and the other 3½12 months old-with fulminant hepatitis whose mothers had similar hepatitis B virus markers to those of the mothers in Beath and colleagues' report died within 36 hours despite intensive medical support. Both of the patients were positive for hepatitis B surface antigen (HBsAg), antibody to hepatitis B core antigen (anti-HBc; IgM), and hepatitis B e antigen (HBeAg) and negative for antibody to HBsAg (anti-HBs), anti-HBc (IgG), and antiHBe. The mothers were positive for HBsAg, anti-HBc (IgG), and anti-HBe and negative for anti-HBs, anti-HBc (IgM), and HBeAg. Our cases together with those reported by Beath and colleagues support the possibility of fulminant hepatitis occurring in infants born to hepatitis B carrier mothers positive for anti-HBe.24 These infants' susceptibility to fulminant hepatitis is not clear, although negativity for HBeAg is associated with low infectivity. Recently, two reports have shown a point mutation on the pre-core region of hepatitis B virus and have suggested that, in the absence of HBeAg, cytotoxic T cells attack HBcAg on hepatocytes, causing fulminant hepatitis.5 6 We agree with Beath and colleagues that all babies born to mothers carrying HBsAg should be vaccinated, and we believe that further research on these patients will help to explain the pathogenesis of fulminant hepatitis. SUKRU HATUN TAHSIN TEZIC

(p=0-2; figure). Calcium containing phosphate binders (calcium carbonate) had to be reduced or stopped in five patients. It is to be hoped that the imminent introduction of calcium acetate may help alleviate the problem of hypercalcaemia related to phosphate control as this agent is less well absorbed3 and has greater phosphate binding ability than calcium carbonate.

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Ankara, Turkey 1 Beath SV, Boxall EH, Watson RM, Tarlow MJ, Kelly DA. Fulminant hepatitis B in infants born to anti-HBe hepatitis B carrier mothers. BMJ 1992;304:1169-70. (2 May.) 2 Delaphane D, Yogev R, Crussi F, Shulman TD. Fatal hepatitis B in early infancy: the importance of identifying HBs Ag-positive pregnant women and providing immunoprophylaxis to their newboms. Pediatrics 1983;72:176-80. 3 Chang M-H, Lee C-H, Chen D-S, Hsu H-C, Lai M-Y. Fulminant hepatitis in children in Taiwan: the important role of hepatitis B virus. J Pediatr 1987;111:34-9. 4 Sinatra FR, Shah P, Weissman JY, Thomas DW, Merritt RJ, Tong MJ. Perinatal transmitted acute icteric hepatitis B in infants bom to hepatitis B surface antigen-positive and anti-hepatitis Be-positive carrier mothers. Pediatrics 1982;70: 557-9. 5 Liang TJ, Hasegawa K, Riman N, Wands JR, Porath EB. A hepatitis B virus mutant associated with an epidemic of fulminant hepatitis. N EnglJ Med 1991;324:1705-9. 6 Omata M, Ekata T, Yokosuka 0, Hosoda K, Ohto M. Mutations in the precore region of hepatitis B virus DNA in patients with fulminant and severe hepatitis. N Engl J Med 1991;324: 1699-704.

Hypercalcaemia in patients receiving dialysis EDITOR,-I Greaves and colleagues draw attention to the high incidence of hypercalcaemia in patients with chronic renal failure.' A colleague and I recently completed a prospective survey comparing the incidence of ionised hypercalcaemia (>1-35 mmolll) in patients receiving haemodialysis and continuous ambulatory peritoneal dialysis.2 When measured monthly the frequency of hypercalcaemia was 2-14 episodes per patient year for patients receiving continuous ambulatory peritoneal dialysis and 0-45 episodes per patient year for patients receiving haemodialysis. As Greaves and colleagues point out, the hypercalcaemia is usually asymptomatic. In our study of 66 patients only three of 69 detected episodes of hypercalcaemia were symptomatic. In an effort to reduce hypercalcaemia in selected patients with continuous ambulatory peritoneal dialysis without resorting to use of aluminium containing phosphate binders we have used peritoneal dialysis solution containing a lower calcium concentration (1-25 mmol/l v the standard 1F62 mmol/l). In eight patients treated in this way for three months the serum calcium concentrations tended to fall (mean (SD) 1-43 (0 1) v 1-39 (0 04) mmol/l), although this did not achieve significance 54

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than 250 [tmol/l; two had haematological malignancies and three had multiorgan failure. Primary hyperparathyroidism was the cause of hypercalcaemia in 63 (52%) patients; in 38 cases this diagnosis was made during our study. In comparison, Greaves and colleagues report only nine (5-5%) patients with hyperparathyroidism, all of whom had been admitted for elective parathyroidectomy. At Selly Oak Hospital the serum calcium concentration is measured routinely as part of a biochemical profile; the practice of discretionary testing at Queen Elizabeth Hospital may lead to failure to identify patients with asymptomatic hypercalcaemia. Despite the difference in hospital setting between the two studies we have found it useful to compare the data obtained. The combined incidence of malignancy associated hypercalcaemia and hyperparathyroidism in the series of Greaves and colleagues was 3-4 patients/week, similar to our finding of 3 - 5 patients/week. The overall incidence of hypercalcaemia found by Greaves and colleagues was roughly three times that found by us (12-5 v 3-8 patients/week), the difference being entirely due to hypercalcaemia in patients with renal disease. This gives additional support to Greaves and colleagues' conclusion that hypercalcaemia has become an important complication of renal failure and transplantation and their management. A C J HUTCHESSON W A RATCLIFFE

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Dialysate calcium (mmol/I) Effect of changing calcium concentration in dialysis solution on serum ionised calcium concentration after three months' treatment. Vertical lines indicate means and SD

I agree entirely that serum calcium concentrations should be monitored closely in renal failure but was surprised to note that corrected calcium rather than ionised calcium concentration was being used. In our study as many as 5% of cases of hypercalcaemia would have been missed if we had relied on the formula used by Greaves and colleagues. I suggest that the ionised calcium concentration should be used to monitor patients with renal failure, particularly when intervention with calcium raising agents (such as 1,25-dihydroxycholecalciferol) is being considered. A R MORTON

Queen's University, Kingston, Ontario, Canada K7L 2V7 1 Greaves 1, Grant AJ, Heath DA, Michael J, Adu D. Hypercalcaemia: changing causes over the past 10 years. BMJ

1992;304:1284. (16 May.) 2 Morton AR, Hercz G. Hypercalcenia in dialysis patients: comparison of diagnostic methods. Dialysis and Transplantatiwn

1991;20:661-8. 3 Mai ML, Emmett M, Sheikh MS, Santa Ana CA, Schiller LR, Fordtran JS. Calcium acetate, an effective phosphate binder in patients with renal failure. Kidney Int 1989;36:690-5.

EDITOR,-I Greaves and colleagues' paper' highlights the dramatic increase in the incidence of hypercalcaemia among patients with renal disease (to 63% of all cases of hypercalcaemia) in one hospital over the past 10 years.2 We believe, however, that this increase principally reflects the specialist nature of the hospital surveyed. Queen Elizabeth Hospital, Birmingham, is a major tertiary referral centre; it has large renal dialysis and transplantation units and also specialist radiotherapy and liver transplantation units but lacks an accident and emergency unit or outpatient clinics in general medicine and surgery. This point is made in the original report by Fisken et al in 19802 but omitted by Greaves and colleagues. Our recently published survey of the causes of hypercalcaemia was based on Selly Oak Hospital, a typical district general hospital less than 3-2 km from the Queen Elizabeth Hospital.3 Of 121 consecutive patients with hypercalcaemia studied, six had a serum creatinine concentration greater

Queen Elizabeth Medical Centre, Birmingham B 15 2TH 1 Greaves I, Grant A], Health DA, Michael J, Adu D. Hypercalcaemia: changing causes over the past 10 years. BMJ 1992;304:1284. (16 May.) 2 Fisken RA, Heath DA, Bold AM. Hypercalcaemia-a hospital survey. QJ Med 1980;1%:405-18. 3 Ratcliffe WA, Hutchesson ACJ, Bundred NJ, Ratcliffe JG. Role of assays for parathyroid-related-protein in investigation of hypercalcaemia. Lancet 1992;339:164-7.

Breast feeding in developing countries EDITOR,-Jose C Martines and colleagues give some of the reasons why many breast feeding mothers in developing countries supplement their milk with water or teas from the first week of life.' Another important reason is the belief that such fluids have "inner cleansing" effects on their babies. In some societies and cultures the baby's first drink is plain water. This may be a few teaspoonfuls or even finger tip quantities in drops. This initial drink is a symbol of welcoming the baby. Subsequently plain water or sugar and water are fed to the baby while the colostrum is discarded as unclean; breast feeding is started when the milk becomes clearer after a few days.2 3 Water and teas are not regarded as supplements to breast milk in the real sense, being given at the beginning of the feed, between feeds, or at the end of the feed. This practice has stood the test of time, and it will not be easy for health professionals to persuade mothers against it. As one of the main reasons for discouraging the practice is diarrhoea in the babies due to dirty water, perhaps the emphasis should be on the importance of giving clean water to infants. Surely all pregnant women should be informed how and why they should breast feed. They should be taught that the inside of the baby is not dirty and that the passage of meconium is normal. If health professionals persuade rather than effectively educate these mothers not to give water to their babies the mothers might resort to other methods of cleaning the baby's inside with enemas, suppositories, and purges, which could be more dangerous.4 JOHN KORAMOA Department of Community Paediatrics, King's College Hospital, London SE5 9RS

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I Martines JC, Rea M, de Zoysa I. Breast feeding in the first six months. BM,7 1992;304:1068-9. (25 April.) 2 Black J. Paediatrics among ethnic minorities. Asian families. II. Conditions that may be found in their children. BMJ 1984; 290:530-3. 3 Lee E. Asian infant feeding. NursingMirror 1985;160(21):S14-5. 4 Koramoa J, Lingam S. Feeding practices and problems in AfroCaribbean children. Clinic Talk-Milupa 1992;No 5 (April): 8-9.

Gonad protection in young orthopaedic patients EDITOR,-We agree with Nicholas Kenny and John Hill that gonad shields tend to be omitted or inadequately positioned in many radiographic examinations.' We can see a potential pitfall, however, in the authors' suggestion that gonad shielding should be used during radiographic assessment of congenital dislocation of the hip (developmental dysplasia of the hip). In the initial assessment of children with developmental dysplasia it is important to exclude congenital lumbosacral abnormalities. There is also value in checking for correct alignment of the symphysis pubis. Our practice, therefore, is to perform the initial examination without a gonad shield, reserving this for subsequent studies. Dosimetry studies with a phantom have shown that we can reduce the radiation dose to the whole region by performing the examination with a fluoroscopic unit equipped with a 100 mm camera. The quality of these images is adequate for measuring the acetabular shape and assessing bony morphology. With a fluoroscopy time of five seconds and a single exposure, the radiation dose to the skin is roughly one sixth of that delivered during a standard radiographic examination. Using fluoroscopy increases the chance of correct alignment on first exposure and reduces the number of repeat films necessary. In young patients the cumulative effects of ionising radiation are a concern, and we see no reason why magnetic resonance imaging should not be used for all examinations for slipped capital femoral epiphysis. A D TASKER D J WILSON J C MACLARNON

Nuffield Orthopaedic Centre NHS Trust, Oxford OX3 7LD I Kenny N, Hill J. Gonad protection in young orthopaedic

patients. BMJ 1992;304: 1411-3. (30 May.)

Epidemiological aspects of travel related illness EDITOR, -We agree with John D H Porter and colleagues about the need for appropriate surveillance systems, improving communication between health professionals, quantifying risks, facilitating targeted education, and a nationally coordinated computer database to combat the increasing problem of travel related illness. Since 1978 a surveillance programme involving 13 816 travellers returning from abroad has been carried out at the Communicable Diseases (Scotland) Unit both to establish the pattern of travel related illnesses and in response to specific episodes of reported illness.2 Comparative analysis of the data has enabled a risk profile to be defined3; this profile correlates with similar studies conducted in Switzerland4 and Finland.' To broaden the epidemiological picture further, analyses have been made of hospital admission data,23 the collated laboratory reports for infections imported into Scotland,67 deaths of Scots abroad,8 travellers attending a local clinic for immunisation against yellow fever,9 and travellers' immunity to infections that are preventable by immunisation.2

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The availability of computer technology in primary care has considerable potential for travel medicine. For example, in Scotland one system is common to over 700 practices, covering 60% of the population.'° The possibility exists of conducting a data search for patients attending for health advice before travelling and, some months later, comparing this with an analogous search for those patients treated for a travel related illness. There is logic in this approach in view of the general practitioner's role in giving advice both before travel and after return." In recognition of the difficulties that the general practitioner may have in giving advice a computerised database (Travax) was established in 1982." This nationally accessible database is freely available to NHS users with suitable hardware; it contains recommendations on immunisations for individual countries, advice on preventing malaria, and details about particular vaccines with information to help make a balanced judgment when indications are not clear cut. A recent development is the installation of a telephone networking system throughout the United Kingdom, enabling easier access by local telephone call from a suitable modem linked to a screen display. Much remains to be done, but progress has been made. JONATHAN H COSSAR ERIC WALKER DANIEL REID

Communicable Diseases (Scotland) Unit. Ruchill Hospital, Glasgow G20 9NB 1 Porter JDH, Stanwell-Smith R, Lea G. Travelling hopefully, returning ill. BMJ 1992;304:1323-4. (23 May.) 2 Cossar JH, Reid D, Fallon RJ, Bell EJ, Riding MH, Follett EAC, et al. A cumulative review of studies on travellers, their experience of illness and the implications of these findings.

J Infect 1990;21:27-42. 3 Cossar JH, Reid D. Health hazards of international travel. World Health Stat Q 1989;42(2):27-42. 4 Steffen R, van der Linde F, Syr K, Schar M. Epidemiology of diarrhea in travellers. JAMA 1983;249:1176-80. S Peltola H, Kyronseppa H, Holsa P. Trips to the south-a health hazard. ScandjInfectDis 1983;15:375-81. 6 Sharp JCM. Imported infections into Scotland, 1975. CDS W'eekly Report 1976;76/26:v-vi. 7 Campbell DM. Imported infections into Scotland, 1986. CDS Weekly Report 1987;87/47:7-8. 8 Paixao MLTD'A, Dewar RD, Cossar JH, Covell RG, Reid D. What do Scots die of when abroad? Scott Med J 1991;46: 114-6. 9 Waclawski ER, Walker E. Yellow fever vaccination and business travel. In: Steffen R, et al. Travel medicine: proceedings of thefirst conference on international travel medicine, Zurich, 1988. Berlii: Springer-Verlag, 1989:238-9. 10 Milne RM, Taylor MW, Duncan R. An assessment ofcomputing activity by GPASS users in Scottish general practice. Health Bull 1991;49:152-60. 11 Cossar JH, Reid D. Immunisation and health advice for travellers: the role of the general practitioner. Health Bull (in press).

Day hospitals for elderly people EDITOR,-The results of the Bradford community stroke trial at six months' and of the Canadian' and New Zealand3 trials of day hospitals give little support to the use of day hospitals in rehabilitation, yet in recent decades geriatricians have tended to rate rehabilitation as the main purpose of day hospitals.4 This expensive service will be under intense scrutiny by those planning services for elderly people. Rehabilitation is only one of the functions of day hospitals. In the early days of geriatric day hospitals their primary objective was stated to be the physical and social maintenance of frail and vulnerable people.' In the 1990s this means keeping patients in their own homes and out of nursing homes. This previously unfashionable aspect of care in geriatric day hospitals has been less well studied but may become fashionable again in the wake of attempts to implement changes in the provision of social services. In the studies from New Zealand and Bradford the patients were relatively young (average age

about 70) and the rates of admission to nursing and residential homes were not quoted. In the Canadian study the patients were considerably older (average 79), and a small, non-significant trend towards lower rates of admission to nursing and residential homes was seen in the day hospital group. Preliminary results from an elderly group (averge age 79) in a randonrised study in Nottingham, however, indicated that death rates and rates of admission to nursing and residential homes were lower in patients attending day hospitals than in those receiving domiciliary rehabilitation.6 The Bradford community stroke trial has shown that rehabilitation is better delivered at home than in a day hospital: this is a step forward for the care of patients with stroke. Some of these patients, however, need maintenance rather than rehabilitation, and day hospitals may best fulfil that role. J R F GLADMAN

Department of Health Care of the Elderly, University Hospital, Nottingham NG7 2UH 1 Young JB, Forster A. The Bradford community stroke trial: results at six months. BMJ 1992;304:1085-91. (25 April.) 2 Eagle DJ, Guyatt GH, Patterson C, Turpie I, Sackett B, Singer J. Effectiveness of a geriatric day hospital. Can Med Assoc J 1991 ;144:699-704. 3 Tucker MA, Davison JG, Ogle SJ. Day hospital rehabilitationeffectiveness and cost in the elderly: a randomised controlled trial. BMJ 1984;289:1209-12. 4 Brocklehurst JC, Tucker JS. Progress in geriatric day care. London: King Edward's Hospital Fund, 1980. 5 Cosin L. The place of the day hospital in the geriatric unit. Practitioner 1954;172:552-9. 6 Gladman JRF. A randomised controlled trial of a domiciliary rehabilitation service for elderly stroke out-patients [abstract).

Age Ageing 1992;21(suppl 1):11.

Implementing patient's charter in outpatient services EDITOR, -Charles Collins's editorial about implementing the patient's charter in outpatient services is mainly about outpatient appointments for those needing surgery.' For those visiting a rheumatology department who will never need surgery the position is entirely different. They need more than is apparently envisaged in the casual direction to explain any treatment, which is slipped in among all the other items suggested to be essential in 20 minute consultation. They need considerable help and counselling about how to manage their arthritis, and it is commonly accepted that those who receive adequate information are likely to make better progress than those who do not. Of course the consultant will not have time to do this, but there should be someone in the team who has. Arthritis Care believes that the provision of a rheumatology practice nurse in every rheumatology department is essential and would welcome the BMA's support for this in any discussions about the patient's charter. R E GUTCH

Arthritis Care, London NW1 2HD I Collins C. Implementing the patient's charter in outpatient services. BMJ7 1992;304:13%. (30 May.)

EDITOR,-In his editorial on implementing the patient's charter in outpatient services Charles Collins advocates the judicious use of telephone contact with patients.' Experience in genitourinary medicine indicates that this can be valuable, but it has staffing costs. Standard practice in most genitourinary medicine clinics has been to allow patients to telephone to learn the results of their investigations with the aim of avoiding unnecessary visits, and of course the results and advice may have to be amplified. The use made of this facility was monitored in a 55