ANKYLOSING SPONDYLITIS AND SLEEP

944 guanoxan and the

aliphatic oxidation of phenacetin. Genetdetermined polymorphisms of oxidation at carbon centres of drugs may be more prevalent than hitherto realised, and it does seem that there is at least one component common to the oxidative metabolism of such structurally dissimilar centres -as aromatic, alicyclic, and aliphatic carbon atoms which is under genetic control and exhibits polymorphism. ically

R. L. SMITH Department of Biochemical and Experimental Pharmacology, St Mary’s Hospital Medical School, London W2 1PG

J. R. IDLE A. A. MAHGOUB T. P. SLOAN R. LANCASTER

HYDROGEN PEROXIDE IN PREVENTION OF WATER CONTAMINATION

SIR,-In an editorial on inhalation fevers (Feb. 4, p. 249) you note that in all reports "symptoms could be related to inhalation of air contaminated by microorganisms, usually from humidifiers". Bacterial contamination of water is not unusual: within hospitals sources of potentially contaminated water include cold nebulisers, mist tests, humidification water in ’Isolettes’ and Armstrong units in nurseries, eyewash bottles, water baths (especially those used for thawing frozen plasma and heating infant formulae), ’Blanketrol’ ice mattresses, partially filled bottles of "sterile" solutions, and flower vases. A statement by J. G. Davis’ that "from many points of view hydrogen peroxide is an ideal sterilant for the food industry, as it readily decomposes into water and oxygen" led to an investigation of this compound to control bacterial contamination in water sources. 3% commercial H202 in small quantities will prevent bacterial multiplication. 10 ml of 3% H202 added to 1 litre of water killed 106 colony-forming units/ml of a variety of microorganisms including the ATC strains derived from the Roche ’Bac-Chek’ set (E. coli, E. cloacce, Ps. ceruginosa, P. vulgaris, S. typhimurium, S. aureus, and S. pyogenes). An approximate 80% kill was found in an hour, with no viable organisms after overnight incubation (18 h) at either room temperature (22°C) or 37°C. 30-60 ml of 3% HP2 controlled contamination of water in flower vases.2 Smaller quantities will often be sufficient to prevent bacterial multiplication in water sources. In isolettes 5 ml 3% H202 per litre of water has prevented contamination of the water reservoirs at this hospital for the past 6 years. With many other water sources, 10 ml of 3% HP2 will control contamination, provided the same ratio is maintained as make-up water is added. With blanketrol units, approximately 750 ml must be added per unit. With heavy contamination, periodic cleaning must also be used. Since H202 slowly decomposes it must be renewed periodically, especially if foreign material is introduced. The germicidal properties of H202 are probably the result of nascent oxygen. The official aqueous solution (3%) has a low toxicity rating,3 and Schumb et al.4 state that H202 "is not toxic in the usual sense" and that "man is admirably adapted to withstand treatment with hydrogen peroxide, the skin being relatively inert and the tissue fluids having an efficient means for decomposing hydrogen peroxide encountered internally". H202 has been recommended for disinfection of water supplies.s In view of its safety, cheapness, and efficacy in controlling contamination in water H202 warrants an investigation in large-scale humidification systems. Department of Microbiology, Richmond Memorial Hospital, Richmond, Virginia 23227, U.S.A.

A. L. ROSENZWEIG

Davis, J. G. Chemical Sterilization. Progress in Industrial Microbiology, London, 1968. 2. Rosenzweig, A. L. Lancet, 1973, ii, 568. 3. Gleason, M. N., and others. Clinical Toxicology of Commercial Products. Baltimore, 1969. 4. Schumb, W. C., and others. Hydrogen Peroxide. New York, 1955. 5. Yoshpe-Purer, Y., Eyland, E. Hlth Lab Sci. 1968, 5, 233. 1.

SPLEEN SIZE AND PREVIOUS TONSILLECTOMY IN AUTOIMMUNE DISEASE OF THE THYROID

SIR,-Graves’ and Hashimoto’s diseases are thought to have an autoimmune basis.’ Splenic atrophy has been observed in thyrotoxicosis/.3 though it is not clear at what stage in the disease splenic atrophy takes place. We have assessed spleen size in patients with thyroid disease, and looked for other evidence of autoimmune disease. Splenic size was estimated from technetium-99m sulphur colloid scans in 32 consecutive patients admitted for thyroid surgery. No patient showed splenic atrophy, but 7 out of 13 patients with thyrotoxicosis, 3 out of 10 with Hashimoto’s disease, and 1 out of 9 with colloid goitre showed some splenic enlargement. No correlation was found between spleen size, duration of disease, or presence of circulating thyroid antibodies. We next looked for evidence of previous immunological disturbance in 138 thyroidectomy patients. Most patients were uncertain of the details of childhood illness, but a history of tonsillectomy was recalled by 80% of 15 patients with Hashimoto’s disease and 66% of 48 with thyrotoxicosis, but only 10% of 75 patients whose thyroidectomy was for colloid goitre (P<0.001). Since the discovery of thyroid antibodies in patients with Graves’ and Hashimoto’s diseases other evidence for an autoimmune mechanism has come to light. The thymus is often enlarged,S6 liver function may be disturbed,4 and even cirrhosis of the liver has been reported.’ Other diseases in which autoimmunity is thought to play a part are associated with these thyroid diseases more often than chance would determine;8 examples are coeliac disease, ulcerative colitis, and diabetes. Our findings on spleen size, although differing from other reports, fit in with this concept of a more general process. An unusual frequency of prior tonsillectomy, found in our patients, has not previously been reported. There may be a genetic basis for these findings. In close relatives of patients with Hashimoto’s disease thyroid antibodies are present in up to 50% although they have no clinical evidence of the disease.9-11 We thank T. Testa and M. Prescott for the

Royal Infirmary, Manchester M13 9WL

scans.

C. METCALFE-GIBSON N. KEDDIE

ANKYLOSING SPONDYLITIS AND SLEEP

SiR,—I have had ankylosing spondylitis for forty years and have the classic "bamboo spine". Sleep is elusive, and going to bed is a positive chore. Draughts and pills do help, but they leave the sleeper unrefreshed in the morning and often with an "ankylosed" mind as well. It is at night that the spondylitic feels his condition most and is most conscious of the skeletal prison within him. The problem is worse when the patient has to travel and leave his special bed at home, for there is usually nothing suitable except the floorboards. I believe that the reason for this night-time discomfort is simply the spondylitic’s own bodyweight, which strains his spine and joints when he is lying prone and immobile. The solution is to offset that weight by using a "flotation" mattress inflated with air at low pressure, ribbed to control air flow when the sleeper moves, and laid on flat boards. The only air Doniach, D., Roitt, I. M. J. clin. Endocr. 1957, 17, 1293. Brownlie, B. E. W., Hamer, J. W., Cook, H. H., Hamwood, S. M. Lancet, 1975, ii, 1046. 3. Wardrop, C. A. J., Lee, F. D., Dyet, J. F., Dagg, J. H., Singh, H., Moffat, A. ibid. 1975, ii, 4. 4. Luxton, R. W., Cooke, R. T. ibid. 1956, ii, 105. 5. Gunn, A., Michie, W., Irvine, W. J. ibid. 1964, ii, 776. 6. Mitchie, W. J., Beck, J. S., Mahaffy, R. G., Honein, E. F., Fowler, G. B. ibid. 1967, i, 691. 7. McConkey, B., Callaghan, P. ibid. 1960, i, 939. 8. Cooper, B. T., Holmes, G. K. T., Cooke, W. T. Br. med. J. 1978, i, 537. 9. Hall, R., Owen, S. G., Smart, G. A. Lancet, 1960, ii, 187. 10. Hall, R., Dingle, P. R., Roberts, D. F. Clin. Genet. 1972, 3, 319. 11. Hall, R., Saxena, K., Owen, S. G. Lancet, 1962, ii, 1291. 1. 2.

945 available are those used for the beach or camping; only partially effective, and not purpose designed. they A rough prototype air mattress made of polyvinyl chloride is being tested for the National Ankylosing Spondylitis Society, mattresses are

and I find it effective: at

(a) The sleeper’s body "floats" and is supported by ballooning air the low-pressure points (or stress points when on a hard bed) such

as

the stiff arch of the back above the buttocks

or at

the waistline when

lying on the side; (b) The air pressure can be accurately adjusted to suit weight and shape. (c) The mattress is light, deflatable, and easy to pack. (d) Drugs are no longer necessary.

the

sleeper’s

It is too early to say whether such a mattress can be used permanently, but I hope that others may be induced to test it. 4 Beaconsfield

Road,

Clifton, Bristol BS8 2TS

M. TANFIELD, Hon. Secretary, National Ankylosing Spondylitis Society

Commentary from Westminster From Our

Parliamentary Correspondent

The

Disappearing Pharmacies ALTHOUGH Britain’s small businesses are again feeling the warmth of Government support, one section is still suffering the cold blast of economic recession. Dispensing chemists and their shops are continuing to fall by the wayside at an alarming rate. In the past twelve years an average of nearly one pharmacy per working day has been going out of business in England and Wales and, although this rate has slowed down recently, the prospect for the next few years is bleak. The Pharmaceutical Services Negotiating Committee has warned that unless action is taken to reverse this decline there will be a further loss of 3000 pharmacies within the next few years.

The plight of the chemists has now been taken up by the Conservative Party’s committee on small businesses. Evidence just submitted to the committee illustrates the depth of the crisis. Falling profitability is one of the main reasons for the closures. Net profits of pharmacists have dropped by about a third, largely because of what they believe to be the inadequate return from the dispensing of N.H.S. prescriptions. As a result many High Street pharmacists are said to be subsidising the Government by dispensing prescriptions at a loss. An estimated 4000 chemists are said to be failing to recover their costs. The work undertaken by the independent pharmaceutical contractor for the N.H.S. now accounts for some 60% of his turnover. But the gross profit he receives for his N.H.S. work has declined during the past two years by over 4% to just over 21.3%. The profit on each prescription has fallen from an average of 3.91p in 1974 to 2.88p in 1976 at 1974 prices. This figure is not sufficient to provide the working capital required to finance the N.H.S. dispensing of the pharmacy, so chemists are faced with the alternative of either closing down or subsidising the N.H.S. In many instances they would do better by refusing to do N.H.S. dispensing and by converting themselves into a drug store. Even worse hit are the small independent community pharmacies. To ensure their survival the Pharmaceutical Services Negotiating Committee launched its

"essential small pharmacies scheme", involving a redistribution of money from the larger contractors to the smaller ones in areas where a continuing pharmaceutical service is regarded as essential. In the first year the scheme was estimated to cost ,E300 000. But the position has now been reached where it cannot be extended significantly without help from the Government. One result of the continuing closures has been a threat to the existence of a comprehensive service throughout the community. The development of health centres and group medical practices has led to the appearance of nearby pharmacies, who take most of the dispensing in the area. So the profession is now discussing with the Government arrangements for introducing a rational distribution of the service through the award of N.H.S. dispensing contracts. But it is not only the loss of outlets which is disturbing the profession. The deteriorating service provided to the public is also causing concern. A chemist making a loss or a very small profit on his N.H.S. dispensing is unable to replace his stock. So more patients are being asked to return for some or all of their prescription. But the major factor indicating more closures ahead is that some 30% of pharmacies are owned or managed by pharmacists over the age of 60-the generation which set up in business after the 1939-45 war. Many of them find they cannot afford to retire, because they are unable to sell businesses which have become uneconomic. On these grounds alone, some 600 pharmacists are thought to be candidates for closure in the next few years. The Pharmaceutical Society has warned the Government that unless and until it recognises the damage being done to retail chemists by its attitude on N.H.S. dispensing, the number of pharmacies will continue to fall. For more than two years the profession has been negotiating with the Government, but without any agreement satisfactory to the pharmacists. Mr David Ennals, Secretary of State for Social Services, has rejected the profession’s claim for an increase in the rate of return on capital employed in N.H.S. dispensing and has also refused to allow the issue of chemists’ net profit margins to go to independent arbitration. He wants time to judge the effect of the new differential system of distribution of pharmacists’ remuneration which was introduced at the beginning of the year. This system is designed to help smaller pharmacies which are most at risk from closure. Mr Ennals has expressed his concern about the effect on patients, particularly the elderly, if the present rate of closures continues. He is worried especially about the problems facing rural pharmacies. But he believes that some of their difficulties stem from the old flat-rate system of N.H.S. remuneration, which did not take account of higher operating costs of smaller pharmacies. His new scheme, backed by c5 million of Government help, is designed to correct this. An estimated 70% of all pharmacies, including most of those serving rural communities, are expected to benefit from this scheme. The profession’s negotiating committee, however, is still pressing strongly for arbitration, after what it describes as "two years of fruitless argument". It says that the level of service being provided is steadily deteriorating and that chemists continue to suffer financial hardship. It is now embarking on a nationwide publicity drive to persuade Mr Ennals to change his mind. A strong Parliamentary campaign is already under way