- Email: [email protected]
AWAY WITH DIASTOLIC PRESSURE
209
including 6 homosexuals and 1 woman practising anal intercourse) underwent day-case surgical excision under general anaesthetic. The result of treatment was assessed by an independent observer at 6, 18, and 42 weeks after the start of treatment. At 6 weeks surgical excision had completely cleared the warts from all patients compared with 10 out of 13 (77%) patients treated with podophyllin. 2 patients treated surgically had recurrent warts at 18 weeks and a further patient had a recurrence at 42 weeks, for a cumulative recurrence rate of 19%. 4 of the 10 patients whose warts were cleared by podophyllin had recurrent warts at 18 weeks and a further 3 at 42 weeks, for a cumulative recurrence rate of 70% (p<0’03, Fisher’s exact test). Moreover, 14 (88%) of the surgical patients were satisfied with the treatment they received while 10 (77%) of the podophyllin patients were dissatisfied with a treatment that necessitated regular outpatient attendances and gave poor results. It may be concluded that surgical excision is preferable to 25% podophyllin application in the treatment of perianal condylomata acuminata. Department of Surgery, St Mary’s Hospital, Portsmouth PO3 6AD
H. T. KHAWAJA
1 Summons PD. Podophyllin 10% and 25% in the treatment of ano-genital warts. Br J Vener Dis 1981; 57: 208-09. 2 Thompson JPS, Grace RH. The treatment of perianal and anal condylomata: a new operative technique. J Roy Soc Med 1978; 71: 180-85.
AWAY WITH DIASTOLIC PRESSURE
SIR,-Dr Fisher’s paper (Dec 14, p 1349) questioning excessive emphasis on diastolic blood pressure supports those of us who have long doubted the value of the diastolic pressure in monitoring during anaesthesia and intensive care. Not only is diastolic pressure much more difficult to obtain than systolic, but also manufacturers of automatic blood pressure recorders have been to include this variable in their devices, greatly the cost. I know of no situation in anaesthesia and intensive care where diastolic blood pressure is itself, and independently of the systolic pressure, a critical consideration in patient management. Although physiologically the diastolic pressure is important (eg, in the context of coronary blood flow) the systolic or mean blood pressure, to which it is so closely linked, is always our practical guide. It is time we abandoned this academic and expensive measurement.
compelled increasing
National Heart Hospital, London W1M 8BA 1. Gilston A Diastolic blood pressure
ALAN GILSTON recording. Anaesthesia 1977; 32:
Our emphasis on the need for ensuring that the correct antiseptic products are used for the appropriate procedures should be reinforced by the need for education of the consequences of dilution of preserved products. Public Health Laboratory, Northern General Hospital, Sheffield S5 7AU
P. NORMAN P. E. GOSDEN
Imperial Chemical Industries, Pharmaceuticals Division, Macclesfield, Cheshire
J. PLATT
Beveridge EG Microbial spoilage and preservation of pharmaceutical products. In: Hugo WB, Russell AD, eds. Pharmaceutical microbiology. Oxford: Blackwell Scientific Publications, 1977 266-79. Marrie TJ, Costerton JW. Prolonged survival of Serratia marcescens in chlorhexidine. Appl Envir Microbiol 1981, 42: 1093-102.
1
2
LOW-TAR CIGARETTES AND FUTURE MORTALITY
SIR,-We were interested in the differing views expressed in your correspondence columns about cigarette smoking and the future of low-tar cigarettes (Dec 14, p 1359) and in Dr Myddelton’s critical discussion of tobacco and mortality (Dec 21/28, p 1430). A life-long smoking history has been taken from asbestos-exposed individuals who have attended this respiratory unit and, since such patients are especially sensitive to the effects of cigarettes,l any future attempted manipulation of smoking habit by whatever agency should produce a more striking effect in this group. Of 135 consecutive patients only 12 had never smoked, but 77 were smoking less and 38 of the group (some 30%) had stopped smoking. Before the advent of the low-tar cigarette the last great change in smoking habit was produced by the introduction of the filter tip. 96 smoked plain cigarettes, 15 (15’° 6°70) changing to the filtered type in the 1950s, 50 (52%) in the 1960s, and 17 (17 -7%) in the 1970s. Out of 85 currently smoking, only 4 are smoking low-tar cigarettes. 26 (30° 5%) prefer cigarettes which reward the smoker with tokens redeemable against gifts. We suggest that any expected change in smoking habit to a lower tar cigarette may require a similar timespan as the initial acceptance of the filter tip. In view of the small number in our group who smoke the low-tar grade and the possible 30-year lag we suggest that little emphasis should be given to the low-tar cigarette as an improved those who are in the apparent option for any smoker, particularly 2 ground-zero of world cancer. Centre for Respiratory Investigation, Glasgow Royal Infirmary, Glasgow G31 2ES
KENNETH ANDERSON FRANCIS MORAN
388.
Selikoff IJ, Hammond EC, Churg J Asbestos exposure, smoking and neoplasia. JAMA 1968; 204: 106-12 2. Kemp I, Boyle P, Swams M, Muir C, eds. Atlas of cancer in Scotland 1975-1985: Incidence and epidemiological perspective (IARC Sci Publ no 72) Oxford: Oxford University Press, for WHO, IARC, and cancer registries of Scotland, 1985. 1.
PSEUDOBACTERAEMIA ASSOCIATED WITH CONTAMINATED SKIN CLEANING AGENT
SIR,-We have described the inappropriate use of an antiseptic handwash (chlorhexidine,’Hibiscrub’) which was contaminated with Pseudomonas cepacia and resulted in positive blood cultures in two patients (Sept 21, p 671). Further studies have shown that hibiscrub does not support the growth of the Pcepacia strain isolated unless diluted, and dilution is probably the explanation for the contamination reported previously. Hibiscrub was deliberately contaminated with about 107 colony forming units of the P cepacia isolate repeatedly for ten consecutive days, and no organisms survived. However, when hibiscrub was diluted 50% v/v in water the organism could be readily recovered from the solution after a single challenge. This handwash contains 4% w/v isopropyl alcohol as a preservative, and dilution may leave it inadequately protected from contamination with certain microorganisms. There is an exponential relation between microbicidal activity and preservative concentration, the value of the exponent varying for different preservatives. Halving the preservative concentration would have greatly reduced the resistance of hibiscrub to microbial contamination. Dilution of hibiscrub, resulting in contamination with gram-negative bacteria, has been reported previously.2In that report the product was diluted in pharmacy 50% v/v in water before distribution to the wards, in a misguided attempt to cut costs.
STANDARDISED FEVERFEW PREPARATIONS
SIR,-Dr Groenewegen and Dr Heptinstall (Jan 4, p 44) report low activity, based on inhibition of secretory activity in platelets, in some commercial preparations of dried feverfew when compared with that in freshly extracted leaves. They call for tighter control of the contents of herbal preparations, echoing the view of Johnson et al,l who noted the variation in sesquiterpene lactone content between feverfew plants harvested in different seasons. ’Lomigran’ capsules (Potter and Clarke Ltd) are now available on general sale and provide a standardised 0-1mg of active constituents (sesquiterpene lactones) of feverfew per capsule. This is equivalent to a nominal 25 mg of freshly dried powdered feverfew. A daily intake of 50 mg of freeze-dried feverfew powder was found to be an effective prophylactic against migraine in the trial reported by I
Johnson et al.
Booker Health Foods Ltd, West Byfleet, Surrey KT14 6NE
L. MERVYN
1. Johnson ES, Kadam NP, Hylands DM, Hylands PJ. Efficacy of feverfew prophylactic treatment of migraine. Br Med J 1985; 291: 569-73.
as
including 6 homosexuals and 1 woman practising anal intercourse) underwent day-case surgical excision under general anaesthetic. The result of treatment was assessed by an independent observer at 6, 18, and 42 weeks after the start of treatment. At 6 weeks surgical excision had completely cleared the warts from all patients compared with 10 out of 13 (77%) patients treated with podophyllin. 2 patients treated surgically had recurrent warts at 18 weeks and a further patient had a recurrence at 42 weeks, for a cumulative recurrence rate of 19%. 4 of the 10 patients whose warts were cleared by podophyllin had recurrent warts at 18 weeks and a further 3 at 42 weeks, for a cumulative recurrence rate of 70% (p<0’03, Fisher’s exact test). Moreover, 14 (88%) of the surgical patients were satisfied with the treatment they received while 10 (77%) of the podophyllin patients were dissatisfied with a treatment that necessitated regular outpatient attendances and gave poor results. It may be concluded that surgical excision is preferable to 25% podophyllin application in the treatment of perianal condylomata acuminata. Department of Surgery, St Mary’s Hospital, Portsmouth PO3 6AD
H. T. KHAWAJA
1 Summons PD. Podophyllin 10% and 25% in the treatment of ano-genital warts. Br J Vener Dis 1981; 57: 208-09. 2 Thompson JPS, Grace RH. The treatment of perianal and anal condylomata: a new operative technique. J Roy Soc Med 1978; 71: 180-85.
AWAY WITH DIASTOLIC PRESSURE
SIR,-Dr Fisher’s paper (Dec 14, p 1349) questioning excessive emphasis on diastolic blood pressure supports those of us who have long doubted the value of the diastolic pressure in monitoring during anaesthesia and intensive care. Not only is diastolic pressure much more difficult to obtain than systolic, but also manufacturers of automatic blood pressure recorders have been to include this variable in their devices, greatly the cost. I know of no situation in anaesthesia and intensive care where diastolic blood pressure is itself, and independently of the systolic pressure, a critical consideration in patient management. Although physiologically the diastolic pressure is important (eg, in the context of coronary blood flow) the systolic or mean blood pressure, to which it is so closely linked, is always our practical guide. It is time we abandoned this academic and expensive measurement.
compelled increasing
National Heart Hospital, London W1M 8BA 1. Gilston A Diastolic blood pressure
ALAN GILSTON recording. Anaesthesia 1977; 32:
Our emphasis on the need for ensuring that the correct antiseptic products are used for the appropriate procedures should be reinforced by the need for education of the consequences of dilution of preserved products. Public Health Laboratory, Northern General Hospital, Sheffield S5 7AU
P. NORMAN P. E. GOSDEN
Imperial Chemical Industries, Pharmaceuticals Division, Macclesfield, Cheshire
J. PLATT
Beveridge EG Microbial spoilage and preservation of pharmaceutical products. In: Hugo WB, Russell AD, eds. Pharmaceutical microbiology. Oxford: Blackwell Scientific Publications, 1977 266-79. Marrie TJ, Costerton JW. Prolonged survival of Serratia marcescens in chlorhexidine. Appl Envir Microbiol 1981, 42: 1093-102.
1
2
LOW-TAR CIGARETTES AND FUTURE MORTALITY
SIR,-We were interested in the differing views expressed in your correspondence columns about cigarette smoking and the future of low-tar cigarettes (Dec 14, p 1359) and in Dr Myddelton’s critical discussion of tobacco and mortality (Dec 21/28, p 1430). A life-long smoking history has been taken from asbestos-exposed individuals who have attended this respiratory unit and, since such patients are especially sensitive to the effects of cigarettes,l any future attempted manipulation of smoking habit by whatever agency should produce a more striking effect in this group. Of 135 consecutive patients only 12 had never smoked, but 77 were smoking less and 38 of the group (some 30%) had stopped smoking. Before the advent of the low-tar cigarette the last great change in smoking habit was produced by the introduction of the filter tip. 96 smoked plain cigarettes, 15 (15’° 6°70) changing to the filtered type in the 1950s, 50 (52%) in the 1960s, and 17 (17 -7%) in the 1970s. Out of 85 currently smoking, only 4 are smoking low-tar cigarettes. 26 (30° 5%) prefer cigarettes which reward the smoker with tokens redeemable against gifts. We suggest that any expected change in smoking habit to a lower tar cigarette may require a similar timespan as the initial acceptance of the filter tip. In view of the small number in our group who smoke the low-tar grade and the possible 30-year lag we suggest that little emphasis should be given to the low-tar cigarette as an improved those who are in the apparent option for any smoker, particularly 2 ground-zero of world cancer. Centre for Respiratory Investigation, Glasgow Royal Infirmary, Glasgow G31 2ES
KENNETH ANDERSON FRANCIS MORAN
388.
Selikoff IJ, Hammond EC, Churg J Asbestos exposure, smoking and neoplasia. JAMA 1968; 204: 106-12 2. Kemp I, Boyle P, Swams M, Muir C, eds. Atlas of cancer in Scotland 1975-1985: Incidence and epidemiological perspective (IARC Sci Publ no 72) Oxford: Oxford University Press, for WHO, IARC, and cancer registries of Scotland, 1985. 1.
PSEUDOBACTERAEMIA ASSOCIATED WITH CONTAMINATED SKIN CLEANING AGENT
SIR,-We have described the inappropriate use of an antiseptic handwash (chlorhexidine,’Hibiscrub’) which was contaminated with Pseudomonas cepacia and resulted in positive blood cultures in two patients (Sept 21, p 671). Further studies have shown that hibiscrub does not support the growth of the Pcepacia strain isolated unless diluted, and dilution is probably the explanation for the contamination reported previously. Hibiscrub was deliberately contaminated with about 107 colony forming units of the P cepacia isolate repeatedly for ten consecutive days, and no organisms survived. However, when hibiscrub was diluted 50% v/v in water the organism could be readily recovered from the solution after a single challenge. This handwash contains 4% w/v isopropyl alcohol as a preservative, and dilution may leave it inadequately protected from contamination with certain microorganisms. There is an exponential relation between microbicidal activity and preservative concentration, the value of the exponent varying for different preservatives. Halving the preservative concentration would have greatly reduced the resistance of hibiscrub to microbial contamination. Dilution of hibiscrub, resulting in contamination with gram-negative bacteria, has been reported previously.2In that report the product was diluted in pharmacy 50% v/v in water before distribution to the wards, in a misguided attempt to cut costs.
STANDARDISED FEVERFEW PREPARATIONS
SIR,-Dr Groenewegen and Dr Heptinstall (Jan 4, p 44) report low activity, based on inhibition of secretory activity in platelets, in some commercial preparations of dried feverfew when compared with that in freshly extracted leaves. They call for tighter control of the contents of herbal preparations, echoing the view of Johnson et al,l who noted the variation in sesquiterpene lactone content between feverfew plants harvested in different seasons. ’Lomigran’ capsules (Potter and Clarke Ltd) are now available on general sale and provide a standardised 0-1mg of active constituents (sesquiterpene lactones) of feverfew per capsule. This is equivalent to a nominal 25 mg of freshly dried powdered feverfew. A daily intake of 50 mg of freeze-dried feverfew powder was found to be an effective prophylactic against migraine in the trial reported by I
Johnson et al.
Booker Health Foods Ltd, West Byfleet, Surrey KT14 6NE
L. MERVYN
1. Johnson ES, Kadam NP, Hylands DM, Hylands PJ. Efficacy of feverfew prophylactic treatment of migraine. Br Med J 1985; 291: 569-73.
as