- Email: [email protected]
MANAGEMENT OF HEATSTROKE
1225
Among the 341 patients who completed the full observation period, 206 (60-4%) had healed ulcers after the first dose and 122 (35 -8%) were cured after the second dose ofthiamphenicol. Only 13 (3 - 8%) did not respond. No side-effects were observed. In developing countries single-dose treatments should be preferred, whenever possible, to long courses of therapy on grounds of both feasibility and cost. Our experience suggests that thiamphenicol may be an effective alternative to the drugs mentioned in your Oct. 2 editorial, especially when patient compliance is uncertain.
"LEPROMATOUS" AND "TUBERCULOID" RHEUMATOID ARTHRITIS
SIR,-Both you (Oct. 2, p. 748) and Panayil attempt to differentiate a systemic "lepromatous" form of rheumatoid arthritis (extra-articular disease, little synovitis, predominant humoral immunity) from "tuberculoid" rheumatoid arthritis (seronegative, synovitis, predominance of cell-mediated immunity). The seropositive "lepromatous" disease is said to have a worse prognosis than the seronegative "tuberculoid" form. However, before this original approach can be considered, one should reassess the concept that seronegative rheumatoid arthritis is merely a benign form of the seropositive disease. An alternative explanation for the differences in these two types of arthropathy is that the two disorders are distinct diseases rather than different ends of the same spectrum. Several lines of evidence suggest that seronegative "rheumatoid arthritis" is not rheumatoid disease. HLA-DR4 is increased only in patients with the seropositive process;2,3 there is a genetic predisposition only for seropositive disease;4,5 and the6 prognosis and natural history are different for the two diseases. Moreover, in a controlled blind study7 we have shown that the nature of the radiological destruction in so-called seronegative "RA" can be differentiated from that seen in seropositive RA. Taken together, these data argue against the seronegative and seropositive disorders being analogous to lepromatous and tuberculoid leprosy. Rather, seronegative "rheumatoid arthritis" is not rheumatoid disease. Department of Medicine, Stanford University Medical Center,
City Health Department and Department of Medicine, University of Zimbabwe, Harare, Zimbabwe Institute of Infectious Diseases,
University of Milan, Ospedale Sacco, 20157 Milan, Italy
SINGLE-DOSE THIAMPHENICOL FOR CHANCROID
SiR,-Your Oct. 2 editorial on chancroid prompts us to report our
experience with single-dose antibiotic therapy. The study was done in Zimbabwe, where a very high incidence of chancroid is one of the legacies of the recent civil strife. Between July and December, 1981, 1204 patients (946 males and 258 females) attended the clinics for sexually transmitted diseases at Mbare, Banks Street, and Wilkins Hospitals in Harare. Chancroid was diagnosed in 374 men (39’ 5%) and in 38 women (34’ 2%). As in most developing countries, isolation techniques are not available in Zimbabwe, and the diagnosis was made by direct microscopy on stained
smears
of ulcer exudates after exclusion of other venereal
diseases, such as syphilis. Previous experience in Zimbabwe with co-trimoxazole, streptomycin, and sulphonamides had been disappointing; many patients defaulted during the two-week course. A single-dose regimen with thiamphenicol (an analogue of chloramphenicol reported to be less toxic) was chosen. All patients were given 2’5g of the drug by mouth under supervision of the hospital staff, and were asked to report back one and two weeks later. If, after a week, the lesions were subsiding and painless, no other treatment was instituted, but patients were invited to attend one week later. If the ulcers remained tender, the patient was given a second dose of thiamphenicol (1-55 g). All patients who, at the third visit, were showing clear signs of improvement and had negative microscopy, were considered to have been cured. Patients in whom treatment was judged ineffective were given co-trimoxazole (trimethoprim 160 mg+sulphamethoxazole 800 mg, three times daily for ten days). 1. Panayi GS. Viewpoint. Ann Rheum Dis 1982; 41: 2. Dobloug JG, Forre O, Kass E, Thorsby E.
102-03.
HLA
antigens
and rheumatoid
arthritis—association between HLA-DRw4 positivity and IgM rheumatoid factor production Arthritis Rheum 1980; 23: 309-13. 3. Stastny P. Joint report: Rheumatoid arthritis. In: Terasaki PI, ed. Histocompatibility testing laboratory. 1980: 681-86. 4. Lawrence JS. Rheumatoid arthritis-nature or nurture? Ann Rheum Dis 1970; 29: 357-79. 5. Bland
JH, Brown EW. Seronegative and seropositive rheumatoid arthritis: Clinical, radiological and biochemical differences. Ann Intern Med 1964; 60: 88-94. 6. Feigenbaum SL, Masi AT, Kaplan SB. Prognosis in rheumatoid arthritis. Am J Med 1979; 66: 377-84. 7 Burns T, Calin A. The hand radiograph as a diagnostic discriminant between seronegative and seropositive "rheumatoid arthritis (RA)": a controlled study. Arthritis Rheum 1982; 25: S124.
ROSSANA LENCIONI PAOLO CROCCHIOLO ROBERTO ESPOSITO
MANAGEMENT OF HEATSTROKE
ANDREI CALIN THOMAS M. BURNS
Stanford, California 94305, U.S.A.
AHMED S. LATIF
’
SIR,-Your Oct. 23 editorial reflects the fact that an ideal, standard management of heatstroke is still not agreed. During the past four years we have been associated with the manangement of heatstroke patients during the Mecca pilgrimages (Hajj). Using the body cooling unit designed by Weiner and Khogali1 we achieved significant success. The cooling rate was very efficient: a drop of03 ° C every 5 min2 is a high physiological cooling rate since these patients have very high oxygen uptakes which greatly increase the heat generated by metabolism. Management of heatstroke under the conditions prevailing in the pilgrimages is beset with many problems, including metabolic acidosis, hypokalaemia, hypoxia, bleeding diathesis, and aspiration pneumonia. Metabolic - acidosis, with or without respiratory compensation, is a frequent presenting disorder, which has led us to administer 4’2% sodium bicarbonate (250 ml) to most patients. Analysis of acid-base balance data of cases seen at Mina Hospital during 19813 showed that 27% presented with metabolic acidosis alone while 33% had metabolic acidosis with respiratory compensation. Respiratory acidosis with (3%) or without (3%) metabolic compensation was also seen. Because ofhypovolaemia, dehydration, and acidosis most patients had normal or high serum potassium on admission. Once cooling was achieved and hypovolaemia and acidosis had been corrected there was a shift into hypokalaemia, which was sometimes very severe. Regular monitoring of electrolytes, especially potassium, is very important. In our experience the most serious early complication is bleeding, especially epistaxis. Sometimes intubation, which is lifesaving, may be hazardous in that it may cause bleeding. Our experience with dextran differs from your view that it should be avoided. During this year’s pilgrimage we introduced low-molecular-weight dextran 500 ml as part of the fluid regimen that is given to patients during the first 3 h. Dextran is a volume expander which improves renal flow and may help prevent sludging of platelets. We recommend giving enough fluids at first to correct the hypovolaemia, but monitoring of urine is essential before large volumes of fluid are given. A major cause of death has been aspiration pneumonia. Our patients used to lie supine on the body cooling unit so as to expose the maximum area to the evaporative process. This year we adopted the semilateral position which ensured free airway and clear outlet for vomitus. It did not affect the cooling rate but was definitely lifesaving and reduced the incidence of aspiration pneumonia. Departments of Community Medicine, Physiology and Biochemistry, Faculty of Medicine, Kuwait University, P.O. Box 24923, Safat, Kuwait
M. KHOGALI M. K. E. MUSTAFA K. GUMAA
1. Khogali M, Weiner JS. Heat stroke: Report on 18 cases. Lancet 1980; ii: 276-78. 2. Alkhawashki M, Khogali M, El Ergesus A, Titchiner J. The biomedical principles of a body cooling unit for treatment of heat stroke. Biomed Eng (in press). 3. Khogali M. Heat disorders with special reference to Makkah Pilgrimage (Hajj): Ministry of Health, Kingdom of Saudi Arabia, 1982.
Among the 341 patients who completed the full observation period, 206 (60-4%) had healed ulcers after the first dose and 122 (35 -8%) were cured after the second dose ofthiamphenicol. Only 13 (3 - 8%) did not respond. No side-effects were observed. In developing countries single-dose treatments should be preferred, whenever possible, to long courses of therapy on grounds of both feasibility and cost. Our experience suggests that thiamphenicol may be an effective alternative to the drugs mentioned in your Oct. 2 editorial, especially when patient compliance is uncertain.
"LEPROMATOUS" AND "TUBERCULOID" RHEUMATOID ARTHRITIS
SIR,-Both you (Oct. 2, p. 748) and Panayil attempt to differentiate a systemic "lepromatous" form of rheumatoid arthritis (extra-articular disease, little synovitis, predominant humoral immunity) from "tuberculoid" rheumatoid arthritis (seronegative, synovitis, predominance of cell-mediated immunity). The seropositive "lepromatous" disease is said to have a worse prognosis than the seronegative "tuberculoid" form. However, before this original approach can be considered, one should reassess the concept that seronegative rheumatoid arthritis is merely a benign form of the seropositive disease. An alternative explanation for the differences in these two types of arthropathy is that the two disorders are distinct diseases rather than different ends of the same spectrum. Several lines of evidence suggest that seronegative "rheumatoid arthritis" is not rheumatoid disease. HLA-DR4 is increased only in patients with the seropositive process;2,3 there is a genetic predisposition only for seropositive disease;4,5 and the6 prognosis and natural history are different for the two diseases. Moreover, in a controlled blind study7 we have shown that the nature of the radiological destruction in so-called seronegative "RA" can be differentiated from that seen in seropositive RA. Taken together, these data argue against the seronegative and seropositive disorders being analogous to lepromatous and tuberculoid leprosy. Rather, seronegative "rheumatoid arthritis" is not rheumatoid disease. Department of Medicine, Stanford University Medical Center,
City Health Department and Department of Medicine, University of Zimbabwe, Harare, Zimbabwe Institute of Infectious Diseases,
University of Milan, Ospedale Sacco, 20157 Milan, Italy
SINGLE-DOSE THIAMPHENICOL FOR CHANCROID
SiR,-Your Oct. 2 editorial on chancroid prompts us to report our
experience with single-dose antibiotic therapy. The study was done in Zimbabwe, where a very high incidence of chancroid is one of the legacies of the recent civil strife. Between July and December, 1981, 1204 patients (946 males and 258 females) attended the clinics for sexually transmitted diseases at Mbare, Banks Street, and Wilkins Hospitals in Harare. Chancroid was diagnosed in 374 men (39’ 5%) and in 38 women (34’ 2%). As in most developing countries, isolation techniques are not available in Zimbabwe, and the diagnosis was made by direct microscopy on stained
smears
of ulcer exudates after exclusion of other venereal
diseases, such as syphilis. Previous experience in Zimbabwe with co-trimoxazole, streptomycin, and sulphonamides had been disappointing; many patients defaulted during the two-week course. A single-dose regimen with thiamphenicol (an analogue of chloramphenicol reported to be less toxic) was chosen. All patients were given 2’5g of the drug by mouth under supervision of the hospital staff, and were asked to report back one and two weeks later. If, after a week, the lesions were subsiding and painless, no other treatment was instituted, but patients were invited to attend one week later. If the ulcers remained tender, the patient was given a second dose of thiamphenicol (1-55 g). All patients who, at the third visit, were showing clear signs of improvement and had negative microscopy, were considered to have been cured. Patients in whom treatment was judged ineffective were given co-trimoxazole (trimethoprim 160 mg+sulphamethoxazole 800 mg, three times daily for ten days). 1. Panayi GS. Viewpoint. Ann Rheum Dis 1982; 41: 2. Dobloug JG, Forre O, Kass E, Thorsby E.
102-03.
HLA
antigens
and rheumatoid
arthritis—association between HLA-DRw4 positivity and IgM rheumatoid factor production Arthritis Rheum 1980; 23: 309-13. 3. Stastny P. Joint report: Rheumatoid arthritis. In: Terasaki PI, ed. Histocompatibility testing laboratory. 1980: 681-86. 4. Lawrence JS. Rheumatoid arthritis-nature or nurture? Ann Rheum Dis 1970; 29: 357-79. 5. Bland
JH, Brown EW. Seronegative and seropositive rheumatoid arthritis: Clinical, radiological and biochemical differences. Ann Intern Med 1964; 60: 88-94. 6. Feigenbaum SL, Masi AT, Kaplan SB. Prognosis in rheumatoid arthritis. Am J Med 1979; 66: 377-84. 7 Burns T, Calin A. The hand radiograph as a diagnostic discriminant between seronegative and seropositive "rheumatoid arthritis (RA)": a controlled study. Arthritis Rheum 1982; 25: S124.
ROSSANA LENCIONI PAOLO CROCCHIOLO ROBERTO ESPOSITO
MANAGEMENT OF HEATSTROKE
ANDREI CALIN THOMAS M. BURNS
Stanford, California 94305, U.S.A.
AHMED S. LATIF
’
SIR,-Your Oct. 23 editorial reflects the fact that an ideal, standard management of heatstroke is still not agreed. During the past four years we have been associated with the manangement of heatstroke patients during the Mecca pilgrimages (Hajj). Using the body cooling unit designed by Weiner and Khogali1 we achieved significant success. The cooling rate was very efficient: a drop of03 ° C every 5 min2 is a high physiological cooling rate since these patients have very high oxygen uptakes which greatly increase the heat generated by metabolism. Management of heatstroke under the conditions prevailing in the pilgrimages is beset with many problems, including metabolic acidosis, hypokalaemia, hypoxia, bleeding diathesis, and aspiration pneumonia. Metabolic - acidosis, with or without respiratory compensation, is a frequent presenting disorder, which has led us to administer 4’2% sodium bicarbonate (250 ml) to most patients. Analysis of acid-base balance data of cases seen at Mina Hospital during 19813 showed that 27% presented with metabolic acidosis alone while 33% had metabolic acidosis with respiratory compensation. Respiratory acidosis with (3%) or without (3%) metabolic compensation was also seen. Because ofhypovolaemia, dehydration, and acidosis most patients had normal or high serum potassium on admission. Once cooling was achieved and hypovolaemia and acidosis had been corrected there was a shift into hypokalaemia, which was sometimes very severe. Regular monitoring of electrolytes, especially potassium, is very important. In our experience the most serious early complication is bleeding, especially epistaxis. Sometimes intubation, which is lifesaving, may be hazardous in that it may cause bleeding. Our experience with dextran differs from your view that it should be avoided. During this year’s pilgrimage we introduced low-molecular-weight dextran 500 ml as part of the fluid regimen that is given to patients during the first 3 h. Dextran is a volume expander which improves renal flow and may help prevent sludging of platelets. We recommend giving enough fluids at first to correct the hypovolaemia, but monitoring of urine is essential before large volumes of fluid are given. A major cause of death has been aspiration pneumonia. Our patients used to lie supine on the body cooling unit so as to expose the maximum area to the evaporative process. This year we adopted the semilateral position which ensured free airway and clear outlet for vomitus. It did not affect the cooling rate but was definitely lifesaving and reduced the incidence of aspiration pneumonia. Departments of Community Medicine, Physiology and Biochemistry, Faculty of Medicine, Kuwait University, P.O. Box 24923, Safat, Kuwait
M. KHOGALI M. K. E. MUSTAFA K. GUMAA
1. Khogali M, Weiner JS. Heat stroke: Report on 18 cases. Lancet 1980; ii: 276-78. 2. Alkhawashki M, Khogali M, El Ergesus A, Titchiner J. The biomedical principles of a body cooling unit for treatment of heat stroke. Biomed Eng (in press). 3. Khogali M. Heat disorders with special reference to Makkah Pilgrimage (Hajj): Ministry of Health, Kingdom of Saudi Arabia, 1982.