logically. Laparotomy showed only small bowel distension and mucosal oedema. Antral and duodenal biopsy specimens taken at gastroscopy showed infection with S stercoralis. After treatment with thiabendazole results of stool examinations became negative for S stercoralis and her symptoms resolved. One year later she again developed symptoms of obstruction, with stool samples positive for S stercoralis. She had a normal blood count. Her symptoms failed to settle on conservative treatment and a second laparotomy showed miliary deposits throughout the jejunum and mesentery. Histological examination of the deposits found S stercoralis, which had generated an aggressive host response and led to the obstructive symptoms. Further treatment with thiabendazole was successful. Eighteen months after her first presentation she developed adult T cell leukaemia/lymphoma with hypercalcaemia. Antibodies to HTLV-I were present. Despite chemotherapy with pentostatin and etoposide she died four weeks later. Opportunistic infection with strongyloides has been reported in patients with pre-existing leukaemia and lymphoma.24 Healthy Jamaicans infected with HTLV-I have been found to have antibodies to S stercoralis.' Nakada et al'suggested that S stercoralis may be a cofactor in the development of adult T cell leukaemia/lymphoma associated with HTLV-1.6 Our experience suggests that patients infected with S stercoralis should be tested for HTLV-I as they may be at risk of developing adult T cell leukaemia/lymphoma. E CLIFFORD J R Y ROSS A L OLGILVIE S B COGHILL
Northampton General Hospital, Northampton NN I 5BD I Weber J. HTLNV-I infection in Britain. Br.Medj 1990;301:71-2.
(14 Julv.
2 Cohen J, Spry CJF. Strongyloides stercoralis infection and small intestinal lymphoma. Parasite Immunol 1979;1: 167-78. 3 O'Doherty MJ, V'an de Pette JE, Nunan TO, Croft DN. Rectirrent Strongyloides stercoralis infection in a patient with T-cell lvmphoma-leukaemia. Lancet 1984;i:858. 4 (Genta RM, Miles P, Fields K. Opportunistic Strongyloides stercoralis itsfection in lymphoma patients. Cancer 1989;63: 1407-11. S Nesa FA, Murphy EL, Gam A, et al. Antibodies to Strongyloides stercoralis in healthv Jamaican carriers of HTLV-1. N EnglJ Med 1989;320:252-3. 6 Nakada K, Yamaguchi K, Furugen S, et al. Monoclonal integration of HTL V-I proviral DNA in patients with strongyloidiasis. Int Cancer 1987;40: 145-8.
frequency of transmission of the virus by blood transfusion is being estimated through a collaborative study of multiply transfused patients funded by the Medical Research Council. Consideration is also being given to measuring the prevalence of HTLV-I in serum from patients attending antenatal and genitourinary medicine clinics, hospital inpatients, and injecting drug users as an adjunct to the recently established unlinked anonymous HIV prevalence monitoring programme. Selective screening of groups such as antenatal women and blood donors for HTLV-I has been proposed and may be an effective prevention strategy. Preliminary epidemiological surveys will provide essential data to assist informed decision making, though there are other important considerations. A high rate of false positive results will result from the use of a screening test with fairly low specificity for an infection of low prevalence, and pretest counselling will pose particular problems. How do patients perceive and react to the 4% lifetime risk of developing disease if they are found to have antibodies to HTLV-I? There are also sensitive issues to be confronted in selecting an at risk population on the basis of ethnic origin. Screening programmes will have substantial financial, social, and psychological costs that should be widely discussed. Increased surveillance of HTLV-I resulting from improved investigation in clinical practice and from serosurveys will provide the context within which this debate can take place. AHILYA NOONE SUSAN HALL NOEL GILL Communicable Disease Surveillance Centre, London NW9 5DF PHILIP P MORTIMER Virus Reference Laboratory, London NW9 5HT 1 Weber J. H'I1LV-I infection in Britain. Br MedJ3 1990;301:71-2. (14 July.) 2 Communicable Disease Surveillance Centre. Human T cell leukaemia virus I. Communicable Disease Report 1987;No 25. 3 Communicable Disease Surveillance Centre. Human T lymphotrophic virus type I (HTLV-I). Communicable Disease Report 1989;No 10. 4 Tosswill JHC, Parry JV. HTLV-I in English patients. Lancet
1989;ii:328. 5 Tosswill JHC, Ades AE, Peckham C, Mortimer PP, Weber JN. Infection with human T cell leukaemiaAlymphoma virus type I in patients attending an antenatal clinic in London. Br Med J 1990;301:95-6. (14 July.)
Faulty heart valves SIR,-We agree with Dr J Weber that investigation of infection with human T cell leukaemia/ lymphoma virus type I (HTLV-I) needs to be extended in Britain. The Public Health Laboratory Service has recommended that infection with the virus be excluded in cases of chronic neurological and joint disease in Afro-Caribbean patients and that all patients with T cell malignancy be screened for HTLV-I.2 A confirmatory service is available at the Public Health Laboratory Service Virus Reference Laboratory, and laboratory reports of infection are collected by the Public Health Laboratory Service Communicable Disease Surveillance Centre. Summaries have appeared in Communicable Disease Report, and the Virus Reference Laboratory recently published an analysis of its data.4 Both the Communicable Disease Surveillance Centre and the Virus Reference Laboratory are participating in several surveys of the prevalence of HTLV-I. Since February 1990 three laboratories have been collaborating in a large survey of antenatal women in selected locations to examine the relation between infection with HTLV-I and ethnic background and country of birth. This follows earlier laboratory work by the Virus Reference Laboratory on antenatal women.' The BMJ
VOLUME 301
1 SEPTEMBER 1990
SIR,-We are concerned by the inaccuracies in Ms Clare Dyer's article.' The convexoconcave valve has saved tens of thousands of lives, and the complex phenomenon of structural failure has occurred in very few cases. In addition, the valve has reduced the most prevalent lifethreatening complication directly related to implantation of heart valves-namely, thromboembolic events. When considering the risk of strut fracture it should be noted that the risk of death associated with a 60 degree convexoconcave valve is comparable with that associated with other heart valves available during the same period. All medical procedures and devices, including heart valves of all types and manufacturers, have risks as well as benefits, but Ms Dyer's article failed to consider the fundamental scientific principles of risk-benefit analysis. The Bjork-Shiley convexoconcave valve in particular offered patients benefits of improved cardiac function, as well as a reduced risk of thrombosis and thromboembolic events. Shiley regrets the death of any patient due to structural failure of a prosthetic valve. The very small risk of structural failure, however, should be set against the much greater risks associated with lifethreateninrg complications such as thromboembolic events
and thrombosis, which have been equally clearly shown with other types of prosthetic valves. Additionally, several studies have shown that the average annual risk for valve replacement varies from 4 2% to 8 1% a year, dependent on the anatomical position.2 This is much higher than the risk of prosthetic structural failure and, indeed, than that of lifethreatening complications associated with other types of valve prosthesis. The company has since developed the technology to manufacture a valve prosthesis from a single piece of metal alloy, still incorporating the essential design improvements contained within the convexoconcave valve. Over 85000 of these valves, called the Monostrut, have now been implanted without any reported structural failure. PHILIP HEDGER
Shiley European Division, Staines, Middlesex TW18 4AN I Dyer C. Faulty heart valves: need for regulation. Br Med J 1990;301:139-40. (21 July.) 2 Schoen FJ. Intervention and surgical cardiovascular pathology: clinical correlations and basic principles. London: Saunders, 1989:137-8.
Will the white paper slay the dragon? SIR,-I was astounded and dismayed that the archetypal general practice receptionist still exists. ' Her performance shows all the elementary errors that should have been eliminated years ago. What an unpleasant and potentially dangerous person she is; what a terrible advertisement for the practice; and what a medicolegal liability for her employer, who is responsible for her actions. Staff can only be as good as they are trained to be. What training had this receptionist received? Had she read any of the receptionists' magazines? Apparently not. I find that receptionists really enjoy training programmes. They meet their colleagues, find that they have the same problems, and exchange ideas, and the training boosts their morale and confidence and increases their efficiency. They even chide their doctors into better ways. Strange working practices come to light. One practice was booking appointments every 10 minutes, but it never occurred to the staff that patients should actually be seen at that time as the doctors always started surgery an hour late. After some discussion it was agreed to make more realistic appointments. Follow on prescriptions after discharge from hospital are a constant problem. This is a dangerous practice and should stop. The saving to the hospital is small and there is a timewasting search of the hospital by telephone to find someone who knows what the prescription should be. The doctor, not the patient, must telephone the hospital to minimise errors. Clearly, in the case described a complaint must be lodged with the doctor and, failing satisfaction, with the community health council. The day of the untrained receptionist should be long over, and it is up to all of us to see that it is. GRAHAM M HUNTER Bexhill on Sea, East Sussex TN40 IJJ 1 Anonymous. Will the white paper slay the dragon? Br Med J 1990;301:185. (21 July.)
SIR,-I have worked in general practice for many years (originally as a receptionist) and have gained knowledge of many different practices through discussion with other receptionists. In my experience many receptionists are given little or no 443
Northampton General Hospital, Northampton NN I 5BD I Weber J. HTLNV-I infection in Britain. Br.Medj 1990;301:71-2.
(14 Julv.
2 Cohen J, Spry CJF. Strongyloides stercoralis infection and small intestinal lymphoma. Parasite Immunol 1979;1: 167-78. 3 O'Doherty MJ, V'an de Pette JE, Nunan TO, Croft DN. Rectirrent Strongyloides stercoralis infection in a patient with T-cell lvmphoma-leukaemia. Lancet 1984;i:858. 4 (Genta RM, Miles P, Fields K. Opportunistic Strongyloides stercoralis itsfection in lymphoma patients. Cancer 1989;63: 1407-11. S Nesa FA, Murphy EL, Gam A, et al. Antibodies to Strongyloides stercoralis in healthv Jamaican carriers of HTLV-1. N EnglJ Med 1989;320:252-3. 6 Nakada K, Yamaguchi K, Furugen S, et al. Monoclonal integration of HTL V-I proviral DNA in patients with strongyloidiasis. Int Cancer 1987;40: 145-8.
frequency of transmission of the virus by blood transfusion is being estimated through a collaborative study of multiply transfused patients funded by the Medical Research Council. Consideration is also being given to measuring the prevalence of HTLV-I in serum from patients attending antenatal and genitourinary medicine clinics, hospital inpatients, and injecting drug users as an adjunct to the recently established unlinked anonymous HIV prevalence monitoring programme. Selective screening of groups such as antenatal women and blood donors for HTLV-I has been proposed and may be an effective prevention strategy. Preliminary epidemiological surveys will provide essential data to assist informed decision making, though there are other important considerations. A high rate of false positive results will result from the use of a screening test with fairly low specificity for an infection of low prevalence, and pretest counselling will pose particular problems. How do patients perceive and react to the 4% lifetime risk of developing disease if they are found to have antibodies to HTLV-I? There are also sensitive issues to be confronted in selecting an at risk population on the basis of ethnic origin. Screening programmes will have substantial financial, social, and psychological costs that should be widely discussed. Increased surveillance of HTLV-I resulting from improved investigation in clinical practice and from serosurveys will provide the context within which this debate can take place. AHILYA NOONE SUSAN HALL NOEL GILL Communicable Disease Surveillance Centre, London NW9 5DF PHILIP P MORTIMER Virus Reference Laboratory, London NW9 5HT 1 Weber J. H'I1LV-I infection in Britain. Br MedJ3 1990;301:71-2. (14 July.) 2 Communicable Disease Surveillance Centre. Human T cell leukaemia virus I. Communicable Disease Report 1987;No 25. 3 Communicable Disease Surveillance Centre. Human T lymphotrophic virus type I (HTLV-I). Communicable Disease Report 1989;No 10. 4 Tosswill JHC, Parry JV. HTLV-I in English patients. Lancet
1989;ii:328. 5 Tosswill JHC, Ades AE, Peckham C, Mortimer PP, Weber JN. Infection with human T cell leukaemiaAlymphoma virus type I in patients attending an antenatal clinic in London. Br Med J 1990;301:95-6. (14 July.)
Faulty heart valves SIR,-We agree with Dr J Weber that investigation of infection with human T cell leukaemia/ lymphoma virus type I (HTLV-I) needs to be extended in Britain. The Public Health Laboratory Service has recommended that infection with the virus be excluded in cases of chronic neurological and joint disease in Afro-Caribbean patients and that all patients with T cell malignancy be screened for HTLV-I.2 A confirmatory service is available at the Public Health Laboratory Service Virus Reference Laboratory, and laboratory reports of infection are collected by the Public Health Laboratory Service Communicable Disease Surveillance Centre. Summaries have appeared in Communicable Disease Report, and the Virus Reference Laboratory recently published an analysis of its data.4 Both the Communicable Disease Surveillance Centre and the Virus Reference Laboratory are participating in several surveys of the prevalence of HTLV-I. Since February 1990 three laboratories have been collaborating in a large survey of antenatal women in selected locations to examine the relation between infection with HTLV-I and ethnic background and country of birth. This follows earlier laboratory work by the Virus Reference Laboratory on antenatal women.' The BMJ
VOLUME 301
1 SEPTEMBER 1990
SIR,-We are concerned by the inaccuracies in Ms Clare Dyer's article.' The convexoconcave valve has saved tens of thousands of lives, and the complex phenomenon of structural failure has occurred in very few cases. In addition, the valve has reduced the most prevalent lifethreatening complication directly related to implantation of heart valves-namely, thromboembolic events. When considering the risk of strut fracture it should be noted that the risk of death associated with a 60 degree convexoconcave valve is comparable with that associated with other heart valves available during the same period. All medical procedures and devices, including heart valves of all types and manufacturers, have risks as well as benefits, but Ms Dyer's article failed to consider the fundamental scientific principles of risk-benefit analysis. The Bjork-Shiley convexoconcave valve in particular offered patients benefits of improved cardiac function, as well as a reduced risk of thrombosis and thromboembolic events. Shiley regrets the death of any patient due to structural failure of a prosthetic valve. The very small risk of structural failure, however, should be set against the much greater risks associated with lifethreateninrg complications such as thromboembolic events
and thrombosis, which have been equally clearly shown with other types of prosthetic valves. Additionally, several studies have shown that the average annual risk for valve replacement varies from 4 2% to 8 1% a year, dependent on the anatomical position.2 This is much higher than the risk of prosthetic structural failure and, indeed, than that of lifethreatening complications associated with other types of valve prosthesis. The company has since developed the technology to manufacture a valve prosthesis from a single piece of metal alloy, still incorporating the essential design improvements contained within the convexoconcave valve. Over 85000 of these valves, called the Monostrut, have now been implanted without any reported structural failure. PHILIP HEDGER
Shiley European Division, Staines, Middlesex TW18 4AN I Dyer C. Faulty heart valves: need for regulation. Br Med J 1990;301:139-40. (21 July.) 2 Schoen FJ. Intervention and surgical cardiovascular pathology: clinical correlations and basic principles. London: Saunders, 1989:137-8.
Will the white paper slay the dragon? SIR,-I was astounded and dismayed that the archetypal general practice receptionist still exists. ' Her performance shows all the elementary errors that should have been eliminated years ago. What an unpleasant and potentially dangerous person she is; what a terrible advertisement for the practice; and what a medicolegal liability for her employer, who is responsible for her actions. Staff can only be as good as they are trained to be. What training had this receptionist received? Had she read any of the receptionists' magazines? Apparently not. I find that receptionists really enjoy training programmes. They meet their colleagues, find that they have the same problems, and exchange ideas, and the training boosts their morale and confidence and increases their efficiency. They even chide their doctors into better ways. Strange working practices come to light. One practice was booking appointments every 10 minutes, but it never occurred to the staff that patients should actually be seen at that time as the doctors always started surgery an hour late. After some discussion it was agreed to make more realistic appointments. Follow on prescriptions after discharge from hospital are a constant problem. This is a dangerous practice and should stop. The saving to the hospital is small and there is a timewasting search of the hospital by telephone to find someone who knows what the prescription should be. The doctor, not the patient, must telephone the hospital to minimise errors. Clearly, in the case described a complaint must be lodged with the doctor and, failing satisfaction, with the community health council. The day of the untrained receptionist should be long over, and it is up to all of us to see that it is. GRAHAM M HUNTER Bexhill on Sea, East Sussex TN40 IJJ 1 Anonymous. Will the white paper slay the dragon? Br Med J 1990;301:185. (21 July.)
SIR,-I have worked in general practice for many years (originally as a receptionist) and have gained knowledge of many different practices through discussion with other receptionists. In my experience many receptionists are given little or no 443
