several Gram positive bacteria but that other factors must also play a part, an observation consistent with our findings in Gram negative shock.6 Nevertheless, if these results can be confirmed in vivo it will give added impetus to the trials of antibody to tumour necrosis factor as empirical treatment in septic shock.7 We thank A Wienecke and Dr R Gilbert of the Food Hygiene Laboratory, CPHL Colindale, for toxin analysis of some of our strains. J COHEN K BAYSTON M TOMLINSON Infectious Diseases Unit, Hammersmith Hospital, London W12 OHS 1 Sanderson PS. Do streptococci cause toxic shock? BMJ 1990; 301:1006-7. (3 November.) 2 Ispahani P, Pearson NJ, Greenwood D. An analysis of community and hospital-acquired bacteraemia in a large teaching hospital in the United Kingdom. QJ3Med 1987;63:427-40. 3 Fong Y, Lowry SL. Tumor necrosis factor in the pathophysiology of infection and sepsis. Clin Immunol Immunopathol 1990;55: 157-70. 4 Tracey KJ, Vlassara H, Cerami A. Cachectin/tumour necrosis factor. Lancet 1989;i: 1122-6. 5 GuttebergTJ, Osterud B, VodenG, JorgensonT. Theproduction of tumour necrosis factor, tissue thromboplastin, lactoferrin and cathepsin C during lipopolysaccharide stimulation in whole blood. Scandj Clin Lab Invest 1990;50:421-7. 6 Silva AT, Appelmelk BJ, Buurman WA, Bayston KF, Cohen J. Monoclonal antibody to endotoxin core protects mice from Escherichia coli sepsis by a mechanism independent of tumor necrosis factor and interleukin-6. J Infect Dis 1990;162:454-9. 7 Exley AR, Cohen J, Buurman WA, et al. Monoclonal antibody to [NF in severe septic shock. Lancet 1990;335:1275-7.

arthritis. We found no significant difference in antibody titres between the two groups.2 This observation does not disprove the hypothesis as the advances in the molecular biology suggest that traditional lymphocytotoxicity assays for HLA-DR typing are not sufficiently sensitive to detect the five amino acid epitope around position 70 of the first domain of the HLA-DR P chain, which is thought to predispose to rheumatoid arthritis irrespective of HLA-DR type.3 These observations suggest that the possibility of cross reactivity between proteus and HLA-DR needs to be examined at a molecular level. People with HLA-DR4 may possess immune response genes that promote a vigorous antibody response to proteus so that the link between rheumatoid arthritis and the antibodies is the association of both variables with HLA-DR4. This is unlikely as in a study of people with inactive rheumatoid arthritis and people without arthritis we have found low titres of antibodies to proteus, irrespective of HLA-DR4 state. The association between rheumatoid arthritis and the antibodies has something to do with the disease and its activity. We now have longitudinal data on 36 patients with rheumatoid arthritis and have found a strong positive correlation between changes in C reactive protein concentration and proteus antibody titres over time. C M DEIGHTON J W GRAY A J BINT D J WALKER

Royal Victoria Infirmary, Newcastle upon Tyne NEI 4LP

Crutches SIR,-As two orthopaedic surgeons who have recently had a ruptured Achilles tendon we can testify to the difficulties associated with the use of crutches as reported by Ms Barbara E Potter and Dr W Angus Wallace.' In particular, mobility is severely restricted because of rapid fatigue and useful function of the hands is precluded. Fortunately we were able to use the K9 orthopaedic scooter. This device, which is basically a shin cradle on wheels,' allowed us to carry on with our normal activities such as ward rounds, clinics, and even operating lists and never failed to amuse the patients. We carried out oxygen consumption studies and found that the energy expenditure of walking with the orthopaedic scooter is 25% less than that with crutches.' We strongly recommend the scooter's use in the rehabilitation of patients with ankle and foot injuries who must remain non-weightbearing with their hands free. P ROBERTS R J GRIMER

Royal Orthopaedic Hospital, Birmingham B31 2AP I Potter BE, Wallace WA. Crutches. BMJ 1990;301:1037-9.

03 November.)

2 Reid M. Medicine and the media. BMJ 1986;293:196. 3 Roberts P, Carnes S. The orthopaedic scooter. J Bone Joint

Surg[Br] 1990;72:620-1.

Bacteria and arthritis SIR,-We would like to comment on some of the issues raised in Dr Bernard Dixon's article.' The theory that proteus reactive arthritis occurs during active phases of rheumatoid arthritis relies on cross reactivity between HLA-DR4 and a proteus antigen so that a humoral response directed against proteus will also attack self tissues expressing HLA-DR4. Thus patients with active rheumatoid arthritis who expressed HLA-DR4 might be expected to have higher antibody titres than those who did not express the antigen. We compared 42 patients with HLA-DR4 with 15 without, all of whom had active rheumatoid

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1 Dixon B. Bacteria and arthritis. BMJ7 1990;301:1043. (3 November.) 2 Gray JW, Deighton CM, Bint AJ, Walker DJ. Anti-proteus antibodies in rheumatoid arthritis same-sexed sibships. BrJ Rheumatol 1990;29(suppl II): 102. 3 Gregersen PK, Silver J, Winchester RJ. The shared epitope hypothesis: an approach to understanding the molecular genetics of susceptibility to rheumatoid arthritis. Arthritis Rheum 1987;30:1205-13.

Home treatment for acute psychiatric illness SIR,-Dr C Dean and Dr E M Gadd confirm that domiciliary treatment of acute mental illness is feasible.' Their caveat that the findings may not apply generally is crucial. In 1987 we conducted a study of emergency psychiatric assessments in Paddington and North Kensington. A total of 443 assessments were made by the on call registrar in one year. Of the patients, 45% did not live in the catchment area, 67% lived alone, 13% were completely homeless. Sixteen per cent of patients were brought to the hospital by the police. Schizophrenia was the commonest diagnosis (35%), accounting for 70% of admissions. Depressive disorders were uncommon ( 1%). Three quarters of the patients were unmarried, less than a quarter were employed, and a quarter were not registered with a general practitioner. The typical patient in inner London is psychotic, socially dislocated, itinerant, and lacking support. Given such characteristics I am not optimistic that domiciliary treatment represents a viable alternative to inpatient care. The severity of the illness at the time of admission to hospital may be another important factor, and studies are currently underway to see how this varies among hospitals in North West Thames region. Certainly one recent study points to violence being a common occurrence among acutely ill inpatients in London hospitals.2 Thus it is important to emphasise the differences in the nature ofpsychiatric practice among different areas and caution against generalising from the results of Drs Dean and Gadds. Perhaps what the most deprived areas need is a domiciliary treatment

service in addition to a full complement of inpatient beds. But that, of course, would require extra funding. C J HAWLEY

Charing Cross Hospital, Fulham W6 8RF

1 Dean C, Gadd EM. Home treatment for acute psychiatric illness. BMJ 1990;301:1021-3. (3 November.) 2 James DV, Fineberg NA, Shah AK, Priest RG. An increa1se in violence on an acute psychiatric ward. A studv of associated factors. Brj Psychiat-v 1990;156:846-52.

Crisis in our schools SIR,-Drs Rachel K Jewkes and Brendan H O'Connor highlight the poor state of toilets in British schools.' Many medical officers for environmental health and consultants for communicable disease control will be heartened to learn that after recommendations were made substantial work was undertaken in the toilets of at least one school. Many school buildings are suffering from acute on chronic "deferred maintenance syndrome." School governors are forced to spend time, money, and effort on emergency repairs to the fabric that should be devoted to supporting the educational work of the school. Reductions in cleaning and caretaking time have followed efficiency savings and the process of contracting out the work. The progressive steps taken to support disabled children in normal schools do not always include modification of toilets and other basic hygiene facilities. A recent hepatitis A outbreak in a primary school in this city was associated with a child who had faecal incontinence; no shower or other provision had been made to help this child and her teachers to overcome the basic hygiene problems or to maintain her dignity. Children unwilling to use the toilets often spend the last part of the school day hoping that their bladders will not burst. This does not help them concentrate on their lessons. Poor sanitation causes serious problems other than the control of infection. If children are denied the means to implement the most basic, noncontroversial, health behaviours of hand washing after using the toilet and before meals how can we expect them to develop more complex health behaviours? Efforts to protect the current generation of schoolchildren from alcohol and substance misuse, smoking, dental decay, and AIDS are being frustrated for the lack of basic amenities. MARTIN SCHWEIGER Leeds LS8 2RG 1 Jewkes RK, O'Connor BH. Crisis in our schools: survey of sanitation facilities in schools in Bloomsbury health district.

BMJ 1990;301:1085-7. (10 November.)

Detecting bladder cancer SIR,-Mr Roger Plail's conclusion that all patients with microhaematuria should be investigated calls for comment.' The importance of the age of the patient, the common occurrence of benign renal microhaematuria, and the availability of simple tests to identify or exclude it should have been stressed. An analysis of the medical records of 1000 asymptomatic men in the air force in Israel showed not only that microhaematuria was very common (38 7%) but also that the incidence of urological neoplasms in this group of men aged 40 or less, was as expected for the general population (0 -1 %).2 A population based study in Rochester, Minneapolis also showed that asymptomatic haematuria was a common finding in 781 adults (13%) and was often not associated with any urologic disease. Age was a significant factor, especially in men. Thus, 63% of

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men aged 35-54 with microhaematuria had no disease, decreasing to 26% between 55 and 74 years and to 5% in patients over 75.' Only 1% of the patients had neoplastic disease, and bladder cancer was found in only three patients (0-5%), all of whom were older than 75. Awareness is growing of IgA nephropathy and thin basement membrane nephropathy as common causes of microhaematuria," and benign renal microhaematuria with normal renal tissue may also be more common than previously realised. 6 Schramek et al suggested that determining the origin of the haematuria by phase contrast microscopy of the urinary sediment could be an important initial step in evaluating asymptomatic microhaematuria: dvsmorphic erythrocytes indicate a renal origin, whereas isomorphic cells (with smooth membranes) suggest a postrenal bleeding source such as bladder tumours.' Initial data support their claim that only non-dysmorphic microhaematuria need be investigated to detect bladder cancer. Thus time consuming, expensive, and invasive diagnostic procedures can be avoided in many patients by using this simple test. Other tests have also been reported to be able to determine the origin of haematuria. A SCHATTNER

Kaplan Hospital, Rehovot 76100, Israel I Plail R. Detecting bladder cancer. BMf

1990;301:567-8.

(22 September.) 2 Froom P, Ribak J, Benbassat J. Significance of microhaematuria in young adults. BM] 1984;288:20-2. 3 Mohr DN, Offord KP, Owen RA, Melton JL III. Asymptomatic microhaematuria and urologic disease: a population-based study. jAMA 1986;256:224-9. 4 Julian BA, Waldo FB, Rifai A, Mestecky J. IgA nephropathy, the most common glomerulonephritis worldwide. Am J Med 1988;84: 129-32. 5 l'iebosch ATA1G, Frederik PMN, Van Breda Vriesman PJC, et al. T'hin-basement-membrane nephropathy in adults with persistent haematuria. N Englj Med 1989;320:14-8. 6 Schramek P, Schuster FX, Georgopoulos M, Porpaczy P, Maier Al. Valuc of urinary erythrocyte morphology in assessment of symptomless microhaematuria. Lancet 1989;ii: 1316-9. 7 Shichiri M, Hosoda K, Nishio Y, et al. Red-cell-volume distribution curves in diagnosis of glomerular and non-glomerular haematuria. Lancet 1988;i:908-1 1.

Potassium and magnesium in essential hypertension SIR,-We agree with Drs Chris O'Callaghan and Laurence Howes' that potassium supplementation in our study' might have reversed the possible hvperglvcaemia and insulin resistance due to previous thiazide treatment. A complete multivariate analysis of the results, however, did not show any greater decrease in cholesterol concentrations in subjects receiving placebo in the early phase, hence we do not believe that there was a waning effect of thiazides on insulin resistance. Though glucose intolerance is a known phenomenon with thiazides, several reports have indicated that patients with high blood pressure are relatively glucose intolerant compared with normotensive patients." Several groups have shown that untreated patients with high blood pressure are also hyperinsulinaemic compared with normotensive patients." Thus it seems reasonable to conclude that resistance to insulin could be a characteristic of a certain proportion of patients with hypertension and that these abnormalities of glucose and insulin metabolism do not necessarily improve when hypertension is controlled by antihypertensive drugs.7 The potential role of potassium as a powerful determinant of cardiovascular morbidity and mortality is being extensively examined.' Potassium supplementation has been shown to prevent development of renal vascular lesions and decrease the rate of cerebral haemorrhage in rats,' and the protective effect of potassium on the vascular

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sequelae of hypertension is greater than could be predicted by the reduction in blood pressure alone. Part of the effect could be due to potassium's hypocholesterolaemic effect. P S PATKI S G GOKHALE JAGMEET SINGH D S SHROTRI Bvramjee Jeejeebhoy Medical College and Sassoon General Hospitals, Pune-41 1007, India BHUSHAN PATWARDHAN Interdisciplinary School of Avurvedic Medicine, University of Poona, Pune-411 007, India 1 O'Callaghan C, Howes L. Potassium and magnesium in essential hypertension. BMJ 1990;301:1164. (17 November.) 2 Patki PS, Singh J, Golchale SV, Bulalch PM, Shrotri DS, Patwardhan B. Efficacy of potassium and magnesium in essential hypertension: a double blind, placebo controlled, crossover study. BMJ 1990;301:521-3. (15 September.) 3 Jarrett RJ, Keen H, McCartney M, et al. Glucose tolerance and blood pressure in two population samples: their relation to diabetes mellitus and hypertension. Int J Epidemiol 1978;7: 15-24. 4 Florey CduV, Uppal S, Lowy C. Relationship between blood pressure, weight, and plasma sugar levels in school children aged 9-12 years in Westland, Holland. BMJ 1976;i: 1368-71. 5 Lucas LP, Estigarribia JA, Darga LL, Reaven GM. Insulin and blood pressure in obesity. Hypertension 1985;7:702-6. 6 Modan M, Halkin H, Almog S, et al. Hyperinsulinemia: a link between hypertension, obesity and glucose intolerance. J Clin Invest 1985;75:809-17. 7 Shen DC, Sheih SM, Fuh M, Chen Y-D, Reaven GM. Resistance to insulin-stimulated glucose uptake in patients with hypertension. J Clin EndocrinolMetab 1988;66:580-3. 8 Packer M. Potential role of potassium as a determinant of morbidity and mortality in patients with systemic hypertension and congestive heart failure. Amj Cardiol 1990;65:45-5 IE. 9 Tobin L, Lange J, Ulm K, Wold L, Iwai J. Potassium reduces cerebral haemorrhage and death rate in hypertensive rats, evett when blood pressure is not lowered. Hypertension 1985;7(suppl 1): 1 10-4.

New agenda for general practice computing SIR,-I was encouraged and reassured by Dr Mike Pringle's editorial. ' Although, understandably, general practice systems were initially developed around labour saving facilities such as repeat prescribing and prevention recalls, this has not been the ideal background for the evolution of these systems. Clearly, the patient clinical record is most important in any general practice system as it enables the record content to be used to identify individual and groups of patients, perform audit, run repeat prescribing, and, indeed, begin to examine quality as well as quantity of care. Any clinically oriented system set up to help in patient management will always have the potential to examine aspects of both quantitative and qualitative care. The data record must remain flexible in terms of both content and method of input into the database. As Dr Pringle rightly points out conditions change rapidly in medicine, and it is important that users do not have recourse to support teams (who in our experience are often poor) or programmers who may not appreciate the need for continuing change. Evolving Hypertext systems may well provide one solution to the flexible data record problem as data transactions can be defined in many ways-structured form, blank page, table, or picture. Although producing offthe shelf general practice systems makes commercial sense, it is short sighted clinically. Each practice should expect to have its own unique system that contains the data and facilities appropriate to the staff of that practice. Inevitably there will be a core data set with core functions and facilities that will be common to most systems, permitting direct comparisons to be made. Introducing new ideas and concepts in relation to computer systems within the health service is far

from easy. Experience suggests that most users with little knowledge of the subject have tended to "stay with the pack" rather than look at more innovative (but more risky) systems. As the knowledge base increases within the profession this is likely to change. If the potential for improving patient care is to be exploited it is imperative that those at the leading edge of the computer technologies liaise closely not only with practitioners with an interest in computers but with groups, university and otherwise, with experience in developing clinically oriented systems within the health sector. MICHAEL WALKER University Computing Service (Medical Unit), Ninewells Hospital and Medical School, Dundee DD2 l UB 1 Pringle M. The new agenda for general practice computing. BMJ 1990;301:827-8. (13 October.)

Tubal pregnancy SIR, -Our findings support Professor James Owen Drife's statement that tests for human chorionic gonadotrophin in urine can exclude ectopic pregnancy in women with lower abdominal pain. ' Over the past nine months we have used the Tandem Icon II immunoenzymetric assay (Hybritech, San Diego, California) to detect urinary human chorionic gonadotrophin in women with abdominal pain suggestive of unruptured ectopic pregnancy. This semiquantitative assay, which can detect human chorionic gonadotrophin at concentrations as low as 2000 mIU/l, can be done at the bedside by the doctor admitting the patient to hospital and takes less than five minutes. During the study we estimated chorionic gonadotrophin concentrations in 350 women. Of these, 142 had a positive test result, 48 of whom were found to have an ectopic pregnancy at laparoscopy. The other 94 women in whom the test was positive were subsequently found to have threatened, complete, or incomplete abortions on ultrasonography. None of the 208 women who had a negative test result had an ectopic pregnancy. These results show that in diagnosing stable ectopic pregnancy a positive urine human chorionic gonadotrophin test result has a sensitivity of 100%, a specificity of 69%, a negative predictive value of. 100%, and positive predictive value of 34%. Similar results have been reported for estimation of serum chorionic gonadotrophin concentrations with the Tandem Icon assay.2 Thus the diagnosis of ectopic pregnancy can be excluded in a woman with abdominal pain if the Tandem Icon II human chorionic gonadotrophin assay produces a negative result, obviating the need for emergency diagnostic laparoscopy. When this assay is combined with ultrasonography, the need for laparoscopy is reduced further. Each assay costs approximately 65p and does not require a laboratory technician. We conclude that this is a highly cost effective screening test for women in whom an ectopic pregnancy is suspected. PAUL BYRNE ONOME OGUEH TOCHUKWU ONYEKWULUJE

Walsgrave Hospital,

Coventry CV2 2DX 1 Drife JO. Tubal (10 November.)

pregnancy.

BMJ7

1990;301:1057-8.

2 Byrne P, Ashley E, Bates G, et al. The value of ultrasound and non-quantitative hCG estimation in the diagnosis of ectopic pregnancy. Lancet 1989;i:386-7.

SIR, -We support the concept of more conservative treatment of tubal pregnancy as proposed by Professor James Owen Drife.' He mentioned local injection of methotrexate for unruptured tubal pregnancy, but there is also evidence that local

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several Gram positive bacteria but that other factors must also play a part, an observation consistent with our findings in Gram negative shock.6 Neve...
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