DIPHOSPHONATES: WHAT DOSE UNITS?

575 rose to 39-6°C. We started treatment with gentamicin and cefazolin, on a working diagnosis of hospitalacquired infection of unknown cause, possibly related to the site of marrow aspiration. The donor’s condition improved rapidly over the next 24 hours. He left hospital next day at his own request. On the tenth postoperative day, routine culture from the marrow suspension and the blood cultures taken during his febrile episode grew B. melitensis. At this time he was reinvestigated and found to have been suffering from malaise, weakness, and sweating since he had gone home. Serum antibodies to B. melitensis were found at a titre of 1:3200 by tube agglutination, and blood cultures were again positive. A titre of 1:400 was found in a serum sample which had been stored from the day before marrow donation. A three week course of tetracycline was given with no apparent relapse after five months. The marrow recipient, a 24-year-old female from the same village, underwent bone-marrow transplantation for severe aplastic anaemia. We found later that she had not attended the same party as her brother. She was prepared for transplantation with fractionated total lymphoid irradiation and cyclophosphamide. During the entire period leading up to the transplantation her neutrophil count remained below 0 - 5 x 109/1 (figure). She ran a low grade fever which exceeded 38°C on the second day before transplantation and the next day she had rigors. We started treatment with cefazoliri, carbenicillin, and gentamicin. All cultures taken at this time were negative and the patient’s condition remained stable despite continued fever. The treatment was continued until brucellosis was diagnosed in the donor. On the assumption that the patient had received a marrow suspension containing B. melitensis, we started three weeks’ treatment with tetracycline. After seven days her temperature dropped below 38°C, in association with a rising neutrophil count (figure). Repeated blood cultures and a bone-marrow sample taken three months later were negative. The patient also remained seronegative-not unexpectedly considering her degree of

rigors and his temperature

immunosuppression. We cannot conclusively demonstrate acquired clinical brucellosis in the recipient, but are certain that she received an infected

Commentary from Westminster Challenge Deferred over Abortion Notification Forms AFTER fifteen years the 1967 Abortion Act is still a battleground between those who think abortion is too freely available in Britain and those who say terminations are not easy enough to obtain. Complicated cross-currents muddy the waters whenever the Act becomes the focus of a new controversy, and the issues are seldom clear. Thus, the decision by the office of the Director of Public Prosecutions not to prosecute two gynaecologists reported to them by the Chief Medical Officer of the D.H.S.S. has not answered all the questions raised by the referral. The precise intention of the 1967 Act in certain respects remains arguable. The D.P.P. has decided not to allow the Chief Medical Officer to pursue the argument now. But a future C.M.O. might find a future D.P.P. taking the opposite attitude. The way in which Mr Peter Huntingford and another gynaecologist completed notification forms about abortions they performed, for despatch to the D.H.S.S., was at the heart of the matter. The forms, recently redesigned by the D.H.S.S., now contain two parallel sets of questions. On one side of the form, gynaecologists are required to add ticks to various boxes, to identify the reasons for the termination and thus establish that the termination is legal within the definition of the Act. On the other side of the form they are requested to give information about the reasons for the

treatment with a broad antibiotic. spectrum Transmission of brucella by blood transfusion has been described.1O Our unusual experience with brucellosis adds yet another to the growing list of pathogens which may be transmitted by bone-marrow transplantation, and underlines the importance of culturing transplant samples for contaminants, some of which may be innocuous in the immunocompetent donor but pose a serious threat to the immunosuppressed recipient. Furthermore we would emphasise the need to bear exotic disease in mind in transplant centres to which patients from many different backgrounds are referred.

transplant and thus required additional

Department of Haematology, Hadassah University Hospital,

E. NAPARSTEK C. S. BLOCK S. SLAVIN

Jerusalem, Israel

DIPHOSPHONATES: WHAT DOSE UNITS?

SIR,-When your editorial on diphosphonates (Dec. 12, p. 1326) appeared we saw no reason to comment upon a well-balanced brief review of this interesting group of compounds. However, it has recently been brought to our notice that some confusion could arise from the units employed in stating the recommended dosage for EHDP (etidronate). You gave this as 20 pmol/kg daily, but unless the reader knew the molecular weight to be 250, he would not know, without reference to the data sheet, that this in practical prescribing terms means 5 mg/kg daily for a 6 month course and might confuse it with 20 mg/kg daily, which should not be administered for longer than 3 months. Whilst working in molar and micromolar terms is an everyday matter for the pharmacologist, the average clinician still states his dosages in the more usual pharmaceutical units. Medical/Scientific Division, Brocades (Great Britain) Ltd, West Byfleet, Surrey KT14 6RA

10. Wood EE. Brucellosis

as

RICHARD WALL

a hazard of blood transfusion. Br Med J

1955;

i:

27.

that the D.H.S.S. can collate information on generally, and thus keep track of how the Act is being applied in practice. When asked to specify grounds for termination in the section meant for D.H.S.S. records, Mr Huntingford and others wrote that there were no medical grounds. But in the section which establishes the abortion’s legality within the meaning of the Act, nothing was entered which suggested that the termination was anything but legal. This manner of completing the forms was plainly intended as a challenge to the D.H.S.S., since Mr Huntingford and the pressure groups rallying round him believed, or at least suspected, that the redesigning of the forms betokened a serious official attempt to change the accepted interpretation of the Act, or, failing that, to change the way it is operated in

termination,

so

terminations

practice. The Health Minister, Dr Gerard Vaughan, insists that: "there has been absolutely no intention or attempt to change the law by the back door". Anybody who wanted to change the law must first change the 1967 Act. But such reassurances are easily drowned in the noise generated by the opposing lobbies on the abortion question: at one extreme the sly and self-righteous categorically anti-abortion groups; at the other extreme, some of the hysterical and equally self righteous defenders of a woman’s right to choose. Against this background it is not surprising that some interested groups have found it hard to accept the official explanation that the forms were redesigned merely for the convenience of computerisation of records, and to take account of changes in abortion procedure since 1967, such as the growth of day-