1362
higher. The amount of prenatal testing1.2 has also increased in recent
years (overall number 1150) because of the greater acceptability of
chorionic villus sampling (CVS), and all at-risk couples with an
affected fetus have decided on termination:
These data confirm the suggestion that the expected number of
Cooley’s patients calculated from the carrier frequency of 5.9%3
may not be correct: in 1988 and 1989 more affected fetuses were
diagnosed than would have been expected (E in right-hand column
above). The heterogeneous distribution of the &bgr;-thalassaemia and
sickle-cell genes may influence the success of a prenatal diagnosis
programme.
Supported by CNR grant 91.041.94.ST75.
Department of Haematology A. MAGGIO
and Prenatal Diagnosis Service,
V Cervello Hospital, F. CARONIA
90146 Palermo, Italy F. ORLANDI
1. Maggio A, Giambona A, Lo Gioco P, et al. Prenatal diagnosis of haemoglobinopathies
in Sicily. Haematologica 1985; 70: 500.
2. Orlandi F, Damiani G, Jakil C, et al. The risks of early cordocentesis (12-21 weeks):
analysis of 500 procedures. Prenat Diagn 1990; 10: 425.
3. Schiliro’ G, Gregono F, Romeo MA, Testa R, Russo A. Incidence of hemoglobin S
carriers in Sicily. Hemoglobin 1986; 10: 95.
Leeches and B SIR,-We agree with Mr Hawkins that the administration of
hepatitis
SIR,- The role of animal vectors in the transmission of hepatitis
B is controversial. Leeches, despite their blood-sucking habits, are
not known to be vectors of disease transmission in man. Some cases
of acute hepatitis B after contact with leeches are presented here.
A 42-year-old man reported to an Ayurvedic (the indigenous
Indian system of medicine) doctor with a chalazion. A leech was
applied to the lesion as part of the treatment. 2 months later this man
presented with acute hepatitis B.
Six men belonging to the State Land Survey Department went to
a hilly area to collect data. The survey was done in a leech-infested
area and after the survey they found many leeches clinging to their
skin. Three members of this team had acute hepatitis within 3
months of the survey.
The four men described above had no exposure to risk factors for
hepatitis B such as reusable needles, blood, or blood products. Nor
did their sexual practices put them at risk of heptitis B. All had an
uneventful recovery, and HBsAg was not detectable in their sera
after recovery from the acute hepatitis.
HBsAg has been detected in mosquitoes1 and bedbugs.2 There is
no evidence that the virus multiplies in them although virus persists
for several weeks in the bedbugs. When the leech bites it secretes an
anticoagulant to prevent clotting of blood and can suck considerable
quantities of blood, which it stores in its highly distensible crop.
Ayurvedic doctors apply turmeric to the leech, after which the
ingested blood is expelled by the worm. Then the leeches are
"cleaned" in milk before being reapplied to another person. These
steps may not be adequate to destroy the hepatitis B virus. The cases
reported here show that the possibility of leeches transmitting
hepatitis B virus cannot be ignored.
Department of Gastroenterology,
Medical College,
695011 Trivandrum, India M. NARENDRANATHAN
1. Prince AM, Metsalaar D, Kafuko GW, Mukawa LG, Ling CM, Overby LR.
Hepatitis B antigen in wild caught mosquitoes m Africa. Lancet 1972; ii: 247-50.
2. Newkirk MM, Downey AER, Simon JB. Fate of ingested hepatitis B antigen in blood
sucking insects. Gastroenterology 1975; 69: 982-87.
Thalidomide: a restricted role
SIR,-Many drugs have teratogenic potential. Fortunately, few
have been consigned to the flames as Mr Hawkins recommends
(April 25, p 1057) for thalidomide.
For the past 2 years we have been treating a 61-year-old woman
for chronic actinic prurigo with thalidomide. For 55 years she had
suffered throughout the year an intensely itchy papulo-vesicular
rash in a photosensitive distribution. The rash erupted within
minutes of exposure to sunlight and lasted several days, making her
housebound. Since starting thalidomide 100 mg on alternate days
she has been tolerant of sunlight and feels that her life has been
transformed. She has noted no side-effects and we are monitoring
for subclinical neuropathy with regular nerve conduction studies.’
In addition to its role in treating actinic prurigo,2 thalidomide is
also of benefit in nodular prurigo,3aphthous ulcers,4 and discoid
lupus erythematosus.s These are all conditions for which the
dermatologist’s armamentarium is severely limited.
Fertile women constitute less than 25 % of dermatology patients.
It would be a great shame if thalidomide was to be burnt at the stake
rather than "let off’ with a warning not to prescribe to fertile
females.
Department of Dermatology,
University Hospital of Wales, ANDREW J. CARMICHAEL
Cardiff CF4 4XW, UK ARTHUR KNIGHT
1. Wulff CH, Hoyer H, Asboe-Hansen G, Brodthagen H. Development of
polyneuropathy during thalidomide therapy. Br JDermatol 1985; 112: 475-80.
2. Lovell CR, Hawk JLM, Calnan CD, Magnus IA. Thalidomide in actinic prungo Br J
Dermatol 1983; 108: 467-71.
3. Winkelmann RK. Thalidomide treatment of prurigo nodularis. Acta Derm Venereol
1984; 64: 412-17.
4. Gnnspan D, Blanco GF, Aguero S. Treatment of aphthae with thalidomide. J Am
Acad Dermatol 1989; 20: 1060-63.
5. Knop J, Bonsmann G, Happle R, et al. Thalidomide in the treatment of sixty cases of
chronic discoid lupus erythematosus. BrJ Dermatol 1983; 108: 461-66.
thalidomide of reproductive age with systemic lupus
to women
erythematosus might, in theory, lead to the birth of phocomelic
children-a dreadful prospect. However, his statement that "all
remaining supplies of thalidomide tablets ... (be) consigned to the
flames" is an emotional non-sequitur. Thalidomide, used with
appropriate care, can benefit certain patients. For example, we, in
common with others,l,2 have found thalidomide useful in treating
AID S patients with severe, resistant ulceration of the mouth. A total
ban on the use of thalidomide would deprive such patients of
much-needed relief.
Does his proposal apply solely to thalidomide or would he extend
the ban to teratogens such as phenytoin?
Department of Genito-urinary Medicine,
St Thomas’ Hospital, STEPHEN P. HIGGINS
London SE1 7EH, UK CAROLINE S. BRADBEER
1. Gorin I, Vilette B, Gehanno P, Escande JP. Thalidomide in hyperalgic pharyngeal
ulceration of AIDS. Lancet 1990; 335: 1343.
2. Youle M, Hawkins D, Gazzard B. Thalidomide in hyperalgic pharnygeal ulceration of
AIDS. Lancet 1990; 335: 1591.
Fatal myocardial infarction and Tyrolean
winds (the Foehn)
SIR,-An increased risk of myocardial infection has been
reported in extreme weather conditions such as heatwaves and cold
fronts.1,2 Deviations from seasonally determined thermally neutral
conditions can unfavourably affect good health.3 In mountainous
areas the weather is influenced decisively by the flow direction of the
air. In the mountains, certain winds are characterised by high
velocity, strong turbulence and low humidity. In the Austrian Tyrol
this wind, called the Foehn, comes from the south. Might fatal
myocardial infarction be more frequent on days when this wind
blows?
To determine weather patterns we used a flow pattern catalogue
(data available from R. Steinacker, Institute of Meteorology and
Geophysics). Our retrospective analysis covered the five years
1987-91. All cases of cardiac death with necropsy done at the

DAILY FREQUENCY OF FATAL MYOCARDIAL INFARCTIONS AND
DURATION OF FOEHN
*Dependent variable was the number of daily fatal myocardial infarctions (events)
coded "zero" (0 or 1 event) or "1" (>1 event). Independent variable was the
duration of previous Foehn situations, coded as number of days.
tp insufficient for inclusion of Foehn variable into model.
Institute of Forensic Medicine and the Institute of Pathology,
University of Innsbruck (1940 cases) were included. Most were
acute myocardial infarctions (pathological criteria).
The table shows mean daily frequencies of fatal myocardial
infarction on days with no Foehn compared with those observed on
days with Foehn, ordered according to increasing number of
preceding days with Foehn conditions. The results are listed
separately for each year. Clearly, there was no consistent association
between the presence/duration of Foehn and the frequency of fatal
myocardial infarction. This was confirmed by logistic regression
analysis. Whereas a significant association between Foehn and an
increased number of cases was observed in 1988 and 1989, no such
association was seen in 1987 and 1991, and in 1990 the significant
association had the reversed sign. Thus, no clear association
emerged from our data. The question whether variations in
atmospheric pressure, which are especially strong in Foehn
conditions, exert a significant adverse effect on individuals remains
onen.
E. AMBACH
Institutes of Forensic Medicine, Pathology, W. TRIBUTSCH
Meteorology and Geophysics, T. MAIRINGER
and Medical Chemistry and Biochemistry,
University of Innsbruck, R. STEINACKER
A-6020 Innsbruck, Austria G. REINEGGER
1. Anderson TW, Le Riche WH. Cold weather and myocardial infarction. Lancet 1970;
i: 291-96.
2. Ellis FP, Nelson F, Pincus L. Mortality during heat waves in New York City, July,
1972 and August and September, 1973. Environ Res 1975; 10: 1-13.
3. Auliciems A, Frost D. Temperature and cardiovascular deaths in Montreal. Int J
Biometeorol 1989; 33: 151-56.
Correct use of laparoscopic insufflator
SIR,-As manufacturers of insufflators of the type that Mr
Watson and colleagues describe (April 4, p 880), we are very
concerned about the hazard that will be created by the use of an
insufflator in the manner suggested, and we cannot recommend that
anyone follows this method unless they are willing to accept the
risks. The manufacturer of the machine will not accept liability
should an incident occur as a result of using a device in a way that is
not as described in the instruction book.
The recirculation rate of the smoke evacuator pump can be as
high as 15 litres per minute, and the pressures developed at the
outlet can greatly exceed the arterial pressure. It is therefore
essential that the return gas line is monitored. This will not be the
case if the unit is connected as suggested by Watson et al and it is
possible, owing to the separate placement of the CO2 supply cannula
and the recirculated gas return cannula, that the intra-abdominal
pressure will not be monitored, which could result in serious over
insufflation of the peritoneal cavity.
Over insufflation cannot occur if the machine is used correctly.
The pressure in the COsupply line and the return gas line are
monitored continually by a sensor within the machine, during both
nonnal insufflation and when the smoke evacuator/recirculating
pump is being used. The insufflator has two alarms-one indicates
1363
if the preselected pressure is exceeded by 6 mm Hg, and one
latching alarm indicates if a pressure of 30 mm Hg is exceeded and
maintained for greater than 6 s. If the second alarm is activated, the
machine turns both the CO2 supply and smoke evacuator/
recirculation pump off. The machine must then be reset manually
before proceeding. The activation of the second alarm indicates that
there is a fault somewhere in the system and that a potentially
dangerous condition exists.
The correct pressure compensating T-piece supplied with the
machine is fitted with silicon tubing that is permanently attached by
metal sleeves that cannot be easily removed. The connectors are all
different and coded, making incorrect connection virtually
impossible. The system tubing cannot be incorrectly set up if the
coded connectors are checked. Incorrect connection of the T-piece
or tubing can only be made if someone has deliberately and forcibly
removed and reconnected the tubing or if some other T-piece, not
supplied by the manufacturer, is used.
Since the basis for correct function is an absolutely closed system,
the system should be tested for leaks as described in the instruction
book before being connected to the patient. Constant triggering of
the alarm will occur as a result of any leak that allows room air to be
sucked into the system, thereby adding to the total gas volume and
increasing the intra-abdominal pressure. This can be avoided if care
is taken to ensure that all cannulae and bottle seals are in good order,
the correct connection of all the tubing has been made, and the
correct supply and return cannulae used, to provide an unrestricted
pathway for the gas both to and from the peritoneal cavity. It is also
important to ensure that these cannulae actually have their distal
lumen within the free peritoneal space and have not migrated back
into the tissue of the abdominal wall.
Richard Wolf UK Ltd,
PO Box 47,
Mitcham,
Surrey, CR4 4TT, UK M. S. PITTAS
New mosquito in Africa
SIR,- The implications of the arrival of Aedes albopictus in
Nigeria1,2 are not confined to Africa. By transportation or by spread
up the Nile valley it could reach the Mediterranean shores. From
there it could certainly reach southern Europe. It can survive over
winter, and in the USA has reached as far north as the Chicago area33
where winter is certainly more severe than in southern and western
Europe. As a vector of dengue and several other viruses of Africa it
might well introduce some unfamiliar arboviral diseases to Europe.
Communicable Disease (Scotland) Unit,
Ruchill Hospital,
Glasgow G20 9NB, UK N. R. GRIST
1. Anon. New mosquito strain for Nigeria. Lancet 1992; 339: 1048.
2. Anon. Aedea albopictus introduction into continental Africa, 1991. Weekly Epidemiol
Rec 1992; 67: 107-09.
3. Anon. Update: Aedes albopictus infestation-United States, Mexico. MMWR 1989;
38: 440-46.
Thromboembolic complications and dose of
monoclonal OKT3 antibody
SIR,- The article by Dr Abramowicz and colleagues (March 28,
p 777) on induction of thrombosis within renal allografts by high
dose (10 mg) prophylactic OKT3 attracted our attention. We have
demonstrated that activation of coagulation at the level of thrombin
also occurs upon the first administration of OKT3 in the commonly
used dose of 5 mg daily.’ The activation of coagulation appeared to
be associated with both complement activation and systemic release
of tumour necrosis factor (TNF&agr;). We also found that the activation
of coagulation coincided with an immediate activation of the
fibrinolytic system at the level of plasmin (figure).
However, in our experience treatment of acute rejection with a
daily dose of 5 mg OKT3 (for 10 days) does not seem to be
associated with thromboembolic complications. In clinical trials
with 5 mg OKT3, thrombotic complications of the renal allograft
are not mentioned.3,4 Retrospectively, we evaluated clinical data of
49 renal transplant recipients treated for a first acute rejection