625
and cost negates any economic benefits of the intradermal route at
Haematological monitoring and renal function in man with
renal failure.
To convert haemoglobin in mmol/l to g,’dl multiply by 1 65.
restoration of normal haemoglobin. The figure shows the data for a
65-year-old man with acute tubular necrosis after complicated
surgery. Further studies on serum EPO in other types of acute renal
failure, of EPO half-life in acute azotaemia, and on the effect of
exogenous EPO in prolonged acute renal insufficiency are clearly
needed. Our preliminary conclusion, however, is that deficient
endocrine secretion of EPO may be an important facet of the acute
renal failure syndrome.
Medical Department P,
Division of Nephrology,
Rigshospitalet, OVE JUUL NIELSEN
DK-2100 Copenhagen, Denmark JØRN HESS THAYSEN
1. McGonigle RJS, Wallin JD, Shadduck RK. Erythropoietin deficiency and
erythropoiesis m renal insufficiency Kidney Int 1984 25: 437-44
2 Winearls CG, Oliver DO, Pippard MJ, et al. Effect of human Epo derived from
recombinant DNA on the anaemia of patients maintained on chronic
haemodialysis. Lancet 1986; n 1175-79.
3. Nielsen OJ. Determination of human Epo by radioimmunoassay: method and clinical
data. Clin Chim Acta 1988 176: 303-13.
INTRADERMAL HEPATITIS B VACCINE
SIR,-Dr Kurtz and colleagues report (Feb 25, p 451) the
effectiveness of hepatitis B vaccine when given intradermally, and
for economic reasons advocate this method. However, there are
practical reasons why the intradermal method should not routinely
be used. We fmd that the recombinant vaccine, when given
intramuscularly to the same age group that Kurtz et al report on,
produces 100 IU/1 anti-HBs antibody or more in at least 97% of
subjects. As is commonly accepted in the USA, post-vaccination
antibody measurement after intramuscular injection is unnecessary
in the under-40 age group. Kurtz and colleagues’ study emphasises
that skill is needed for intradermal injection, and that efficacy varies
with the route of administration and should not be assumed. In field
use a high standard of intradermal technique is not maintained and
post-vaccination antibody measurement is mandatory. The time
current vaccine prices. The vaccine price is likely to continue to fall
and the intramuscular route, which is effective, should be the
recommended method. This will ensure not only a much higher
conversion rate than that produced in Kurtz and colleagues’ study
but also avoid the need for post-vaccination antibody assay.
Northwick Park Hospital
and Clinical Research Centre,
Harrow, Middlesex HA1 3UJ J. A. LUNN
VANCOMYCIN AND NEPHROTOXICITY
SIR,-Vancomycin is often reserved for seriously ill patients
being treated simultaneously with other drugs, making it difficult to
decide on the role of vancomycin if nephrotoxicity ensues. Our
study on renal function in patients on prophylactic vancomycin may
shed some light on this question.
In a prospective, randomised study of prophylactic vancomycin
in vascular prosthetic surgery caudal to the diaphragm’ patients
were randomly allocated to receive 1 g vancomycin in 100 ml saline
intravenously over 20 min 1 h before the operation and again 4 h
later (n=101) or physiological saline given in the same fashion
(n=99). Serum creatinine (normal 62-133 Vmol/1) was measured
before and after surgery. Because of missing data 4 patients were
excluded in the vancomycin group and 3 in the placebo group.
Nephrotoxicity was defined by an increase in creatinine
concentration of at least 40 J.1111ol/l above baseline.2
In the vancomycin group we found 14 cases of nephrotoxicity
(14%) and in the placebo group 2 (2%) (p < 0005). In all cases but 1
the creatinine peaked between postoperative days 1 and 5, usually
on day 2. In 10 of the patients in the vancomycin group who showed
signs of nephrotoxicity the serum creatinine level had returned to
normal or baseline by postoperative day 2-10 (average 4!days); 1
acute
patient died from heart failure 2 days after surgery and another from
myocardial infarction after 2 months, the serum creatinine in both
still being high; in the other 2 cases renal function had returned to
normal by 2 and 9 months. In the placebo group both patients
having abnormal renal function after surgery died shortly
afterwards.
Despite the many concurrent reasons for renal failure in vascular
graft surgery, such as renal ischaemia during surgery on the
abdominal aorta, hypotension, and postoperative infection, our
study indicates that vancomycin, even in a short regimen, is
responsible for reversible nephrotoxicity in several cases. This must
be taken into account when weighting the pros and cons of
vancomycin therapy.
Department of Thoracic
and Cardiovascular Surgery,
Aarhus University Hospital, G. H. GUDMUNDSSON
8000 Aarhus C, Denmark L. JUHL JENSEN
1 Jensen LJ, Aagaard MT, Schifter S Prophylactic vancomycin versus placebo in
arterial prosthetic reconstructions. Thorac Cardiovasc Surg 1985; 33.
2. Appel GB, Given DB, Levme LR, Cooper GL. Vancomycin and the kidney. Am J
Kidney Dis 1986; 8: 75-80.
LIFE-THREATENING SALMONELLA ENTERITIDIS
PHAGE TYPE 4 GASTROENTERITIS IN INFANCY
SiR,&mdash; Attention has recently been drawn to the contamination of
eggs with Salmonella enteritidis phage type 4 (S enteritidis PT4).1;2
We would like to emphasise the life-threatening nature of infection
with this organism in early infancy.
Case 1.-This boy had loose stools at 3 days of age. S enteritidis
PT4 was isolated from his stools and from those of his symptom-free
mother. He was discharged at 7 days but readmitted 2 days later
with diarrhoea and severe dehydration. Five times a return to
formula (regrade) feeds was tried but diarrhoea persisted. At 4
weeks he was transferred to the Children’s Hospital, Birmingham.
He had hypocalcaemic and hypomagnesaemic convulsions, and was
very ill, with severe protein-energy malnutrition (weight-for-age
54% of expected). He was hypoalbuminaemic (19 g/1) and anaemic
(haemoglobin Hb 7 7 g/dl), but not oedematous. Blood cultures
626
were sterile. Dietary regrading with a modular feed based on
minced chicken was successful, and he gained weight. However, 7
days after transfer, a previous infusion site became inflamed and
5 ml purulent fluid was aspirated. S enteritidis PT4 was isolated;
there was no radiological evidence of osteomyelitis and blood
cultures were sterile. Oral amoxycillin was prescribed. The patient
continued to gain weight but transfusion-dependent anaemia
developed, and 16 days after transfer two pustules developed on the
surface of a cephalhaematoma and discharged purulent material:
culture again yielded S enteritidis. Drainage was successful. Blood
cultures were repeatedly sterile and amoxycillin was discontinued
after 19 days. The patient was discharged at age 9 weeks.
Case 2.-This 8-week-old girl was admitted with a 10-day
history of bloody diarrhoea. S enteritidis PT4 was isolated from the
stool. The diarrhoea improved at first on a glucose-electrolyte
solution, but recrudesced on dietary regrading, with dehydration
(plasma sodium 163 mmol/1) requiring intravenous fluids. Blood
cultures were sterile but intravenous chloramphenicol was given for
7 days. Further regrading onto a hydrolysed casein-based formula
was associated with more diarrhoea and dehydration. Weight gain
was then satisfactory on the casein formula, initially given by
continuous infusion. She was discharged after 5 weeks but was
readmitted a few days later because of further diarrhoea, responding
to another regrade. The stools were persistently positive for
S enteritidis PT4.
Case 3.--An 11-week-old infant came to hospital with a 2-week
history of watery diarrhoea. S enteritidis PT4 was isolated from the
stool and intravenous ampicillin was given for 7 days. Three dietary
regrades were required because of persistent diarrhoea, despite a
hydrolysed casein-based formula given by nasogastric infusion. She
was discharged after 19 days.
Haematogenous spread of S enteritidis in infancy (to bone, the
meninges, and soft tissues, for example) is well recognised, but until
the strain PT4 emerged, protracted diarrhoea leading to protein-
energy malnutrition in young babies seems to have been
uncommon.3 Subclinical bacteraemia is probably common,4 and it
has been suggested that salmonella infection in infants less than 3
months of age should always be treated with antibiotics, despite the
risk of a prolonged carrier state. 5,6 Even though blood cultures were
repeatedly sterile in our cases the metastatic infection observed
supports that recommendation. The source of infection in two of
our cases was unknown but S enteritidis PT4 infection in the UK is
commonly related to egg or poultry products, and the Department
of Health recommends that eggs should be cooked until the yolk is
hard before being fed to young children (or the elderly). Our cases
emphasise the virulent nature of the PT4 strain in early infancy, and
lend weight to this recommendation.
Children’s Hospital,
J. H. CROSS
Birmingham B16 8ET R. H. GEORGE
I. W. BOOTH
Sandwell District General Hospital,
Lyndon, West Bromwich A. J. MAYNE
1. Editorial. Salmonella enteritidis phage type 4: chicken and egg Lancet 1988; ii. 720-22.
2.Sharp JCM. Salmonellosis and eggs. Br Med J 1988; 297: 1557-58
3. Lloyd Still JD, Schwachman H, Filler RM. Protracted diarrhea of infancy treated by
intravenous alimentation. Am J Dis Child 1973; 125: 358-64.
4 Meadow WL, Schneider H,, Beem MO Salmonella enteritidis bacteremia in
childhood. J Infect Dis 1985; 152: 185-89.
5 Nelson SJm Granoff D. Salmonella gastroenteritis in the first three months of life a
review of management and complications. Clin Pediatr 1982, 21: 709-12.
6. Sanders DY, Sinal SN, Morrison L. Chronic salmonellosis in infancy. Clin Pediatr
1974, 13: 640-43.
PRE-IMPLANTATION EMBRYOS?
SIR,-A paper in your issue of Feb 18 (p 347) prompts the
following:
A conceptus at pre-implantation
Is at pre-embryonic gestation.
You cannot dismiss
That the blastocyst is
The embryo’s younger relation
St George’s Hospital Medical School,
London SW170RE GEOFFREY CHAMBERLAIN
Notes and News
UNDERSTANDING WOMEN WITH POSITIVE
SMEARS
A Lancet editorial (Jan 14, p 83) has already provoked letters
commenting critically on aspects of cervical laser therapy (Feb 11, p
335; March 4, p 494). A doctor has sent us an anonymous account of
her own unpleasant experience of gynaecological treatment, which
we reproduce in part here.
"... did I have cancer, as I feared, or only a few abnormal cells?
Friendly evasions are the opposite of reassuring, and histological
findings are rarely shared with patients, even when they are
informed and ask. The tone of grim satisfaction with which the
clinic nurse told me: ’that’s what comes from sleeping with too
many men too young’ made me want to hit her".
The patient’s first laser treatment was done without anaesthetic
and was watched by nine or ten men who were interested in the
technique. "Although I was offered the opportunity to ask them to
leave, the offer was made in such a way as to make such a request
seem churlish and ungrateful... That gaggle of men’s faces peering
down my vagina is not a pleasant memory.The laser treatment was
excruciatingly painful. "They told me afterwards that the pain
indicator did not register a high level. I forgot to thank them for the
computation. I was sent out into the windy streets of London utterly
alone, with no glimmer of sympathy or concern about how I was
going to get home ... I had no advance warning of how weak I
would be, nor how much blood I would lose ... It was at least two
weeks before the pain and blood loss ceased, bleeding which was
interspersed with horrible black lumps of charred tissue. For
anyone less knowledgeable of medicine this could have been a truly
frightening experience. There had been no warning of that, either."
The treatment was unsuccessful. By the time a second operation
was arranged "enough other women had registered acceptable facial
expressions to justify pain relief. Repeat laser therapy, though
painless, was no more successful and cone biopsy was decided on.
This procedure, which was successful, was accompanied by full
explanations before and after the operation under anaesthetic.
However, "... the memory of the pain, embarrassment and trauma
remains, and is re-activated whenever I have the smallest
gynaecological problem ... In the right hands laser treatment may
well be a useful, swift and economical therapy for cervical dysplasia.
In the wrong hands it’s a nightmare, even for a doctor, to undergo".
If that doctor could be treated in such an off-hand way, how
much worse it must be for other patients-which is reflected in the
many books advising women how to cope with an abnormal cervical
smear finding and its consequences. The latest of these books is
Positive Smear.1
Another effort to provide women with the emotional and
psychological backup they need was a conference held in London
earlier this month by Women and Medical Practice (WAMP),
backed by a number of women’s health and cancer care groups, and
part sponsored by Penguin Books. The conference, entitled Positive
Smear: A Positive Approach, afforded patients and health
professionals a chance to hold a dialogue on these issues.
The key-note of the report-back from the six afternoon
workshops was the need for better communication: the provision of
accurate information, use of agreed terminology, demystification,
destigmatisation, and counselling (though in the discussion that
followed a talk by Sue Mack, a psychotherapist, it was felt that
counselling is a luxury that cannot normally be afforded).
Understanding, by patients, of the medical rationale for
intervention and, by staff, of women’s feelings about that
intervention, was important, but judgmental messages that linked
women’s sexuality and cervical cancer were unhelpful, conclusions
also reached in a study published last year by the King’s Fund
(Prevention of Cervical Cancer: the Patient’s View, by T. Posner
and M. Vessey, see Lancet Jan 28, p 230).
1 Positive Smear. By Susan Quilliam Harmondsworth: Penguin. 1989. Pp 185. &pound;3.99
ISBN 0-140106901