- Email: [email protected]
INDIRECT LIVER LYMPHOGRAPHY
281 of
an
infant with
a
large myelocoele after
slightly Campbell a
raised et awl.4 raised
had been recorded. amniotic-fluid terminated an apparently normal pregnancy after a A.F.P. had been observed, and this error was presumably due to fetal-blood contamination of the amniotic-fluid sample.5 It has been shown that the macrophage count in amniotic fluid is raised in cases of open c.N.s. lesions. 6,7 Although this test cannot be regarded as diagnostic because false-positive results may occur, no false-negative findings have been recorded. Since the macrophage count of an A.F.P.
amniotic fluid can be determined simply6 and is not affected by either fetal or maternal blood contamination, it should provide a useful adjunct to the antenatal diagnosis of open C.N.S. lesions. This will apply especially in cases where the amniotic fluid contains fetal blood and where A.F.P. levels are equivocal and/or at variance with ultrasonic
findings. Cytogenetics Unit, Department of Histopathology, Adelaide Children’s Hospital, North Adelaide, South Australia, 5006, Australia.
GRANT R. SUTHERLAND.
SIR,-Like
Dr Lrilman and his
obtained (and all of the patients on chemotherapy yielded the remaining 16 smear-positive culture-negative results) had other specimens from which tubercle bacilli were grown. A genuine false positive occurred in only 1 specimen, a liver biopsy which had been ground with sterile distilled water obtained from a supply of deionised water distributed through black plastic piping. Centrifuged specimens of this water were found to contain acid-fast bacilli. Deionised water systems are an unusual source of contamination, possibly relevant to the investigation of Weinstein et al. We conclude that direct-smear examination in our hands has been a remarkably specific test and that genuine false
colleagues (May 31,
positives "
false
positives resulting
to
be of great value in the
the low yield of Salmonella typhi from urine reported by Dr Gilman and his associates. The statement that excretion of typhoid bacilli in the urine is common in the late stage of typhoid fever belongs to the pre-antibiotic era, but has not been corrected even in the latest editions of textbooks of bacteriology and infectious diseases. It has been our experience during the past 20 years that urine cultures are rarely positive in adequately treated patients. This may change again in areas where antibiotic-resistant strains of S. typhi are common. In countries where sensitive strains are predominant, positive urine cultures may suggest the development of a focus in a damaged or obstructed kidney.
G. ALTMANN.
FALSE-POSITIVE ACID-FAST SMEARS SIR,-While the article by Dr Weinstein and his p. 173) reminds us of the value of prompt detective work in uncovering laboratory error, the impression is given that smear examination is often an unreliable procedure. Thus " false positives ", operationally defined by the authors as smear-positive, culture-negative specimens from patients not on chemotherapy, were said to occur in 0-1-5% of all specimens examined and in 3-55% of smear-positive specimens-the proportion in their own results being 4-1%. We have therefore examined our own data over the past two years. Out of a total of 7774 unselected specimens of all types examined by direct
colleagues (July 26,
smear
and culture for mycobacteria, 248 yielded a and, of these, 19 failed to grow on culture.
positive
Of the 19 smear-positive culture-negative specimens, only 3 were from patients not on chemotherapy, so that " false positives " were obtained from 0-04% of all specimens and 1-2% of smear-positive specimens-proportions lower than any quoted. Furthermore, the patients from whom 2 of the 3
smear
Kitau, M. J., Leighton, P., Gordon, Y. B., Chard, T. ibid. p. 1336. Sutherland, G. R., Brock, D. J. H., Scrimgeour, J. B. J. med. Genet. 1975, 12, 135. 7. Nelson, M. M., Orford, J., Ruttiman, M-T. S. Afr. med. J. 1975,
5. 6.
49, 72.
smears
laboratory
are
seen.
Department of Bacteriology, Royal Postgraduate Medical School, Du Cane Road, London W12 0HS.
RUTH S. MITCHISON B. W. ALLEN D. A. MITCHISON.
diagnosis of
typhoid fever, especially in children who received antibiotics before admission to hospital. I was interested in
Chaim Sheba Medical Center, Tel Hashomer, and Tel Aviv University, Tel Aviv, Israel.
from
error are exceedingly prepared directly from sputum specimens on new glass slides, stained with auramine, and examined by fluorescence microscopy, a very specific procedureavoiding some of the pitfalls which beset the conventional Ziehl-Neelsen stain. Smears (except those from cerebrospinal fluid) are only reported as positive if at least 3 acid-fast bacilli with convincing morphology have
Our
rare.
1211), the paediatricians of this hospital have found
bone-marrow culture
were
who
been
DIAGNOSIS OF TYPHOID FEVER p.
"
TERMINATION OF PREGNANCY SIR,-The H.C.S.A. will fight for the independence of the profession and will oppose any attempt to manipulate the practice of medicine for reasons of temporary political
expediency. The Association’s Council regards the directive2 issued by the Chief Medical Officer of the Department of Health to regional medical officers on Feb. 19, 1975, as such an attempt. It states that when certain consultant posts in obstetrics and gynaecology, anaathetics, and psychiatry fall vacant, applicants should be appointed only if they are personally prepared to advise on, undertake, or participate in the termination of pregnancy. The Council believes that this advice constitutes a potential threat to both professional and personal freedom. I was surprised and concerned to discover that the directive was sent out with the agreement of the Joint Consultants Committee.22 Parliament will determine when abortion is permissible, but it would surely be intolerable for participation in termination of pregnancy to be made compulsory for consultants. The Chief Medical Officer’s letter is the thin end of the wedge of compulsion and my Council has resolved to resist the directive with all the power at its disposal. Accordingly, our members will be advised to do all they can to prevent its implementation. Hospital Consultants and Specialists Association, The Old Court House, London Road, Ascot, Berkshire SL5 7EN.
N. A. SIMMONS, President.
INDIRECT LIVER LYMPHOGRAPHY
SiR,—A retrograde cannulation of the common bileduct a balloon-tipped catheter through a flexible duodenoscope, as described by Dr Shapiro and Dr Cotton (July 5, p. 13), may make possible indirect liver lymphography, displaying the hepatic lymph drainage. In the past, radiographic investigation of the lymph drainage of internal organs has not been possible, because indirect lymphography could not provide adequate pictures. Indirect liver lymphography under general anaesthesia was performed in 9 cholecystectomised dogs: through a
with
1. Bennedsen, J., Larsen, S. O. 2. Br. med. J. 1975, ii, 761.
Scand. J. resp. Dis. 1966, 47,
114.
282 detection of metastases from carcinoma of the liver, gallbladder, biliary tree, pancreas, stomach, and duodenum may be possible. However, at this time, hepatic damage cannot be completely excluded on the basis of this study. Department of Radiology, University of Rochester Medical Center, Rochester, New York 14642, U.S.A.
FRANCIS A. BURGENER STEPHEN I. SCHABEL.
Notes and News HOSPITAL COSTS FOR
1973/74
THE average N.H.S. hospital costs per inpatient week in England increased by about 20% compared with 1972/73; most of this increase was caused by pay increases and higher prices during the year.1 The costs per patient treated increased by about 16%, reflecting a continuing trend towards shorter stays in hospital. LANGUAGE COURSES FOR OVERSEAS DOCTORS
Anteroposterior view of canine abdomen liver lymphography. Dense hepatogram lymph-nodes.
one
and excellent view of
week after indirect
hepatic
and coeliac
modified Thomas cannula,l the common bileduct could be cannulated under direct vision with a Foley catheter. The balloon of the catheter was inflated to prevent leakage. After aspiration of the bile, the biliary system was filled to capacity with ethiodised oil (’ Lipiodol Ultra-Fluid’) and an additional 5-10 ml was infused slowly with a hydrostatic pressure slightly exceeding the biliary excretion pressure of 35 cm of water.2 A dense hepatogram and excellent and constant visualisation of the hepatic and coeliac lymph-nodes was obtained (see accompanying figure).
Splenic, pancreaticoduodenal, gastric, aortic, iliac, retrosternal, mediastinal, and supraclavicular lymph-nodes were displayed less frequently and they were usually incompletely filled. These results disagree with those of Mallet-Guy et a1.,3 who could only identify the hepatic lymph drainage radiographically by retrograde injection of barium sulphate but not ethiodised oil into the biliary system.4 The retrograde biliary injection of barium sulphate caused hepatic-cell necrosis.3 Judged by the estimation of iodine concentrations in the hepatic vein, no significant reflux of ethiodised oil occurred from the biliary system into the blood. No pulmonary complications have been observed by serial radiographs and lung scans. Bilirubin and S.G.O.T. levels increased from five to eight times above the average baseline value within two hours of the procedure, but returned to nearly normal the following day. A more delayed and less dramatic increase in S.G.P.T. and alkaline phosphatase occurred, reaching a peak at 24 hours after the procedure and returning to normal by one week. Periodic needle liver biopsies failed to show signs of hepatic inflammation or necrosis. Indirect liver lymphography offers a possible means of obtaining diagnostic information previously unavailable without laparotomy. By visualising lymph-nodes in the upper abdomen which are not accessible to direct lymphography, a more accurate staging of lymphoma, and earlier 1. Thomas, J. E. Proc. Soc. exp. Biol. Med. 1941, 46, 260. 2. Burgener, F. A., Fischer, H. W. Radiology, 1975, 116, 441. 3. Mallet-Guy, P., Michoulier, J., Kesner, L. F., Dolinski, J., Galindo, F., Leroy, J. Lyon Chir. 1964, 60, 816. 4. Mallet-Guy, P., Michoulier, J., Baev, S., Osleskiewicz, L., Woszczyk, M. ibid. 1962, 58, 847.
SPECIAL courses to help overseas doctors to communicate with their patients are being developed by English language specialists in the department of linguistics and modern English language at Lancaster University. The courses, which are based on a study of the language requirements of doctors in casualty departments, will be tried out by groups of 25 overseas doctors at 4 colleges of further education in the autumn. As a result of these pilot courses, the teaching materials and audiovisual aids (which have been designed with the help of a grant from the Nuffield Provincial Hospitals Trust) will be modified as necessary, and will then be made available for teaching on a national scale next year. The teaching materials are flexible enough to allow doctors to study at evening classes, while It is hoped that on day-release, or during short courses. the courses will be of benefit to those preparing for the General Medical Council tests in English language and clinical competence as well as to overseas doctors already employed in the National Health Service. Further details
on
the courses may be had from the Information
Officer, University of Lancaster, University House, Bailrigg, Lancaster.
University
of Liverpool
The status and title of professor of tropical have been conferred on Dr R. G. Hendrickse.
paediatrics
Dr Hendrickse, who is 48, graduated M.B. from the University of Cape Town in 1948 and M.D. in 1947; he became F.R.C.P. in 1973. After working at hospitals in Durban and Southern Rhodesia he was appointed lecturer in paediatrics at the University of Ibadan, Nigeria, becoming professor and head of the department in 1962 and director of the Institute of Child Health in Ibadan in 1964. In 1969 he moved to Liverpool, where he is at present senior lecturer in child health and tropical paediatrics, director of the course for the diploma in tropical child health, and consultant paediatrician to Alder Hey Children’s Hospital. His research has covered many aspects of tropical pasdiatrics, including sickle-cell ansemia, nutritional problems, the nephrotic syndrome, measles, tetanus, and malaria.
Royal College Prof. C.
of Obstetricians and
Gynaecologists
J. Dewhurst has been elected president.
Nuffield Foundation Mr John Maddox, formerly editor of Nature, has been appointed director in succession to Dr Clifford Butler. 1. Hospital
Costing Returns. H.M. Stationery Office. £1.70.
an
infant with
a
large myelocoele after
slightly Campbell a
raised et awl.4 raised
had been recorded. amniotic-fluid terminated an apparently normal pregnancy after a A.F.P. had been observed, and this error was presumably due to fetal-blood contamination of the amniotic-fluid sample.5 It has been shown that the macrophage count in amniotic fluid is raised in cases of open c.N.s. lesions. 6,7 Although this test cannot be regarded as diagnostic because false-positive results may occur, no false-negative findings have been recorded. Since the macrophage count of an A.F.P.
amniotic fluid can be determined simply6 and is not affected by either fetal or maternal blood contamination, it should provide a useful adjunct to the antenatal diagnosis of open C.N.S. lesions. This will apply especially in cases where the amniotic fluid contains fetal blood and where A.F.P. levels are equivocal and/or at variance with ultrasonic
findings. Cytogenetics Unit, Department of Histopathology, Adelaide Children’s Hospital, North Adelaide, South Australia, 5006, Australia.
GRANT R. SUTHERLAND.
SIR,-Like
Dr Lrilman and his
obtained (and all of the patients on chemotherapy yielded the remaining 16 smear-positive culture-negative results) had other specimens from which tubercle bacilli were grown. A genuine false positive occurred in only 1 specimen, a liver biopsy which had been ground with sterile distilled water obtained from a supply of deionised water distributed through black plastic piping. Centrifuged specimens of this water were found to contain acid-fast bacilli. Deionised water systems are an unusual source of contamination, possibly relevant to the investigation of Weinstein et al. We conclude that direct-smear examination in our hands has been a remarkably specific test and that genuine false
colleagues (May 31,
positives "
false
positives resulting
to
be of great value in the
the low yield of Salmonella typhi from urine reported by Dr Gilman and his associates. The statement that excretion of typhoid bacilli in the urine is common in the late stage of typhoid fever belongs to the pre-antibiotic era, but has not been corrected even in the latest editions of textbooks of bacteriology and infectious diseases. It has been our experience during the past 20 years that urine cultures are rarely positive in adequately treated patients. This may change again in areas where antibiotic-resistant strains of S. typhi are common. In countries where sensitive strains are predominant, positive urine cultures may suggest the development of a focus in a damaged or obstructed kidney.
G. ALTMANN.
FALSE-POSITIVE ACID-FAST SMEARS SIR,-While the article by Dr Weinstein and his p. 173) reminds us of the value of prompt detective work in uncovering laboratory error, the impression is given that smear examination is often an unreliable procedure. Thus " false positives ", operationally defined by the authors as smear-positive, culture-negative specimens from patients not on chemotherapy, were said to occur in 0-1-5% of all specimens examined and in 3-55% of smear-positive specimens-the proportion in their own results being 4-1%. We have therefore examined our own data over the past two years. Out of a total of 7774 unselected specimens of all types examined by direct
colleagues (July 26,
smear
and culture for mycobacteria, 248 yielded a and, of these, 19 failed to grow on culture.
positive
Of the 19 smear-positive culture-negative specimens, only 3 were from patients not on chemotherapy, so that " false positives " were obtained from 0-04% of all specimens and 1-2% of smear-positive specimens-proportions lower than any quoted. Furthermore, the patients from whom 2 of the 3
smear
Kitau, M. J., Leighton, P., Gordon, Y. B., Chard, T. ibid. p. 1336. Sutherland, G. R., Brock, D. J. H., Scrimgeour, J. B. J. med. Genet. 1975, 12, 135. 7. Nelson, M. M., Orford, J., Ruttiman, M-T. S. Afr. med. J. 1975,
5. 6.
49, 72.
smears
laboratory
are
seen.
Department of Bacteriology, Royal Postgraduate Medical School, Du Cane Road, London W12 0HS.
RUTH S. MITCHISON B. W. ALLEN D. A. MITCHISON.
diagnosis of
typhoid fever, especially in children who received antibiotics before admission to hospital. I was interested in
Chaim Sheba Medical Center, Tel Hashomer, and Tel Aviv University, Tel Aviv, Israel.
from
error are exceedingly prepared directly from sputum specimens on new glass slides, stained with auramine, and examined by fluorescence microscopy, a very specific procedureavoiding some of the pitfalls which beset the conventional Ziehl-Neelsen stain. Smears (except those from cerebrospinal fluid) are only reported as positive if at least 3 acid-fast bacilli with convincing morphology have
Our
rare.
1211), the paediatricians of this hospital have found
bone-marrow culture
were
who
been
DIAGNOSIS OF TYPHOID FEVER p.
"
TERMINATION OF PREGNANCY SIR,-The H.C.S.A. will fight for the independence of the profession and will oppose any attempt to manipulate the practice of medicine for reasons of temporary political
expediency. The Association’s Council regards the directive2 issued by the Chief Medical Officer of the Department of Health to regional medical officers on Feb. 19, 1975, as such an attempt. It states that when certain consultant posts in obstetrics and gynaecology, anaathetics, and psychiatry fall vacant, applicants should be appointed only if they are personally prepared to advise on, undertake, or participate in the termination of pregnancy. The Council believes that this advice constitutes a potential threat to both professional and personal freedom. I was surprised and concerned to discover that the directive was sent out with the agreement of the Joint Consultants Committee.22 Parliament will determine when abortion is permissible, but it would surely be intolerable for participation in termination of pregnancy to be made compulsory for consultants. The Chief Medical Officer’s letter is the thin end of the wedge of compulsion and my Council has resolved to resist the directive with all the power at its disposal. Accordingly, our members will be advised to do all they can to prevent its implementation. Hospital Consultants and Specialists Association, The Old Court House, London Road, Ascot, Berkshire SL5 7EN.
N. A. SIMMONS, President.
INDIRECT LIVER LYMPHOGRAPHY
SiR,—A retrograde cannulation of the common bileduct a balloon-tipped catheter through a flexible duodenoscope, as described by Dr Shapiro and Dr Cotton (July 5, p. 13), may make possible indirect liver lymphography, displaying the hepatic lymph drainage. In the past, radiographic investigation of the lymph drainage of internal organs has not been possible, because indirect lymphography could not provide adequate pictures. Indirect liver lymphography under general anaesthesia was performed in 9 cholecystectomised dogs: through a
with
1. Bennedsen, J., Larsen, S. O. 2. Br. med. J. 1975, ii, 761.
Scand. J. resp. Dis. 1966, 47,
114.
282 detection of metastases from carcinoma of the liver, gallbladder, biliary tree, pancreas, stomach, and duodenum may be possible. However, at this time, hepatic damage cannot be completely excluded on the basis of this study. Department of Radiology, University of Rochester Medical Center, Rochester, New York 14642, U.S.A.
FRANCIS A. BURGENER STEPHEN I. SCHABEL.
Notes and News HOSPITAL COSTS FOR
1973/74
THE average N.H.S. hospital costs per inpatient week in England increased by about 20% compared with 1972/73; most of this increase was caused by pay increases and higher prices during the year.1 The costs per patient treated increased by about 16%, reflecting a continuing trend towards shorter stays in hospital. LANGUAGE COURSES FOR OVERSEAS DOCTORS
Anteroposterior view of canine abdomen liver lymphography. Dense hepatogram lymph-nodes.
one
and excellent view of
week after indirect
hepatic
and coeliac
modified Thomas cannula,l the common bileduct could be cannulated under direct vision with a Foley catheter. The balloon of the catheter was inflated to prevent leakage. After aspiration of the bile, the biliary system was filled to capacity with ethiodised oil (’ Lipiodol Ultra-Fluid’) and an additional 5-10 ml was infused slowly with a hydrostatic pressure slightly exceeding the biliary excretion pressure of 35 cm of water.2 A dense hepatogram and excellent and constant visualisation of the hepatic and coeliac lymph-nodes was obtained (see accompanying figure).
Splenic, pancreaticoduodenal, gastric, aortic, iliac, retrosternal, mediastinal, and supraclavicular lymph-nodes were displayed less frequently and they were usually incompletely filled. These results disagree with those of Mallet-Guy et a1.,3 who could only identify the hepatic lymph drainage radiographically by retrograde injection of barium sulphate but not ethiodised oil into the biliary system.4 The retrograde biliary injection of barium sulphate caused hepatic-cell necrosis.3 Judged by the estimation of iodine concentrations in the hepatic vein, no significant reflux of ethiodised oil occurred from the biliary system into the blood. No pulmonary complications have been observed by serial radiographs and lung scans. Bilirubin and S.G.O.T. levels increased from five to eight times above the average baseline value within two hours of the procedure, but returned to nearly normal the following day. A more delayed and less dramatic increase in S.G.P.T. and alkaline phosphatase occurred, reaching a peak at 24 hours after the procedure and returning to normal by one week. Periodic needle liver biopsies failed to show signs of hepatic inflammation or necrosis. Indirect liver lymphography offers a possible means of obtaining diagnostic information previously unavailable without laparotomy. By visualising lymph-nodes in the upper abdomen which are not accessible to direct lymphography, a more accurate staging of lymphoma, and earlier 1. Thomas, J. E. Proc. Soc. exp. Biol. Med. 1941, 46, 260. 2. Burgener, F. A., Fischer, H. W. Radiology, 1975, 116, 441. 3. Mallet-Guy, P., Michoulier, J., Kesner, L. F., Dolinski, J., Galindo, F., Leroy, J. Lyon Chir. 1964, 60, 816. 4. Mallet-Guy, P., Michoulier, J., Baev, S., Osleskiewicz, L., Woszczyk, M. ibid. 1962, 58, 847.
SPECIAL courses to help overseas doctors to communicate with their patients are being developed by English language specialists in the department of linguistics and modern English language at Lancaster University. The courses, which are based on a study of the language requirements of doctors in casualty departments, will be tried out by groups of 25 overseas doctors at 4 colleges of further education in the autumn. As a result of these pilot courses, the teaching materials and audiovisual aids (which have been designed with the help of a grant from the Nuffield Provincial Hospitals Trust) will be modified as necessary, and will then be made available for teaching on a national scale next year. The teaching materials are flexible enough to allow doctors to study at evening classes, while It is hoped that on day-release, or during short courses. the courses will be of benefit to those preparing for the General Medical Council tests in English language and clinical competence as well as to overseas doctors already employed in the National Health Service. Further details
on
the courses may be had from the Information
Officer, University of Lancaster, University House, Bailrigg, Lancaster.
University
of Liverpool
The status and title of professor of tropical have been conferred on Dr R. G. Hendrickse.
paediatrics
Dr Hendrickse, who is 48, graduated M.B. from the University of Cape Town in 1948 and M.D. in 1947; he became F.R.C.P. in 1973. After working at hospitals in Durban and Southern Rhodesia he was appointed lecturer in paediatrics at the University of Ibadan, Nigeria, becoming professor and head of the department in 1962 and director of the Institute of Child Health in Ibadan in 1964. In 1969 he moved to Liverpool, where he is at present senior lecturer in child health and tropical paediatrics, director of the course for the diploma in tropical child health, and consultant paediatrician to Alder Hey Children’s Hospital. His research has covered many aspects of tropical pasdiatrics, including sickle-cell ansemia, nutritional problems, the nephrotic syndrome, measles, tetanus, and malaria.
Royal College Prof. C.
of Obstetricians and
Gynaecologists
J. Dewhurst has been elected president.
Nuffield Foundation Mr John Maddox, formerly editor of Nature, has been appointed director in succession to Dr Clifford Butler. 1. Hospital
Costing Returns. H.M. Stationery Office. £1.70.