- Email: [email protected]
NO ASSOCIATION BETWEEN LITHIUM THERAPY AND LEUKAEMIA
940 attended the general hospital in the decade 1971-80 and who had received a diagnosis of leukaemia (ICD 204-7) yielded 187 panels aged 18 and over. The Chichester psychiatric index showed that 13 (7°70) of these patients has been seen by the local psychiatric services. Their psychiatric records showed that none had been treated with lithium. The characteristics of the population and the health services in the area make it almost certain that all patients receiving lithium treatment would have been known to the specialist services. Although not conclusive, 4 our findings are reassuring and accord with an American survey. Department of Mental Health, School of Medicine, University College London, London WC1E 6AS St James’
Hospital, Portsmouth
GEORGE RESEK STEFANO OLIVIERI
BACTERIA IN TOTAL PARENTERAL NUTRITION CATHETERS
Aortic
compliance in patients with ruptured intracranial aneurysm.
In a single-blind pilot study we measured aortic compliance in ten patients, with known type ill collagen levels. Six had aortic compliances more than 2SD above the normal population mean (figure) and eight had clinical changes and family histories compatible with generalised connective tissue abnormalities. Six of those eight were type iii collagen deficient and four of them had increased aortic compliance, although two of the type-m-deficient patients had normal compliances. Of the two positive patients with normal type ui levels (figure), one was at the lower limit of normal.
The other
was over
hypertension
both
60 years old and hypertensive, and age and interfere with accurate compliance
measurements.
We believe that this simple and harmless test may be very important in the assessment of patients with subarachnoid haemorrhage and would be of great value as a screen for type in collagen deficiency amongst their apparently normal relatives. This should allow an accurate survey of the genetics of type m deficiency as a cause of subarachnoid haemorrhage. Neurosurgical Unit, Brook General Hospital, London SE18 4LW
Non-invasive Angiology Group, Guy’s Hospital, London SE1
G. NEIL-DWYER A. H. CHILD D. E. DORRANCE
Dermatology Research Group, Northwick Park
Hospital, Neurosurgical Unit, Brook General Hospital
Harrow
F. M. POPE
J. BARTLETT
NO ASSOCIATION BETWEEN LITHIUM THERAPY AND LEUKAEMIA
SIR,-Long-term treatment with lithium salts is frequently associated with leucocytosis, which disappears when the drug is discontinued-indeed lithium has been tried for granulocytopenic syndromes such as lymphoma, Felty’s syndrome, and neutropenia and thrombocytopenia associated with chemotherapy. Even though lithium has been safely and widely used in psychiatry for some thirty years, anecdotal reports have led to warnings about a possible link with leukaemia. 2,3 To test this possibility epidemiologically we did a study, while working at the MRC Clinical Psychiatry Unit and Graylingwell Hospital, respectively, in the Chichester district (population 173 000). A computer search for patients who had 1. Tisman G, Wu S-J G, In: Johnson FN, ed. Handbook of lithium therapy. Lancaster: MTP Press. 1980: 338-40. 2. Orr LE, McKernan JF Lithium reinduction of acute myeloid leukaemia during lithium treatment. Lancet 1979, i: 449-50 3. Nielsen JL. Development of acute myeloid leukemia during lithium treatment. Acta
Haematol 1980; 63: 172-73.
SIR,-Dr Sitges-Serra and colleagues (March 5, p 531) wonder if the incidence of sepsis in our study may have been falsely low because of a lack of blood cultures. We have done two prospective studies covering over 150 courses of total parenteral nutrition (TPN).5,6 Although in the methods of both papers we stated that blood cultures were obtained at the discretion of the physician, in fact every patient with fever has blood cultures done. In addition, in 130 of the 150 patients we drew blood for culture twice or three times weekly through the TPN line while the line was in place.We have since felt that this was not a specific or sensitive method for determining which lines might become infected. The sepsis rate in both studies was 507o and is clearly comparable with rates elsewhere.7,8There is noB reason to believe that positive semiquantitative cultures of the intravascular segment from vascular cannulae, such as TPN cannulae, would always be associated with positive blood cultures as Sitges-Serra implies. In our studies and in Maki’s9,1O many cannulae were heavily colonised without the presence of bacteraemia or fungaemia. We have confirmed Maki’s demonstration of an association between positive semiquantitative cultures of the cannula and inflammation at the skin vascular interface. The issue of the microorganism growth at the catheter insertion site and the ultimate colonisation of the catheter in patients receiving TPN was also questioned by Sitges-Serra et al. We and others, using independent methods, have demonstrated very similar findings." Bjornson and colleagues" showed that there is an association between the presence of more than 1000 bacterial or fungal colony forming units at the insertion site and colonisation of catheters. These findings independently confirmed our own study despite slightly different methods. I believe that is ample evidence that bacterial colonisation of the skin vascular interface at the cannula insertion site in TPN patients may serve as a predictor for those patients who will have cannula associated infections. Sitges-Serra correctly points out that we did not speciate the Staphylococcus epidermidis. However, we did test antibiotic sensitivity of the isolates to ensure that skin and cannula isolates were the same. We did not culture the catheter hub. If, as SitgesSerra implies, the hub becomes colonised first, iris possible that the 4.
Lyskowski J, Nasrallah HA. Lithium therapy and the risk for leukaemia Br J Psychiatry 1981, 139: 256. 5. Snydman DR, Gorbea HF, Pober BR, et al. Predictive value of surveillance skin cultures in total-parenteral-nutrition-related infection. Lancet 1982, ii: 1385-88. 6. Snydman DR, Murray SA, Kornfeld DJ, et al. Total parenteral nutrition-related infections prospective epidemiologic study using semiquantitative methods Am J Med 1982; 73: 695-99. 7. Sanders
RA, Sheldon GF. Septic complications oftotal parenteral nutrition a five year
experience Am J Surg 1976; 132: 214-19 8. Ryan JA, Abel RM, Abbott WM, et al. Catheter complications in total parenteral nutrition: a prospective study of 200 consecutive patients. N Engl J Med 1974: 290: 757-61. 9. Maki DG, Weise CE, Sarafin HW A semiquantitative culture method for identifying intravenous-catheter-related infection. N EnglJ Med 1977; 296: 1305-09 10. Makr DG, Jarrett F, Sarafin HW A semiquantitative culture method for identification of catheter-related infection in the burn patient. J Surg Res 1977, 22: 513-20 11 Bjornson HS, Colley R, Bower RH, et al. Association between microogranism growth at the catheter insertion site and colonisation of the catheter in patients receiving total parenteral nutrition Surgery 1982, 92: 720-25
Hospital, Portsmouth
GEORGE RESEK STEFANO OLIVIERI
BACTERIA IN TOTAL PARENTERAL NUTRITION CATHETERS
Aortic
compliance in patients with ruptured intracranial aneurysm.
In a single-blind pilot study we measured aortic compliance in ten patients, with known type ill collagen levels. Six had aortic compliances more than 2SD above the normal population mean (figure) and eight had clinical changes and family histories compatible with generalised connective tissue abnormalities. Six of those eight were type iii collagen deficient and four of them had increased aortic compliance, although two of the type-m-deficient patients had normal compliances. Of the two positive patients with normal type ui levels (figure), one was at the lower limit of normal.
The other
was over
hypertension
both
60 years old and hypertensive, and age and interfere with accurate compliance
measurements.
We believe that this simple and harmless test may be very important in the assessment of patients with subarachnoid haemorrhage and would be of great value as a screen for type in collagen deficiency amongst their apparently normal relatives. This should allow an accurate survey of the genetics of type m deficiency as a cause of subarachnoid haemorrhage. Neurosurgical Unit, Brook General Hospital, London SE18 4LW
Non-invasive Angiology Group, Guy’s Hospital, London SE1
G. NEIL-DWYER A. H. CHILD D. E. DORRANCE
Dermatology Research Group, Northwick Park
Hospital, Neurosurgical Unit, Brook General Hospital
Harrow
F. M. POPE
J. BARTLETT
NO ASSOCIATION BETWEEN LITHIUM THERAPY AND LEUKAEMIA
SIR,-Long-term treatment with lithium salts is frequently associated with leucocytosis, which disappears when the drug is discontinued-indeed lithium has been tried for granulocytopenic syndromes such as lymphoma, Felty’s syndrome, and neutropenia and thrombocytopenia associated with chemotherapy. Even though lithium has been safely and widely used in psychiatry for some thirty years, anecdotal reports have led to warnings about a possible link with leukaemia. 2,3 To test this possibility epidemiologically we did a study, while working at the MRC Clinical Psychiatry Unit and Graylingwell Hospital, respectively, in the Chichester district (population 173 000). A computer search for patients who had 1. Tisman G, Wu S-J G, In: Johnson FN, ed. Handbook of lithium therapy. Lancaster: MTP Press. 1980: 338-40. 2. Orr LE, McKernan JF Lithium reinduction of acute myeloid leukaemia during lithium treatment. Lancet 1979, i: 449-50 3. Nielsen JL. Development of acute myeloid leukemia during lithium treatment. Acta
Haematol 1980; 63: 172-73.
SIR,-Dr Sitges-Serra and colleagues (March 5, p 531) wonder if the incidence of sepsis in our study may have been falsely low because of a lack of blood cultures. We have done two prospective studies covering over 150 courses of total parenteral nutrition (TPN).5,6 Although in the methods of both papers we stated that blood cultures were obtained at the discretion of the physician, in fact every patient with fever has blood cultures done. In addition, in 130 of the 150 patients we drew blood for culture twice or three times weekly through the TPN line while the line was in place.We have since felt that this was not a specific or sensitive method for determining which lines might become infected. The sepsis rate in both studies was 507o and is clearly comparable with rates elsewhere.7,8There is noB reason to believe that positive semiquantitative cultures of the intravascular segment from vascular cannulae, such as TPN cannulae, would always be associated with positive blood cultures as Sitges-Serra implies. In our studies and in Maki’s9,1O many cannulae were heavily colonised without the presence of bacteraemia or fungaemia. We have confirmed Maki’s demonstration of an association between positive semiquantitative cultures of the cannula and inflammation at the skin vascular interface. The issue of the microorganism growth at the catheter insertion site and the ultimate colonisation of the catheter in patients receiving TPN was also questioned by Sitges-Serra et al. We and others, using independent methods, have demonstrated very similar findings." Bjornson and colleagues" showed that there is an association between the presence of more than 1000 bacterial or fungal colony forming units at the insertion site and colonisation of catheters. These findings independently confirmed our own study despite slightly different methods. I believe that is ample evidence that bacterial colonisation of the skin vascular interface at the cannula insertion site in TPN patients may serve as a predictor for those patients who will have cannula associated infections. Sitges-Serra correctly points out that we did not speciate the Staphylococcus epidermidis. However, we did test antibiotic sensitivity of the isolates to ensure that skin and cannula isolates were the same. We did not culture the catheter hub. If, as SitgesSerra implies, the hub becomes colonised first, iris possible that the 4.
Lyskowski J, Nasrallah HA. Lithium therapy and the risk for leukaemia Br J Psychiatry 1981, 139: 256. 5. Snydman DR, Gorbea HF, Pober BR, et al. Predictive value of surveillance skin cultures in total-parenteral-nutrition-related infection. Lancet 1982, ii: 1385-88. 6. Snydman DR, Murray SA, Kornfeld DJ, et al. Total parenteral nutrition-related infections prospective epidemiologic study using semiquantitative methods Am J Med 1982; 73: 695-99. 7. Sanders
RA, Sheldon GF. Septic complications oftotal parenteral nutrition a five year
experience Am J Surg 1976; 132: 214-19 8. Ryan JA, Abel RM, Abbott WM, et al. Catheter complications in total parenteral nutrition: a prospective study of 200 consecutive patients. N Engl J Med 1974: 290: 757-61. 9. Maki DG, Weise CE, Sarafin HW A semiquantitative culture method for identifying intravenous-catheter-related infection. N EnglJ Med 1977; 296: 1305-09 10. Makr DG, Jarrett F, Sarafin HW A semiquantitative culture method for identification of catheter-related infection in the burn patient. J Surg Res 1977, 22: 513-20 11 Bjornson HS, Colley R, Bower RH, et al. Association between microogranism growth at the catheter insertion site and colonisation of the catheter in patients receiving total parenteral nutrition Surgery 1982, 92: 720-25