- Email: [email protected]
ANAEROBIC SUBAREOLAR BREAST ABSCESS
35
in a school suggest that annual revaccination with inactivated influenza-A vaccine confers no long-term advantage. The practice of offering annual revaccination to adults seems open to question. Requests for reprints should be addressed to A.J.S. REFERENCES
Williams, M. C., Davignon, L., McDonald, J. C., Pavilanis, P. V., Boudreault. A., Clayton, A. J. Bull. Wld Hlth Org. 1973, 49, 333. 2. Hoskins, T. W., Davies, J. R., Allchin, A., Miller, C. L., Pollock, T. M. Lancet, 1973, ii, 116. 3. Hoskins, T. W., Davies, J. R., Smith, A. J., Allchin, A., Miller, C. L., Pollock, T. M. ibid. 1976, i, 105. 4. Smith, A. J., Davies, J. R. J. Hyg., Camb. 1976, 77, 271. 1.
mosorb 101’.’ All specimens were cultured on Columbia agar (Oxoid CM 331) with lowdefibrinated horse blood and incubated aerobically and in an atmosphere of 10 c carbon dioxide in nitrogen in an anaerobic jar. Some specimens were also cultured anaerobically on brain-heart infusion agar (Oxoid CM 375) with the following additives: 0.05’c cysteine hydrochloride, 1 % vitamin K-hxmin solution, 0-5c yeast extract, 100 mg/1 neomycin, 7.5% whole defibrinated horse blood, and 2-3?f lysed (by freezing and thawing) defibrinated horse blood. Anaerobic isolates were fully identified by conventional methods, and their susceptibility to penicillin, tetracycline, and metronidazole was assessed by disc testing. RESULTS
year, 22 breast abscesses were drained, 5 one occasion. 15 occurred in non-puerand anaerobes were cultured from 8 of women peral these: the identity of these organisms, and their susceptibility to penicillin, tetracycline, and metronidazole is shown in table i together with the G.L.c. results where this technique was used. The anaerobes most frequently isolated were Bacteroides melaninogenicus, Bacteroides bivius (an organism very similar to B. melaninogenicus), Peptococcus spp., and Peptostreptococcus spp. The common colonic anaerobe Bacteroides fragilis was not isolated. Staphylococcus aureus alone was isolated from 6 of the 15 non-puerperal abscesses and the swab from one abscess was sterile on culture. 7 abscesses were drained in puerperal women: all grew Staph. aureus on culture. All isolates of Staph. aureus were resistant to penicillin. The clinical details for the 8 patients with proven anaerobic breast abscesses and the patient with a presumptive anaerobic breast abscess are given in table 11. 6 of these 9 patients had borne at least one child, 1 was nulliparous, and the parity of the other 2 patients was not known. The follow-up details given, whilst complete for those patients with recurrent abscesses, are not avail-
During
Hospital
Practice
ANAEROBIC SUBAREOLAR BREAST ABSCESS R. D. LEACH IAN PHILLIPS
SUSANNAH J. EYKYN BRYAN CORRIN
Departments of Surgery, Microbiology, and Surgical Pathology, St. Thomas’ Hospital, London SE1 7EH 15 non-puerperal women with breast abscess were seen during one year. In 8, anaerobes were cultured from pus obtained from the abscess, in 6, Staphylococcus aureus was grown, and in 1 the pus was sterile on culture. All 7 breast abscesses in puerperal women seen during the same period were staphylococcal. The anaerobic abscesses were all subareolar; they were recurrent in 4 patients and were associated with retracted nipples in 7. The anaerobes isolated were those found as normal commensals in the oropharynx and vagina but did not include the colonic commensal Bacteroides fragilis. Squamous metaplasia with keratin plugging of the breast ducts was identified histologically in the 2 non-puerperal patients in whom duct excision was performed. Surgical treatment of the underlying duct abnormality is important in the management of recurrent non-puerperal subareolar breast abscess.
Summary
INTRODUCTION
CURRENT interest in anaerobic infections has been stimulated by improved techniques for the isolation oi anaerobes, and this has led to increasing awareness oi their clinical importance. Although Staphylococcus aureus is the major pathogen in puerperal breast abscess, the organisms involved in non-puerperal breast abscesses are much less well-defined, at least in British reports. We reviewed all cases of breast abscess treated at this hospital over the past year and give details of the non-puerperal patients with breast abscesses that were not caused by staphylococci.
on more
one
than
able for those patients who apparently were successfully treated. Tissue was examined histologically in 5 of the 8 cases from which anaerobes were grown and from the case with sterile pus. Only 2 of these patients had undergone a formal duct excision: both showed squamous metaplasia and keratin plugging of subareolar breast ducts (see accompanying fiure) in addition to non-specific inflammatory changes that were seen also in the other cases. Tissue from 4 staphylococcal breast abscesses (2 puerperal and 2 non-puerperal) was also examined histo-
logically ; only non-specific inflammatory changes
were
seen.
BACTERIOLOGICAL METHODS
In every case specimens of pus or swabs were submitted tc the laboratory for culture. A gram-stained film was made initially from each specimen, and whenever possible gas liquid chromatography (G.L.c.) was used to determine volatile fatty acids in those specimens which were not obviously staphylococcal in origin. The method used did not involve derivatisation or extraction of the volatile substances from the specimen, which was injected directly on to a column containing ’Chro-
Breast duct of with keratin.
case
8 lined
by squamous epithelium
Hæmatoxylin and eosin, reduced to41 from -× 40.
and filled
36
patients. Anaerobes
DISCUSSION
Although there is little information on anaerobic breast abscess in published reports from Britain, our experience suggests that anaerobes are common pathogens in this infection in non-puerperal women, and indeed may well be the major pathogens. Earlier Beigelman and Rantz2 in the U.S.A. reported a case of anaerobic breast abscess from which bacteroides and anaerobic streptococci were recovered on culture. Pearson,3in 1967, in a review of breast abscesses seen over four years in a Los Angeles hospital reported 9 cases infected with bacteroides. More recently Hale et al. reported 3 cases of bacteroides breast abscess seen in 2 London hospitals, one said to be caused by B. fragilis, one not fully identified but thought to be caused by B. fragilis, and third caused by B. melaninogenicus. Apart from this latter paper little attempt appears to have been made to determine the species of the anaerobes involved. In the present series, anaerobes, on occasion with aerobes but never with Staph. aureus, were isolated from 8 TABLE I-RESULTS OF CULTURE AND GAS
*Gas
thus were responsible for one-third of all breast abscesses and over a half of those in the non-puerperal woman. In two cases a single anaerobic species, B. bivius, was grown, but in the other cases up to four different anaerobes were recovered. The anaerobes isolated were common commensals, particularly of the oropharynx and vagina; and the absence of the common colonic anaerobe B. fragilis suggests that the source of anaerobes is unlikely to be the colon. We do not know how oropharyngeal or vaginal anaerobes reach the breast. Although B. fragilis was isolated from the patient described by Hale et al.,4 the organism may have been B. bivius, a member of the Bacteroidaceae which is not infrequently resistant to penicillin, ampicillin, and tetracycline and therefore easily confused with B. fragilis. Indeed in our case 7 the organism was initially identified as B. fragilis. The swab from one of the nonpuerperal abscesses was sterile on culture-anaerobes may well have been present but transport on a dry swab, delayed in transit, could have led to their death.
LIQUID CHROMATOGRAPHY OF
liquid chromatography excluding acetic, lactic,
and
PUS OBTAINED FROM
8 ANAEROBIC
BREAST ABSCESSES
propionic acids which were produced in all cases; (P) penicillin resistant, (T) tetracycline
resistant, (M) metronidazole resistant. TABLE II—CLINICAL DETAILS OF
9
NON-PUERPERAL PATIENTS WITH ANAEROBIC SUBAREOLAR BREAST ABSCESS
37 All but 1 of the non-puerperal patients were of childbearing age. The oldest patient (case 4) had severe diabetes, and this may well have been relevant to the development of particularly extensive necrosis in her case. In all 8 patients with anaerobic breast abscess, and the patient from whom no organisms were isolated, the abscess was subareolar; this seems to be a feature of anaerobic breast abscesses.3 Staphylococcal abscesses were not subareolar. Anaerobic breast abscesses tend to be recurrent, as in 4 of our patients from whom anaerobes were isolated and the case with a sterile culture. Indeed case 8 had five documented recurrences before being cured by surgery. Caswell and Burnett5 described a patient who had had recurrent subareolar abscesses for twenty years. Inverted or retracted nipples are important in the pathogenesis of this infection5 and 7 of our 8 patients with anaerobic abscesses and the patient with sterile pus had this feature. Inverted nipples were not a feature of the staphylococcal abscesses. Habif et al.,6 in a largely histological study of 152 patients with subareolar abscesses, concluded that most of these abscesses in the non-puerperal woman were caused by infection in ducts that are lined with squamous epithelium and filled with keratin plugs. This feature was noted in the 2 patients in our series in whom formal duct excision was undertaken. Habif et awl. emphasised that surgery to the underlying duct abnormality was the key to successful therapy and this is well illustrated by patient 8 who had had recurrent abscesses until duct excision was performed. The essential role of surgery in this condition has been mentioned more recently by
Hughes.7 Whilst appropriate surgery is clearly the only treatfor those patients with recurrent subareolar breast abscess, attempts should be made to isolate the pathogen(s) from the pus and the clinician should be aware of the importance of anaerobes. Ampicillin, often an inappropriate drug, was the most commonly prescribed antibiotic in our series, particularly by G.P.s. The presence of a subareolar breast abscess with a retracted nipple should alert the clinician to the probability of anaerobes; a foul discharge or foul pus on drainage confirms their presence. Gram-stained films are useful not only in confirming the absence of staphylococci but also in demonstrating gram-negative bacilli typical of bacteroides, and G.L.C., where available, provides further immediate confirmation. If an antibiotic is to be given at the time of drainage, a drug such as metronidazole with predictable anti-anaerobic activity can be confidently prescribed. In our experience, most surgeons, if they prescribed an antibiotic for a patient with a breast abscess, would choose a specifically antistaphylococcal drug, assuming the pathogen to be ment
Staph.
aureus.
BX’e thank Miss E. Taylor for expert technical assistance in the isolation and identification of anaerobes, and the clinicians for permission to study their patients.
Requests for reprints should be addressed to I.P., Department Microbiology, St. Thomas’ Hospital, London SE1 7EH.
of
REFERENCES 1. Carlsson,J J appl.Microbiol. 1973, 25, 287. 2. Beigelman, P M., Rantz, L. A. Archs. intern. Med. 1949, 84, 605. 3. Pearson, H E Surgery Gynec. Obstet. 1967, 125, 800. 4. Hale. J. E.. Pennpanayagam, R M., Smith, G. Lancet, 1976, ii, 70. 5. Casvwell, H. T., Burnett, W. E. Surgery Gynec. Obstet. 1956, 102, 439. 6 Habif, D V., Perzin, K. H., Lipton, R., Lattes, R. Am. J. Surg. 1970, 523 7. Hughes, L. E.Lancet, 1976, ii, 198.
119,
Round the World From
our
Correspondents
Italy INFORMATION ABOUT DRUGS
THE most widely circulated Italian monthly publication for the medical profession is the Bollettino dinformazione sui Farmaci (Information Bulletin on Drugs), an eight-page pocketsize production devoted primarily to undesirable effects of drugs. With 200 000 copies of each issue distributed free, it exceeds by far any other Italian medical periodical. It surpasses even Federazione Medica, the official organ of the Italian Medical Association, which each of Italy’s 140 000 doctors is entitled to receive, the subscription being included in the annual Association fee. The Bollettino started its third year of publication this month, and its circulation has jumped from 182 000 to about 200 000, because the Ministry of Health, which publishes it, decided to include 15 000 drug-house representatives in the mailing list, which also includes the 140 000 doctors, 40 000 pharmacists, and some 2000 leading health experts and other moulders of public opinion. The Bollettino includes warnings about side-effects of drugs, therapeutic notes, and news of the Ministry of Health’s activities. It is Italy’s biggest educational effort promoted by a Government agency and directed to health workers. Prof. Duilio Poggiolini, general director of the pharmaceutical division at the Ministry, is both the promoter and the editor of the Bollettino. A strong supporter of rigid regulations on approval of drugs and on distribution and prescription, Professor Poggiolini is openly against the consumer approach in pharmaceutical advertising. He insists that the medical profession is entitled to be better informed. The 1979 series of his Bollettino will include lists of drugs with their chemical names and the corresponding trade names. He thereby hopes to achieve at least one goal: to help doctors to avoid listing in the same prescription identical substances disguised under different trade names.
United States and Canada TELEVISION
THE three large U.S. television networks put forth a flow of soap operas, cops and robbers, ancient motion pictures, and maudlin sentiment, punctuated by disheartening commercials. It is left to the Public Broadcasting System (P.B.S.) to restore faith in humanity. Unfortunately, P.B.S. is available only to a minority, and many large U.S. cities soldier on in philistine isolation. Although P.B.S. is partly supported by Federal grants, and by contributions from various philanthropic trusts and other most P.B.S. stations have to rely on contributions from the viewing public to remain in business, and for the most part they lead a precarious hand-to-mouth financial existence. But P.B.S. has done a marvellous job and an increasing number of North Americans have been introduced to, and have greatly enjoyed, many B.B.C. productions, including The Forsyte Saga, The Pallisers, and Jude the Obscure. The situation in Canada is appreciably better, and aside from the usual large U.S. networks, and in some areas P.B.S. (which is usually pirated), the Canadian Broadcasting Company (C.B.C.) has its own television programmes. Both P.B.S. and C.B.C. also maintain excellent radio programmes. Although Canadians seem to be perpetually criticising C.B.C., and, at recent public hearings, C.B.C. was repeatedly hauled over the coals, Canadians would do well to count their blessings. While C.B.C. may not quite achieve the standard of the B.B.C., it is streets ahead of all its American rivals. Many of its programmes, and in particular its documentaries, compare very favourably with those of the B.B.C. Like P.B.S., C.B.C. exists on a shoestring budget, and, moreover, the recent austerity programme introduced by the Government sliced large sums from C.B.C.’s appropriations. It is hoped that the Canadian Government, in its zeal for balancing the budget, remembers that C.B.C. does much to balance the mind throughout the long Canadian winter.
organisations,
in a school suggest that annual revaccination with inactivated influenza-A vaccine confers no long-term advantage. The practice of offering annual revaccination to adults seems open to question. Requests for reprints should be addressed to A.J.S. REFERENCES
Williams, M. C., Davignon, L., McDonald, J. C., Pavilanis, P. V., Boudreault. A., Clayton, A. J. Bull. Wld Hlth Org. 1973, 49, 333. 2. Hoskins, T. W., Davies, J. R., Allchin, A., Miller, C. L., Pollock, T. M. Lancet, 1973, ii, 116. 3. Hoskins, T. W., Davies, J. R., Smith, A. J., Allchin, A., Miller, C. L., Pollock, T. M. ibid. 1976, i, 105. 4. Smith, A. J., Davies, J. R. J. Hyg., Camb. 1976, 77, 271. 1.
mosorb 101’.’ All specimens were cultured on Columbia agar (Oxoid CM 331) with lowdefibrinated horse blood and incubated aerobically and in an atmosphere of 10 c carbon dioxide in nitrogen in an anaerobic jar. Some specimens were also cultured anaerobically on brain-heart infusion agar (Oxoid CM 375) with the following additives: 0.05’c cysteine hydrochloride, 1 % vitamin K-hxmin solution, 0-5c yeast extract, 100 mg/1 neomycin, 7.5% whole defibrinated horse blood, and 2-3?f lysed (by freezing and thawing) defibrinated horse blood. Anaerobic isolates were fully identified by conventional methods, and their susceptibility to penicillin, tetracycline, and metronidazole was assessed by disc testing. RESULTS
year, 22 breast abscesses were drained, 5 one occasion. 15 occurred in non-puerand anaerobes were cultured from 8 of women peral these: the identity of these organisms, and their susceptibility to penicillin, tetracycline, and metronidazole is shown in table i together with the G.L.c. results where this technique was used. The anaerobes most frequently isolated were Bacteroides melaninogenicus, Bacteroides bivius (an organism very similar to B. melaninogenicus), Peptococcus spp., and Peptostreptococcus spp. The common colonic anaerobe Bacteroides fragilis was not isolated. Staphylococcus aureus alone was isolated from 6 of the 15 non-puerperal abscesses and the swab from one abscess was sterile on culture. 7 abscesses were drained in puerperal women: all grew Staph. aureus on culture. All isolates of Staph. aureus were resistant to penicillin. The clinical details for the 8 patients with proven anaerobic breast abscesses and the patient with a presumptive anaerobic breast abscess are given in table 11. 6 of these 9 patients had borne at least one child, 1 was nulliparous, and the parity of the other 2 patients was not known. The follow-up details given, whilst complete for those patients with recurrent abscesses, are not avail-
During
Hospital
Practice
ANAEROBIC SUBAREOLAR BREAST ABSCESS R. D. LEACH IAN PHILLIPS
SUSANNAH J. EYKYN BRYAN CORRIN
Departments of Surgery, Microbiology, and Surgical Pathology, St. Thomas’ Hospital, London SE1 7EH 15 non-puerperal women with breast abscess were seen during one year. In 8, anaerobes were cultured from pus obtained from the abscess, in 6, Staphylococcus aureus was grown, and in 1 the pus was sterile on culture. All 7 breast abscesses in puerperal women seen during the same period were staphylococcal. The anaerobic abscesses were all subareolar; they were recurrent in 4 patients and were associated with retracted nipples in 7. The anaerobes isolated were those found as normal commensals in the oropharynx and vagina but did not include the colonic commensal Bacteroides fragilis. Squamous metaplasia with keratin plugging of the breast ducts was identified histologically in the 2 non-puerperal patients in whom duct excision was performed. Surgical treatment of the underlying duct abnormality is important in the management of recurrent non-puerperal subareolar breast abscess.
Summary
INTRODUCTION
CURRENT interest in anaerobic infections has been stimulated by improved techniques for the isolation oi anaerobes, and this has led to increasing awareness oi their clinical importance. Although Staphylococcus aureus is the major pathogen in puerperal breast abscess, the organisms involved in non-puerperal breast abscesses are much less well-defined, at least in British reports. We reviewed all cases of breast abscess treated at this hospital over the past year and give details of the non-puerperal patients with breast abscesses that were not caused by staphylococci.
on more
one
than
able for those patients who apparently were successfully treated. Tissue was examined histologically in 5 of the 8 cases from which anaerobes were grown and from the case with sterile pus. Only 2 of these patients had undergone a formal duct excision: both showed squamous metaplasia and keratin plugging of subareolar breast ducts (see accompanying fiure) in addition to non-specific inflammatory changes that were seen also in the other cases. Tissue from 4 staphylococcal breast abscesses (2 puerperal and 2 non-puerperal) was also examined histo-
logically ; only non-specific inflammatory changes
were
seen.
BACTERIOLOGICAL METHODS
In every case specimens of pus or swabs were submitted tc the laboratory for culture. A gram-stained film was made initially from each specimen, and whenever possible gas liquid chromatography (G.L.c.) was used to determine volatile fatty acids in those specimens which were not obviously staphylococcal in origin. The method used did not involve derivatisation or extraction of the volatile substances from the specimen, which was injected directly on to a column containing ’Chro-
Breast duct of with keratin.
case
8 lined
by squamous epithelium
Hæmatoxylin and eosin, reduced to41 from -× 40.
and filled
36
patients. Anaerobes
DISCUSSION
Although there is little information on anaerobic breast abscess in published reports from Britain, our experience suggests that anaerobes are common pathogens in this infection in non-puerperal women, and indeed may well be the major pathogens. Earlier Beigelman and Rantz2 in the U.S.A. reported a case of anaerobic breast abscess from which bacteroides and anaerobic streptococci were recovered on culture. Pearson,3in 1967, in a review of breast abscesses seen over four years in a Los Angeles hospital reported 9 cases infected with bacteroides. More recently Hale et al. reported 3 cases of bacteroides breast abscess seen in 2 London hospitals, one said to be caused by B. fragilis, one not fully identified but thought to be caused by B. fragilis, and third caused by B. melaninogenicus. Apart from this latter paper little attempt appears to have been made to determine the species of the anaerobes involved. In the present series, anaerobes, on occasion with aerobes but never with Staph. aureus, were isolated from 8 TABLE I-RESULTS OF CULTURE AND GAS
*Gas
thus were responsible for one-third of all breast abscesses and over a half of those in the non-puerperal woman. In two cases a single anaerobic species, B. bivius, was grown, but in the other cases up to four different anaerobes were recovered. The anaerobes isolated were common commensals, particularly of the oropharynx and vagina; and the absence of the common colonic anaerobe B. fragilis suggests that the source of anaerobes is unlikely to be the colon. We do not know how oropharyngeal or vaginal anaerobes reach the breast. Although B. fragilis was isolated from the patient described by Hale et al.,4 the organism may have been B. bivius, a member of the Bacteroidaceae which is not infrequently resistant to penicillin, ampicillin, and tetracycline and therefore easily confused with B. fragilis. Indeed in our case 7 the organism was initially identified as B. fragilis. The swab from one of the nonpuerperal abscesses was sterile on culture-anaerobes may well have been present but transport on a dry swab, delayed in transit, could have led to their death.
LIQUID CHROMATOGRAPHY OF
liquid chromatography excluding acetic, lactic,
and
PUS OBTAINED FROM
8 ANAEROBIC
BREAST ABSCESSES
propionic acids which were produced in all cases; (P) penicillin resistant, (T) tetracycline
resistant, (M) metronidazole resistant. TABLE II—CLINICAL DETAILS OF
9
NON-PUERPERAL PATIENTS WITH ANAEROBIC SUBAREOLAR BREAST ABSCESS
37 All but 1 of the non-puerperal patients were of childbearing age. The oldest patient (case 4) had severe diabetes, and this may well have been relevant to the development of particularly extensive necrosis in her case. In all 8 patients with anaerobic breast abscess, and the patient from whom no organisms were isolated, the abscess was subareolar; this seems to be a feature of anaerobic breast abscesses.3 Staphylococcal abscesses were not subareolar. Anaerobic breast abscesses tend to be recurrent, as in 4 of our patients from whom anaerobes were isolated and the case with a sterile culture. Indeed case 8 had five documented recurrences before being cured by surgery. Caswell and Burnett5 described a patient who had had recurrent subareolar abscesses for twenty years. Inverted or retracted nipples are important in the pathogenesis of this infection5 and 7 of our 8 patients with anaerobic abscesses and the patient with sterile pus had this feature. Inverted nipples were not a feature of the staphylococcal abscesses. Habif et al.,6 in a largely histological study of 152 patients with subareolar abscesses, concluded that most of these abscesses in the non-puerperal woman were caused by infection in ducts that are lined with squamous epithelium and filled with keratin plugs. This feature was noted in the 2 patients in our series in whom formal duct excision was undertaken. Habif et awl. emphasised that surgery to the underlying duct abnormality was the key to successful therapy and this is well illustrated by patient 8 who had had recurrent abscesses until duct excision was performed. The essential role of surgery in this condition has been mentioned more recently by
Hughes.7 Whilst appropriate surgery is clearly the only treatfor those patients with recurrent subareolar breast abscess, attempts should be made to isolate the pathogen(s) from the pus and the clinician should be aware of the importance of anaerobes. Ampicillin, often an inappropriate drug, was the most commonly prescribed antibiotic in our series, particularly by G.P.s. The presence of a subareolar breast abscess with a retracted nipple should alert the clinician to the probability of anaerobes; a foul discharge or foul pus on drainage confirms their presence. Gram-stained films are useful not only in confirming the absence of staphylococci but also in demonstrating gram-negative bacilli typical of bacteroides, and G.L.C., where available, provides further immediate confirmation. If an antibiotic is to be given at the time of drainage, a drug such as metronidazole with predictable anti-anaerobic activity can be confidently prescribed. In our experience, most surgeons, if they prescribed an antibiotic for a patient with a breast abscess, would choose a specifically antistaphylococcal drug, assuming the pathogen to be ment
Staph.
aureus.
BX’e thank Miss E. Taylor for expert technical assistance in the isolation and identification of anaerobes, and the clinicians for permission to study their patients.
Requests for reprints should be addressed to I.P., Department Microbiology, St. Thomas’ Hospital, London SE1 7EH.
of
REFERENCES 1. Carlsson,J J appl.Microbiol. 1973, 25, 287. 2. Beigelman, P M., Rantz, L. A. Archs. intern. Med. 1949, 84, 605. 3. Pearson, H E Surgery Gynec. Obstet. 1967, 125, 800. 4. Hale. J. E.. Pennpanayagam, R M., Smith, G. Lancet, 1976, ii, 70. 5. Casvwell, H. T., Burnett, W. E. Surgery Gynec. Obstet. 1956, 102, 439. 6 Habif, D V., Perzin, K. H., Lipton, R., Lattes, R. Am. J. Surg. 1970, 523 7. Hughes, L. E.Lancet, 1976, ii, 198.
119,
Round the World From
our
Correspondents
Italy INFORMATION ABOUT DRUGS
THE most widely circulated Italian monthly publication for the medical profession is the Bollettino dinformazione sui Farmaci (Information Bulletin on Drugs), an eight-page pocketsize production devoted primarily to undesirable effects of drugs. With 200 000 copies of each issue distributed free, it exceeds by far any other Italian medical periodical. It surpasses even Federazione Medica, the official organ of the Italian Medical Association, which each of Italy’s 140 000 doctors is entitled to receive, the subscription being included in the annual Association fee. The Bollettino started its third year of publication this month, and its circulation has jumped from 182 000 to about 200 000, because the Ministry of Health, which publishes it, decided to include 15 000 drug-house representatives in the mailing list, which also includes the 140 000 doctors, 40 000 pharmacists, and some 2000 leading health experts and other moulders of public opinion. The Bollettino includes warnings about side-effects of drugs, therapeutic notes, and news of the Ministry of Health’s activities. It is Italy’s biggest educational effort promoted by a Government agency and directed to health workers. Prof. Duilio Poggiolini, general director of the pharmaceutical division at the Ministry, is both the promoter and the editor of the Bollettino. A strong supporter of rigid regulations on approval of drugs and on distribution and prescription, Professor Poggiolini is openly against the consumer approach in pharmaceutical advertising. He insists that the medical profession is entitled to be better informed. The 1979 series of his Bollettino will include lists of drugs with their chemical names and the corresponding trade names. He thereby hopes to achieve at least one goal: to help doctors to avoid listing in the same prescription identical substances disguised under different trade names.
United States and Canada TELEVISION
THE three large U.S. television networks put forth a flow of soap operas, cops and robbers, ancient motion pictures, and maudlin sentiment, punctuated by disheartening commercials. It is left to the Public Broadcasting System (P.B.S.) to restore faith in humanity. Unfortunately, P.B.S. is available only to a minority, and many large U.S. cities soldier on in philistine isolation. Although P.B.S. is partly supported by Federal grants, and by contributions from various philanthropic trusts and other most P.B.S. stations have to rely on contributions from the viewing public to remain in business, and for the most part they lead a precarious hand-to-mouth financial existence. But P.B.S. has done a marvellous job and an increasing number of North Americans have been introduced to, and have greatly enjoyed, many B.B.C. productions, including The Forsyte Saga, The Pallisers, and Jude the Obscure. The situation in Canada is appreciably better, and aside from the usual large U.S. networks, and in some areas P.B.S. (which is usually pirated), the Canadian Broadcasting Company (C.B.C.) has its own television programmes. Both P.B.S. and C.B.C. also maintain excellent radio programmes. Although Canadians seem to be perpetually criticising C.B.C., and, at recent public hearings, C.B.C. was repeatedly hauled over the coals, Canadians would do well to count their blessings. While C.B.C. may not quite achieve the standard of the B.B.C., it is streets ahead of all its American rivals. Many of its programmes, and in particular its documentaries, compare very favourably with those of the B.B.C. Like P.B.S., C.B.C. exists on a shoestring budget, and, moreover, the recent austerity programme introduced by the Government sliced large sums from C.B.C.’s appropriations. It is hoped that the Canadian Government, in its zeal for balancing the budget, remembers that C.B.C. does much to balance the mind throughout the long Canadian winter.
organisations,