Letters

Out of the blue and into the pink A new litmus test for chlorine gas exposure MJA 1997; 167: 651 To the Editor: A 40-year-old man arrived at the emergency department by ambulance in respiratory distress. In his duties as a hotel maintenance worker, he had been mixing swimming pool chemicals in a dark, confined space. Inadvertently, he had mixed liquid pool "chlorine" (sodium hypochlorite) with a hydrochloric acid solution, forming an irritating yellow-green gas. Despite a brief exposure, he rapidly developed eye irritation, burning in his oropharynx, cough and chest pain. He noticed that the keys in his pocket had turned a dull colour. On arrival, about 20 minutes after the exposure, he had an irritating cough, but his vital signs were normal, oxygen saturation was 99%, and his chest was clear to auscultation. His clothing smelt of chlorine and was removed to prevent skin irritation. On removing his white overalls, it was noticed that his blue underpants had changed colour to a pink-mauve hue. Although he suffered acute embarrassment, he developed no acute clinical or radiographic signs and was discharged well after several hours' observation. Chlorine gas exposure is not an uncommon hazard of mixing household cleaners or pool chemicals. The addition of an acid to a chloride-containing base releases chlorine gas in an exothermic reaction. Chlorine gas is highly water soluble and on moist surfaces is transformed into hydrochloric acid and an oxygen radical. This mechanism explains the clinical manifestations, with the hydrochloric acid causing immediate irritation to mucosal surfaces, leading to lacrimation, burning sensations and cough. These symptoms usually serve as a warning to the victim to move away from the gas to prevent the more serious sequelae of laryngeal oedema, bronchospasm and adult respiratory distress syndrome. Presumably in this case, the elaboration of acid in the sweaty confines of his true-blue Y-fronts mimicked the classic pH indicator reaction of litmus paper. Perhaps he should have worn his underpants on the outside! Tim C Green Staff Specialist, Emergency Department, Royal Prince Alfred Hospital Missenden Road, Camperdown, NSW 2050. E-mail: timgreenATmpx.com.au Reference: Hoffman RS. Toxic inhalations. In: Rosen P, Barkin R, et al., editors. Emergency medicine -- concepts and clinical practice. 3rd ed. 1992: 2673-2682. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Tim C Green

A sad stool MJA 1997; 167: 654 To the Editor: With greater attention being given to improving communication between healthcare professionals and the public, the following incident is a simple yet worthy reminder that effective communication depends not only on the information that is transmitted but, more importantly, on the information that is received. A young woman came into my pharmacy with a prescription for Ferro-Gradumet (ferrous sulfate, Abbott), and it was obvious that she was reluctant to have it dispensed. During our conversation, she remarked that she was very concerned about becoming depressed because the doctor had told her that while taking this medicine her emotions would be black. This certainly wasn't the message that the doctor intended to transmit (viz. her motions would be black), and it could have led her to abandon the treatment. How can we ensure that the correct message is received? Failures in communication like this can be avoided if plain, straightforward words are used instead of outdated euphemisms. In this instance, the more direct word "faeces" is less likely to be misinterpreted and, if not understood, is more likely to prompt the question, "What do you mean by that?". Richard M Worrell Pharmacist, PO Box 274, Rose Bay, NSW 2029 - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Richard M Worrell

"Hale-Bopp" and "Knocking on Heaven's Gate" Hits of the Net, 1997 MJA 1997; 167: 654 "If anyone comes to Me and does not hate his father and mother and his wife and children and brothers and sisters -- and even his own life also -- he cannot be My disciple". Luke 14:261 To the Editor: This Christmas, as we renew old family quarrels, we should remember we are celebrating the birth of Christ, who, according to the Heaven's Gate cult, was the first visitor from TELAH -- The Evolutionary Level Above Human.1 On 22 March 1997, when the Hale-Bopp comet was nearest to Earth, 39 members of this cult left earth to link up with the comet's "companion spaceship" bound for TELAH,2 wearing black Nike sneakers. Their transport to TELAH began with deliberate self-poisoning. Although we previously found no relationship between self-poisoning and celestial or occult events,3 this event combined both and suggested that we might have overlooked a synergistic mechanism. We also examined the possibility that traffic was going in the opposite direction that day, with ancient astronauts escaping their spaceship to appear on earth as newborn babies. We used two databases to test our hypothesis: a register of births in the Canberra Hospital (which we felt would closely resemble the sterile environment of a spaceship) and the Hunter Area Toxicology Service database of presentations to hospital with self-poisoning in the Lower Hunter Valley of New South Wales. To examine for evidence of massive successful and attempted soul migrations, we compared the number of births and self-poisonings between 21 and 23 March with those for the rest of the month. There did not appear to be any significant surge in self-poisonings or births at this time. On those three days, there were eight self-poisonings, compared with 51 on all the other days in March (P = 0.24, Mann-Whitney test), and 13 births compared with 141 (P = 0.61). However, we did note a surprisingly strong correlation between self-poisonings and the Nike share price4 (P = 0.005, Spearman) (Figure). In the three months after the Heaven's Gate tragedy, the share price of Nike fell by 20%, despite a 15% increase in the market index and a 28% increase in sales.4 This could either be a suicide prevention strategy or evidence that people are reducing their Nike stocks to invest in futures. When surfing the Internet, it is quickly apparent that data-dredging is not confined to medicine and there is no statistical refereeing. Significance can be found everywhere on the Net: a place to publish and perish. Nicholas A Buckley Visiting Fellow,National Centre for Epidemiology and Population Health The Australian National University, Canberra, ACT 0200 E-mail: mdnabATcc.newcastle.edu.au Janelle A McDonald Obstetric Registrar, National Centre for Epidemiology and Population Health The Australian National University, Canberra, ACT 0200 Do, Ti, et al. How and when Heaven's Gate may be entered (The door to the Physical Kingdom Level Above Human). Phoenix (Ariz): TELAH Services, 1997. On the Internet: http://www5.zdnet.com/yil/higher/heavensgate/ http://www.neosoft.com/~cshramek/comet.htm Buckley NA, Whyte IM, Dawson AH. There are days . . . and moons. Self-poisoning is not lunacy. Med J Aust 1993; 159 (11/12): 786-789. http://quote.yahoo.com/ - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Nicholas A Buckley · Janelle A McDonald

Effect of postgraduate exams on putting performance MJA 1997; 167: 655 Objective: To test the hypothesis that examination stress adversely affects golf putting performance. Participant: An advanced trainee of a learned specialist college, with moderate golfing skills and about to undertake final fellowship examinations. Methods: A week before the exams, the subject was asked to perform 50 consecutive 60 cm putts on the practice putting green, under standard conditions. The hole was cut on a flat portion of the green, with negligible borrow or irregularities. The number of successful putts was recorded. Two weeks after successfully completing the exams, the subject was asked to repeat the test. The hole and the weather conditions were similar. Results: Test one. Successful putts: 40 (including three mulligans); unsuccessful putts: 10. Test two. Successful putts: 46 (including one mulligan); unsuccessful putts: 4. Mulligans were putts that, while not successfully "holed", were deemed by the subject to have been so close that they were considered "holed". Reasons included: "The wind changed direction at the last minute" and "The hole moved after I had putted". Statistical analysis: Two new techniques relevant to golfing data were used. The Norman Index of the sum of rank performances (n value) was multiplied by the Tiger Woods covariant of superior performances (t value). The resulting score was divided by the square root of the subject's handicap, giving a dubious value (d) which was statistically feasible (d < 0.05). Like all golfing data, these values need to be treated with suspicion. Discussion: The adverse affects of examination stress on putting performance could be a result of physical impairment (tremors and sleep deprivation) and psychological impairment (distraction and fear of failure). As putting is a vital component of a golfer's repertoire, it is reasonable to extrapolate that examination stress would be detrimental to overall golfing performance. It may be that poor golfing performances adversely impact upon examination performances. This requires further testing, preferably over a long period of time (several months would be fine), at a suitable golf course (perhaps Port Douglas in far north Queensland) and with appropriate funding (to cover travel expenses!). Conclusion: Examination stress adversely affects putting performance. Postgraduate examinations should be scheduled to avoid significant golfing fixtures, such as club championships. (Disclosure: Any resemblance between the author and subject is purely coincidental.) Craig T Hore Clinical Fellow, CareFlight, NSW Medical Retrieval Services PO Box 159, Westmead, NSW 2145 - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Craig T Hore

Letter Ultrarapid opiate detoxification. What's all the fuss about? MJA 1997; 167: 393 To the Editor: In the past few months, the Australian electronic and print media have hailed ultrarapid opiate detoxification (UROD) as being able to "cure" 60%-100% of heroin addicts. These claims were initially made as part of a professionally organised media campaign by CITA/ATT, a Spanish-Israeli organisation, but have been repeated by opponents of harm-minimisation addiction treatments.1 While there is no conclusive evidence as to the efficacy of UROD, CITA/ATT has attempted to patent and franchise what it considers to be "its" treatment. In UROD, opioid addicts are anaesthetised for several hours and given naltrexone to precipitate withdrawals. Naltrexone is a long-acting, opioid antagonist with little or no agonist activity that is effective orally. It has not been approved for use in Australia. While there are benefits in terms of speed and reduced suffering, there are no published reports comparing the long-term outcome after UROD with other methods of rapid opioid detoxification. UROD is expensive and has obvious risks; a patient died during treatment in the United Kingdom.2 After UROD, patients are given up to a year's maintenance treatment with naltrexone, usually 100 mg on Mondays and Wednesdays and 150 mg on Fridays. While the available evidence is contradictory, there is a suggestion that socially stable addicts with no psychiatric comorbidity may benefit from postdetoxification naltrexone treatment. In two randomised, placebo-controlled, double-blind trials the treated group tended to use less heroin, but the differences were not statistically significant.3,4 CITA claimed UROD was discovered by a Spanish psychologist, Dr Juan Legarda.5 However, rapid opiate detoxification was first described by researchers working at Vienna University in a series of papers published in the international peer-reviewed literature between 1988 and 1991.6 Dr Legarda's first and only published account dates from 1994 and refers to the work of the Vienna group and others.7 CITA/ATT sought to franchise "its" treatment (international patent application PCT/ES94/100108),5 and has threatened to sue a British and American physician who offer patients similar services. CITA/ATT has also attempted to issue national franchises for the "CITA Method". A United Kingdom version of the franchise agreement stipulated "the Method" must remain secret. A minimum 240 detoxifications had to be performed in the first six months and one-quarter of all payments were to be paid to the parent company. The British licensee would have been obliged to spend no less than US$50 000 in the first year and US$25 000 in subsequent years marketing and advertising "the Method".2 The CITA/ATT marketing campaign represents a corruption of the scientific process and is unethical. The profession should condemn this and similar attempts to use the mass media to bypass the peer-reviewed literature. However, despite the concerns raised by the CITA/ATT media campaign, a local, randomised trial of UROD versus another form of rapid, antagonist-assisted detoxification is warranted.5 Such a study should include a double-blind, placebo-controlled trial of postdetoxification naltrexone maintenance. John R M Caplehorn PhD Student, Department of Public Health and Community Medicine University of Sydney, NSW 2006 E-mail: johncATpub.health.su.oz.au Ackerman P. Aim must be abstinence when it comes to drugs. Sunday Telegraph 1997 March 23; 143. Tyaransen O. The strange and terrible saga of Brendan Woolhead. Hot Press (Dublin) 1997 May 14; 12, 13, 62. National Research Council Committee on Clinical Evaluation of Narcotic Antagonists. Clinical evaluation of naltrexone treatment of opiate-dependent individuals. Arch Gen Psychiatry 1978; 35: 335-340. Shufman EN, Porat S, Witzum E, et al. The efficacy of naltrexone in preventing reabuse of heroin after detoxification. Biol Psychiatry 1994; 35: 935-945. Brewer C. Ultra-rapid, antagonist-precipitated opiate detoxification under general anaesthesia or sedation. Addiction Biol 1997; 2: 291-302. Loimer N, Schmid R, Presslich Q, Lenz K. Continuous naloxone administration suppresses opiate withdrawal symptoms in human opiate addicts during detoxification treatment. J Psychiatr Res 1988; 23: 81-96. Legarda J, Gossop M. A 24-h inpatient detoxification treatment for heroin addicts: a preliminary investigation. Drug Alcohol Depend 1994; 35: 91-93.