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GIVE A DRUG A BAD NAME: CINNARIZINE
1034 methods having been challenged: the question that arose was how to estimate the excess risk, and at the hearing there was some confusion among those who were not familiar with the topic. This was unfortunate because the calculation is straightforward. Your correspondent cites Prof Fritz Scheler as claiming that "The therapeutic decision was properly an individual one, and should not be based mainly on epidemiological considerations. Dipyrone .... should be replaced by better tolerated analgesics". In other words therapeutic decisions should mainly be made without quantitative data on risk. In the absence of such data, how does one determine which are the better tolerated analgesics. Hadassah University Hospital, Jerusalem, Israel
Drug Epidemiology Unit, Boston University School of Medicine, Brookline, Massachusetts 02146, USA
MICHA LEVY
SAMUEL SHAPIRO
GIVE A DRUG A BAD NAME: CINNARIZINE
SIR,-Dr Laporte and Dr Copella (Oct 11, p 853) suggest that cinnarizine is a "useless drug" and should be banned. There is, however, considerable evidence that cinnarizine does modify the effects of labyrinthine stimulation, though the mechanism of this action remains obscure. This activity was suggested, first in connection with studies of drugs against motion sickness,l and later in troopship and slow-rotation-room studies,2 Perry and 13 found the evidence of efficacy in man less convincing, but more recent studies by Stott et allusing cross-coupled stimuli, confirm its effect. Further, there is much anecdotal evidence from yachtsmen and others for the value of cinnarizine in motion sickness. In the UK cinnarizine is recommended for the treatment of disorders of labyrinthine function, not for chronic cerebrovascular disease, and it seems unfair to dismiss cinnarizine as "useless" on the basis of studies with incorrect indications and inappropriate doses and without due consideration to the drug’s time course of action. J. J. BRAND 1. DeWit G. Seasickness (motion sickness). Acta Otolaryngol 1953; suppl 108. 2. Wood DC, Graybiel A. Evaluation of sixteen antimotion sickness drugs under controlled laboratory conditions. NAMI Rep 1968, no 983. 3. Brand JJ, Perry WLM. Drugs used in motion sickness. Pharmacol Rev 1966; 18: 895-924. 4. Stott JRR, et al. In: Davis CJ, et al, eds. Nausea and vomiting: Mechanisms and treatment Berlin: Springer-Verlag, 1986: 126.
PREVALENCE OF UNDIAGNOSED SYPHILIS IN THE ELDERLY
SIR,-Serological tests for syphilis are widely used in the screening of patients with no history or findings of syphilis. What should a clinician do when faced with an unexpected positive test in an elderly patient being investigated for other medical problems? Between 1982 and 1985 Venereal Disease Research Laboratory (VDRL) Treponema pallidum haemagglutination assay (TPHA) and fluorescent treponemal antibody (FTA) tests were routinely done on 1820 new patients over the age of 55 attending the department of medicine and rehabilitation, Nether Edge Hospital, Sheffield. Some were outpatients and some inpatients, 1170 being women and 650 men. 46 patients (2-5%) were positive on one or more of the three tests. 4 were false positive (positive VDRL but negative TPHA and FTA). 10 patients, aged 60-85, had been treated for syphilis between 1920 and 1961; of these, 1 had neurosyphilis, 1 tabes dorsalis, 1 a luetic aortic arch aneurysm, 1 congenital syphilis, and 1 positive cerebrospinal fluid serology in 1946 but no manifest neurological complications. The remaining 32 patients, aged 57-93, had had undiagnosed syphilis as evidenced by a positive FTA. No patient in this group showed complications of spirochaetal disease either on examination or on chest X-ray. Degenerative changes in the lumbar spine and ligamentous calcification make lumbar puncture difficult in the elderly and only 2 had cerobrospinal fluid examined; CSF serology was negative in both.
Syphilis used to be a very common infection, its prevalence at necropsy being 5-10 % in the early 1900s; 39 % of untreated patients had anatomical lesions attributable to syphilis! and 15-40% of untreated patients had late tertiary complications. The probability of dying directly as a result of untreated syphilis used to be 17% in men and 8% in women after 40 years of infection.’ When dealing with the elderly with positive syphilitic serology it is often difficult to decide whether antibiotics, given for unrelated conditions, will have been sufficient to eradicate the treponemal disease. In a study of patients with undiagnosed syphilis only 7% had received curative doses of penicillin by the 20th year of the study.3 These results suggest that there remains a large group of patients with undiagnosed syphilis that will only be picked up by routine screening. Whether treatment alters the course of the disease is debatable but results suggest that, except in the very old or in patients with underlying fatal illnesses, undiagnosed syphilis should be treated using schedules recommended for syphilis of more than 1 year’s duration. Any treatment given should be carefully recorded. Department of Genito-urinary Medicine, Royal Hallamshire Hospital, Sheffield S10 2JF
P. D. WOOLLEY
Department of Medicine and Rehabilitation, Nether Edge Hospital, Sheffield
A.
J. ANDERSON
1. Rosahn PD. Autopsy studies in syphilis. J Ven Dis Inf 1947; suppl 21. 2. Gjestland T. The Oslo study of untreated syphilis: an epidemiologic investigation of the natural course of the syphilitic infection based upon a restudy of the Boeck-Bruusgaard material. Acta Dermatol Venereol 1955; suppl 35: 11. 3. Schuman SH. Untreated syphilis in the male negro: background and current status of patients in the Tuskegee study. J Chron Dis 1955; 2: 543.
CONSEQUENCES OF CHERNOBYL ACCIDENT FOR HEALTH SERVICES
SiR,—Your Sept 13 editorial states that the reactor accident at Chernobyl on April 26 required a local medical response on a scale which the UK and most other countries might find hard to match. Indeed, the events following that accident even showed up serious shortcomings in the response within the UK to an accident some 2000 km away. There are more than forty nuclear power stations within 500 km of south-east England, and since two major reactor accidents (Three Mile Island in the USA and Chernobyl in the USSR) have occurred within the past decade, the possibility of a similar accident cannot be ignored. Therefore the effects on health services produced by the accident at Chernobyl should be explored. The Chernobyl accident prompted many people to ask this hospital for advice-travellers returning from Eastern Europe asked to be monitored for radioactivity, school parties sought advice about travelling abroad, and local residents inquired about the consumption of milk and vegetables. Several outpatients who had received 1311 treatment for thyrotoxicosis expressed concern about the effect of additional 1311 ingestion on their thyroid function, or, after reading misleading press reports, were alarmed that they had been given potentially carcinogenic material despite reassurances at the time of treatment. Many of these concerns stemmed from a false perception of the risks of radiation, exacerbated by erroneous or conflicting statements in the media. Answers to these inquiries had to be based on scientific data. Travellers returning from overseas could be reassured by direct measurements of contamination. However, during the weeks after the accident, we were given no information, unless we asked for it, about fall-out locally, nationally, or abroad. Consequently, we monitored the levels of z1 in local bottled milk daily from May 6 to May 19, when the activity dropped below our detection limits.1 Although there was environmental contamination to a lesser degree from other radionuclides,2 the effective adult dose equivalent of just 10 pSv (1 mrem) calculated from these 1311 measurements supported our advice that there was no local cause for concern (typically, 0-7 kBq [19 nCi] of 13’I was ingested). Subsequent comparison of these measurements with others showed large variations in 131 concentrations in milk even within east Kent, due partly to rainfall variations, and this demonstrated the value of local measurements. 1-3
Drug Epidemiology Unit, Boston University School of Medicine, Brookline, Massachusetts 02146, USA
MICHA LEVY
SAMUEL SHAPIRO
GIVE A DRUG A BAD NAME: CINNARIZINE
SIR,-Dr Laporte and Dr Copella (Oct 11, p 853) suggest that cinnarizine is a "useless drug" and should be banned. There is, however, considerable evidence that cinnarizine does modify the effects of labyrinthine stimulation, though the mechanism of this action remains obscure. This activity was suggested, first in connection with studies of drugs against motion sickness,l and later in troopship and slow-rotation-room studies,2 Perry and 13 found the evidence of efficacy in man less convincing, but more recent studies by Stott et allusing cross-coupled stimuli, confirm its effect. Further, there is much anecdotal evidence from yachtsmen and others for the value of cinnarizine in motion sickness. In the UK cinnarizine is recommended for the treatment of disorders of labyrinthine function, not for chronic cerebrovascular disease, and it seems unfair to dismiss cinnarizine as "useless" on the basis of studies with incorrect indications and inappropriate doses and without due consideration to the drug’s time course of action. J. J. BRAND 1. DeWit G. Seasickness (motion sickness). Acta Otolaryngol 1953; suppl 108. 2. Wood DC, Graybiel A. Evaluation of sixteen antimotion sickness drugs under controlled laboratory conditions. NAMI Rep 1968, no 983. 3. Brand JJ, Perry WLM. Drugs used in motion sickness. Pharmacol Rev 1966; 18: 895-924. 4. Stott JRR, et al. In: Davis CJ, et al, eds. Nausea and vomiting: Mechanisms and treatment Berlin: Springer-Verlag, 1986: 126.
PREVALENCE OF UNDIAGNOSED SYPHILIS IN THE ELDERLY
SIR,-Serological tests for syphilis are widely used in the screening of patients with no history or findings of syphilis. What should a clinician do when faced with an unexpected positive test in an elderly patient being investigated for other medical problems? Between 1982 and 1985 Venereal Disease Research Laboratory (VDRL) Treponema pallidum haemagglutination assay (TPHA) and fluorescent treponemal antibody (FTA) tests were routinely done on 1820 new patients over the age of 55 attending the department of medicine and rehabilitation, Nether Edge Hospital, Sheffield. Some were outpatients and some inpatients, 1170 being women and 650 men. 46 patients (2-5%) were positive on one or more of the three tests. 4 were false positive (positive VDRL but negative TPHA and FTA). 10 patients, aged 60-85, had been treated for syphilis between 1920 and 1961; of these, 1 had neurosyphilis, 1 tabes dorsalis, 1 a luetic aortic arch aneurysm, 1 congenital syphilis, and 1 positive cerebrospinal fluid serology in 1946 but no manifest neurological complications. The remaining 32 patients, aged 57-93, had had undiagnosed syphilis as evidenced by a positive FTA. No patient in this group showed complications of spirochaetal disease either on examination or on chest X-ray. Degenerative changes in the lumbar spine and ligamentous calcification make lumbar puncture difficult in the elderly and only 2 had cerobrospinal fluid examined; CSF serology was negative in both.
Syphilis used to be a very common infection, its prevalence at necropsy being 5-10 % in the early 1900s; 39 % of untreated patients had anatomical lesions attributable to syphilis! and 15-40% of untreated patients had late tertiary complications. The probability of dying directly as a result of untreated syphilis used to be 17% in men and 8% in women after 40 years of infection.’ When dealing with the elderly with positive syphilitic serology it is often difficult to decide whether antibiotics, given for unrelated conditions, will have been sufficient to eradicate the treponemal disease. In a study of patients with undiagnosed syphilis only 7% had received curative doses of penicillin by the 20th year of the study.3 These results suggest that there remains a large group of patients with undiagnosed syphilis that will only be picked up by routine screening. Whether treatment alters the course of the disease is debatable but results suggest that, except in the very old or in patients with underlying fatal illnesses, undiagnosed syphilis should be treated using schedules recommended for syphilis of more than 1 year’s duration. Any treatment given should be carefully recorded. Department of Genito-urinary Medicine, Royal Hallamshire Hospital, Sheffield S10 2JF
P. D. WOOLLEY
Department of Medicine and Rehabilitation, Nether Edge Hospital, Sheffield
A.
J. ANDERSON
1. Rosahn PD. Autopsy studies in syphilis. J Ven Dis Inf 1947; suppl 21. 2. Gjestland T. The Oslo study of untreated syphilis: an epidemiologic investigation of the natural course of the syphilitic infection based upon a restudy of the Boeck-Bruusgaard material. Acta Dermatol Venereol 1955; suppl 35: 11. 3. Schuman SH. Untreated syphilis in the male negro: background and current status of patients in the Tuskegee study. J Chron Dis 1955; 2: 543.
CONSEQUENCES OF CHERNOBYL ACCIDENT FOR HEALTH SERVICES
SiR,—Your Sept 13 editorial states that the reactor accident at Chernobyl on April 26 required a local medical response on a scale which the UK and most other countries might find hard to match. Indeed, the events following that accident even showed up serious shortcomings in the response within the UK to an accident some 2000 km away. There are more than forty nuclear power stations within 500 km of south-east England, and since two major reactor accidents (Three Mile Island in the USA and Chernobyl in the USSR) have occurred within the past decade, the possibility of a similar accident cannot be ignored. Therefore the effects on health services produced by the accident at Chernobyl should be explored. The Chernobyl accident prompted many people to ask this hospital for advice-travellers returning from Eastern Europe asked to be monitored for radioactivity, school parties sought advice about travelling abroad, and local residents inquired about the consumption of milk and vegetables. Several outpatients who had received 1311 treatment for thyrotoxicosis expressed concern about the effect of additional 1311 ingestion on their thyroid function, or, after reading misleading press reports, were alarmed that they had been given potentially carcinogenic material despite reassurances at the time of treatment. Many of these concerns stemmed from a false perception of the risks of radiation, exacerbated by erroneous or conflicting statements in the media. Answers to these inquiries had to be based on scientific data. Travellers returning from overseas could be reassured by direct measurements of contamination. However, during the weeks after the accident, we were given no information, unless we asked for it, about fall-out locally, nationally, or abroad. Consequently, we monitored the levels of z1 in local bottled milk daily from May 6 to May 19, when the activity dropped below our detection limits.1 Although there was environmental contamination to a lesser degree from other radionuclides,2 the effective adult dose equivalent of just 10 pSv (1 mrem) calculated from these 1311 measurements supported our advice that there was no local cause for concern (typically, 0-7 kBq [19 nCi] of 13’I was ingested). Subsequent comparison of these measurements with others showed large variations in 131 concentrations in milk even within east Kent, due partly to rainfall variations, and this demonstrated the value of local measurements. 1-3