomised controlled trial. The matter of tilt testing is not the only way in which Petch is misleading. Patients sustaining a simple faint or vasovagal component, and debility, nausea, or headache are often seen. Furthermore, every age is affected. Diagnosis of any kind of syncope by event recording sometimes proves unrewarding. It is contradictory to state that warning is insufficient in a simple faint to apply the recorder and to maintain that the warning in such a faint is diagnostic. Finally, carotid sinus massage causing symptomatic asystole cannot be ignored, especially when no other explanation of syncope has been determined; this is confirmed by all series directed towards this.' The clinical history here is paramount but not perfect, and tilt testing is a necessary adjunct in the investigation of syncopy. RICHARD SUTTON
President ANTHONYNATHAN
Secretary JOHN PERRINS Treasurer DOUGIAS SKEHAN Member WYN DAVIES Member
British Pacing and Electrophysiology Group, Royal Brompton National Heart and Lung Hospital, London SW3 6NP 1 Petch MC. Syncope. BMJ 1994;308:1251-2. (14 May.) 2 Sutton R. Vasovagal syndrome. Could it be malignant? Eur
J
Cardiac Pacing Electrophysiol 1992;2:89. 3 Kenny R-A, Ingram A, Bayliss J, Sutton R. Head-up tilt: a useful test for investigating unexplained syncope. Lancet 1986;ii: 1352-4. 4 Petersen MEV, Chamberlain-Webber R, Fitzpatrick AP, Ingram A, Williams T, Sutton R. Permanent pacing for cardioinhibitory malignant vasovagal syndrome. Br Heart J 1994;71:
274-81. 5 Brignole M, Menozzi C, Gianfranchi L. Neurally mediated syncope detected by carotid sinus massage and head-up tilt test in sick sinus syndrome. AmJCardiol 1991;68:1032-6.
History may be inaccurate in elderly people ED1TOR,-M C Petch's editorial on syncope is misleading.' It is untrue that "an accurate history tells all." In older patients, in whom the annual incidence of syncope is at least 6% with an annual recurrence of 30%, the history is unreliable. In 1993 colleagues and I investigated 900 new referrals with a diagnosis of syncope or possible syncope. Over two thirds were aged over 65; a witness account of events or an accurate history was available for only two fifths of these elderly patients. Of the elderly patients in whom loss of consciousness had been witnessed and symptoms recurred during provocation testing, one third maintained on presentation that they had suffered only recurrent unexplained falls; they denied syncope, thus showing retrograde amnesia for loss of consciousness.23 Half of the patients referred for investigation had sustained a serious injury during a syncopal episode, and symptoms had been present for four years on average. Patients had experienced a mean of 13 syncopal episodes or unexplained falls.2 The reasons why such patients are not referred earlier are unclear. Patients benefit from diagnosis and intervention.245 A diagnosis can be made in 83% of older
BMJ VOLUME 309
13 AUGUST 1994
patients with recurrent unexplained falls and syncope, and 82% of this group benefit from intervention.2 Simple faints are uncommon in elderly people, partly because of their altered baroreflex sensitivity. Treatment with a vasodilator is the commonest cause of vasovagal syncope, and symptoms may be modified or abolished by a change in treatment. If carotid sinus massage produces an important reproducible asystolic response this is not normal5 and in symptomatic patients requires physiological pacing to abort recurrent syMptoms.4 Slowing of the heart rate of greater than 3 seconds during carotid sinus massage does not occur in asymptomatic elderly people.5 The carotid sinus syndrome is an underdiagnosed cause of dizziness, falls, and syncope,3 and cardiac pacing will abort syncopal episodes in most cases, although dizziness may persist because of persistent hypotensive features.4 ROSE ANNE KENNY Consultant physician
Cardiovascular Investigation Unit, Department of Medicine (Geriatric Medicine), Royal Victoria Infirmary, Newcastle upon Tyne NEI 4LP 1 Petch H. Syncope. BMJ 1994;308:1251-2. (14 May.) 2 McIntosh S, da Costa D, Kenny RA. Outcome of an integrated approach to the investigation of dizziness, falls and syncope in elderly patients referred to a syncope clinic. Age Ageing 1993;22:53-8. 3 McIntosh S, Lawson J, Kenny RA. Clinical characteristics of cardioinhibitory vasodepressor and mixed carotid sinus syndrome. Am JMed 1993;95:203-8. 4 Morley CA, Perrins EJ, Grant P, Chan SL, McBrien DJ, Sutton R. Carotid sinus syncope treated by pacing: analysis of persistent symptoms and role of atrioventricular sequential pacing. BrHearty 1982;47:411-8. 5 McIntosh S, Lawson J, Kenny RA. Heart rate and blood pressure responses to carotid sinus massage in healthy elderly subjects.
AgeAgeing 1994;23:57-61.
Vulvovaginal candidiasis EDITOR,-Susan M Sawyer and colleagues state that they report the rate of vulvovaginal candidiasis in young women with cystic fibrosis.' This, however, is not justified by the evidence presented; rather, what they report is the rate of genital symptoms. The authors do not state whether an affirmative answer given to the question "Have you had thrush infections (candida infection)?" meant that a microbiological diagnosis had been made or that certain symptoms had been experienced by the patient. If it meant that certain symptoms had been experienced, what were they? Self diagnosis of vaginal thrush is unsatisfactory as this term may be used by patients to describe a wide variety of symptoms not always relating to candidal infection (or any genital infection, for that matter.) Although the answers given by the patients may not truly reflect the incidence of vaginal candidiasis, this report highlights important morbidity that, as the authors indicate, needs to be addressed. Given that this is a group of young sexually active women, however, advice should be given not only about candidiasis but about sexual health in general. CHRISTINE M BATES
Senior registrar Department of Genitourinary Medicine, Royal Liverpool University Hospital, Liverpool L7 8XP 1 Sawyer SM, Bowes G, Phelan PD. Vulvovaginal candidiasis in young women with cystic fibrosis. BMJ 1994;308:1609. (18June.)
Authors' reply EDIrOR,-Christine Bates appropriately raises the concern that the high rate of self-reported vulvovaginal candidiasis that we recently described' could be explained by a variety of disorders. We
BMJ VOLUME 309
13 AUGUST 1994
were surprised by the high rates reported and subsequently telephoned a quarter of the participants for clarification of their response to this question. All of those who had reported vulvovaginal candidiasis had obtained microbiological confirmation on at least one occasion. Recently, 54 of 66 adult women with cystic fibrosis (82%) who attend Boston Children's Hospital cystic fibrosis clinic were investigated (unpublished data). In response to the question, "Have you ever had an episode of vulvovaginal candidiasis (vaginal yeast infections, vaginal thrush, vaginal candida)?" 91 % reported they had experienced at least one episode and 35% reported very frequent infections (the two most severe categories). These figures are similar to, but slightly higher than, the data we recently reported (80% and 23% respectively). Two thirds of the Boston women with a history of self reported vulvovaginal candidiasis had microbiological confirmation on at least one occasion, and four women (8%/o) reported other vaginal infections (gardnerella, trichomonas (2), and vaginal warts). About half the participants reported an increase in vulvovaginal candidiasis when they changed oral antibiotics or started intravenous antibiotics. The lack of recognition of these vaginal symptoms suggests that health care professionals have failed to notice the broader health concerns of these women beyond the recognised morbidities of cystic fibrosis. We strongly agree with Bates that advice to this group of women should be given not only about candidiasis but about reproductive and sexual health in general. As we have recently described, however, this is not straightforward.2 What little information is currently available (such as the risks of pregnancy or the risk of having a child with cystic fibrosis) seems not to be adequately communicated to, or understood by, this group of patients, and in other cases the required information is simply not available (such as how cystic fibrosis affects fertility). S M SAWYER
Research fellow Physiology Program, Harvard School of Public Health, Boston MA 02115, USA G BOWES Professor ofadolescent health P D PHEILAN Stevenson professor of paediatrics
Royal Children's Hospital,
Melbourne, Australia
1 Sawyer SM, Bowes G, Phelan PD. Vulvovaginal candidiasis in young women with cystic fibrosis. BMJ 1994;308:1609. 2 Sawyer SM, Phelan PD, Bowes G. Reproductive health in young women with cystic fibrosis knowledge, behaviour and
attitudes. YAdol Health (in press).
Managing patients who refuse blood transfusions
experienced in medical or surgical management not entailing blood transfusion is welcome to contact one of the Witnesses' hospital liaison committees, now established in 36 locations in Britain and in over 1000 cities around the world. J W A BRACE Deputy hospital information coordinator Watch Tower Bible and Tract Society of Pennsylvania, London NW7 lRP 1 Finfer S, Howell S, Miller J, Willett K, Wilson-MacDonald J, Wilson DH, et al. Managing patients who refuse blood transfusions: an ethical dilemma. BMJ 1994;308:1423-6.
(28 May.) 2 Saha A, Elstein M. Managing patients who refuse blood trans-
fusions. BMJ 1994;309:125. (9 July.)
Will consent if confidentiality is maintained EDITOR,-The article by Simon Finfer and colleagues highlighted the practical dilemmas associated with treating Jehovah's Witnesses.' The stand of Jehovah's Witnesses concerning blood transfusion is based on an interpretation of certain Levitical texts (Leviticus 7:26-7 and 17:10-4). Should a Witness be given a transfusion, the same texts allow for the individual to be "cast out" ("disfellowshipped") from the community. Disfellowshipping (a combination of excommunication and shunning) can be a severe sanction for the individual. In addition there is a considerable grey area concerning protein products,2 and the decision whether or not to accept these is one of individual conscience. Should a coagulopathy develop, it is helpful to establish which clotting factors (or combinations) would be acceptable. A recent patient was prepared to accept plasma protein fraction, cryoprecipitate, and individual factors, but not fresh frozen plasma. The Jehovah's Witnesses Hospital Liaison Committee has been helpful in explaining the theological and doctrinal differences between various products to their members. I have anaesthetised Witnesses for cardiac surgery for several years. It is my practice to tell each patient that any decision on whether they wish to receive blood or products will be respected totally and will remain absolutely confidential, and that no clinical information concerning treatment will be divulged in any circumstances. As long as strict confidentiality could be maintained, several Witnesses have said that they would accept blood or products rather than die of anaemia or a coagulopathy, in spite of having signed a special consent form for Jehovah's Witnesses which forbids the use of blood. P D COOPER
Consultant cardiothoracic anaesthetist Freeman Hospital, Newcastle upon Tyne NE7 7DN
1 Finfer S, Howell S, Miller J, Willett K, Wilson-MacDonald J, Wilson DH, et al. Managing patients who refuse blood transfusions: an ethical dilemma. BMY 1994;308:1423-6. (28 May.) 2 Questions from readers. Watchtower 1978 June 15:30-1.
Register of willing consultants exists EDr1OR,-Commenting on the article by Simon Finfer and colleagues concerning two Jehovah's Witnesses who refused blood transfusions,' Arabinda Saha and Max Elstein suggest the establishment of a register of consultants willing to accept such patients so that referral and appropriate management can be undertaken.2 For many years Jehovah's Witnesses have themselves researched and maintained such a confidential register, names from which are released to bona fide applicants on a case by case basis. The register contains the names of some 2400 consultants in Britain and is part of a worldwide listing of more than 45000 specialists. Any doctor who wishes to refer a patient who is a Jehovah's Witness or to consult with a colleague
Cardiopulmonary resuscitation EDrTOR,-In 1991 the chief medical officer promulgated the health service commissioner's comments on the processes involved in identifying the resuscitation status of patients in hospital.' Since then my department has audited its practices and introduced changes in an effort to follow the suggestions recommended. We find that consultant staff review patients at least twice a week and inform the nursing staff of patients' resuscitation status during visits to the ward. Despite various attempts to find a practicable and safe way to document decisions in the notes, however, we have encountered major difficulties. If the decisions are
475
