- Email: [email protected]
AWARENESS DURING ANÆSTHESIA
97 detectable by indirect immunofluoresThe latter may therefore be a more reliable marker for B cells than the E.A.c. rosette-technique used by Irvine and Cooper, although we have carried out no systematic studies of changes in B-cell markers in stored whole blood.
POWDERED GLOVES
immunoglobulins cence.
M.R.C. Clinical and
Population Cytogenetics Unit, Western General Hospital, Crewe Road, Edinburgh
JUDITH EVANS MARILYN A. SMITH C. M. STEEL.
EH4 2XU.
PAPER SHORTAGE
SIR,-We in the hospitals are in dire straights because of shortages of fuel, plastics, dressings, and paper. Even the Administration has noticed. We have been circularised in this group with " Notes of a meeting " to discuss the situation, duplicated on one side only of large foolscap paper! It was introduced by a 12-line memorandum on a sheet the same size. Their exhortations to economy used only 1102 sq. cm. of a total paper area of 5040 sq. cm. A note from Regional Board used only 140 sq. cm. of a sheet 1200 sq. cm. writing area. Still we receive one sheet in a 27-34 envelope-four times the size needed if folded. What shining examples! What preceptive leadership! 3 Charlton
Road, Sunderland, Co. Durham SR5 1PJ.
T. DOWELL.
LITHIUM IN MANIC-DEPRESSIVE ILLNESS
SIR,-The hypothesis of Dr Glen and Dr Reading
(Dec. 1,
p.
1239) depends
on
four
assumptions
for which
there is little evidence: 1. Therapeutic levels of lithium in the extracellular fluid increase the efflux of sodium from cells. Though Glen et al.l showed that, in the presence of 2 mM potassium, 3 mM lithium increased the efflux of sodium from erythrocytes, in our laboratories L. J. Boardman (unpublished results) has found no effect of 1 mM lithium at 5 mM potassium concentration. 2. Therapeutic levels of intracellular lithium decrease the efflux of sodium from cells. This claim is based on the report of Keynes and Swan,2 but they used highly unphysiological frog muscles in which " a large part of their potassium had been replaced by lithium ". 3. In-vivo increases in cellular sodium are accompanied by significant decreases in cellular lithium. If the lithium ion is actively transported by the same mechanism as sodium (an essential part of Glen and Reading’s hypothesis), then any change affecting the active expulsion of sodium would presumably affect lithium expulsion similarly, so that both concentrations should change in the same way. 4. Changes in ouabain-insensitive magnesium A.T.P.ase are directly related to changes in ouabain-insensitive membrane transport of sodium and potassium. Since much of the latter is due to passive diffusion, this seems unlikely.
We and
colleagues3 have shown that erythrocyte sodium-potassium A.T.P.ase and ouabain-sensitive potassium influx increase on recovery from a depressive psychosis. We have also found that lithium treatment causes an increase in erythrocyte sodium-potassium A.T.P.ase (unpublished results). It thus seems possible that, at therapeutic levels, lithium may act in part by increasing the amount of cation carrier in cells. GRAHAM J. NAYLOR D. A. T. DICK.
Dundee.
Glen,
10 Kingswood Drive, London SE19 1UT.
1505)
concern-
D. F. ELLISON NASH
AWARENESS DURING ANÆSTHESIA
SIR Your editorial of Dec. 8 (p. 1305) properly pointed
inadvisability of the use of muscle relaxants with inadequate doses of anaathetic agents in the operatingroom. However, it should additionally be pointed out that in the medical intensive-care unit patients on mechaniout
the
cal ventilators may receive muscle relaxants to allow the to be " in phase " with the ventilator, especially with the current frequent use of positive end-expiratory pressure. If these drugs are administered without adequate the patient may experience the sensation of hypnotics " being paralysed and unable to breathe " which you have described for anæsthetised patients. It is therefore recommended that small doses of hypnotic agents almost always be used to render the patient unconscious concurrently with muscle relaxants when the patient is on assisted ventilation.
patient
Cornell University Medical College, North Shore University Hospital, 300 Community Drive, Manhasset, New York 11030, U.S.A.
DANIEL
J. NICOLL.
REACTIONS TO ALCLOFENAC
SIR,-The Committee on Safety of Medicines is currently adverse reactions to the anti-rheumatic drug alclofenac (’ Prinalgin ’), as its use appears to be associated with a relatively high incidence of adverse effects. The reports we have received are, in summary, as follows:
reviewing
Types of reaction
No.
%
Rash without systemic disturbance.... Rash with systemic disturbance.... Gastrointestinal hæmorrhage or other symptoms Other reactions (cedema, vasculitis, &c.) Total ............
168 34 7 21 230
74 14 3 9 100
..
A. I.
M., Bradbury, M.
W.
B., Wilson, J. Nature, 1972, 239,
Some skin reactions were associated with systemic disturbances severe enough to prevent the patients from pursuing their normal daily activities. To enable us to assess the importance of this problem the Committee invites information regarding any instance of serious adverse reactions suspected to be due to alcloIt may be convenient to use the Committee’s fenac. pre-paid yellow card for this purpose. Department of Health and Social Security, Medicines Division, Finsbury Square House, 33-37A Finsbury Square, London EC2A 1PP.
339. 2. 3.
p.
of carbolic to remove powder from operatingThe method which is being adopted increasingly is to have two bowls available, one containing water and A " green " swab is one containing dilute cetrimide. moistened with cetrimide and used to wipe the gloves, particularly between the fingers. It is folded over after wiping the first glove, and used for the second glove and then discarded. A second swab is dipped in water and the same procedure adopted. Dipping the hands in a bowl of water is useless, as friction is needed to remove the ingrained powder. It is regrettable that, in spite of the many warnings that have now been given to the Press about the dangers of corn starch reactions,’2 many surgeons are failing to take this precaution. use
our
Departments of Psychiatry and Anatomy, The University, 1.
SIR,—Mr Lynn Evans writes (Dec. 29,
ing the gloves.
Keynes, R. D., Swan, R. C. J. Physiol., Lond. 1959, 147, 626. Naylor, G. J., Dick, D. A. T., Dick, E. G., Le Poidevin, D., Whyte, S. F. Psychol. Med. 1973, 3, 502.
1. 2.
D.
MANSEL-JONES,
Medical Assessor to the Committee on Safety of Medicines.
Nash, D. F. E. N. Br. med. J. 1971, iii, 183; ibid. 1973, i, 485. Neely, J., Davies, J. D. ibid. 1971, iii, 625.
POWDERED GLOVES
immunoglobulins cence.
M.R.C. Clinical and
Population Cytogenetics Unit, Western General Hospital, Crewe Road, Edinburgh
JUDITH EVANS MARILYN A. SMITH C. M. STEEL.
EH4 2XU.
PAPER SHORTAGE
SIR,-We in the hospitals are in dire straights because of shortages of fuel, plastics, dressings, and paper. Even the Administration has noticed. We have been circularised in this group with " Notes of a meeting " to discuss the situation, duplicated on one side only of large foolscap paper! It was introduced by a 12-line memorandum on a sheet the same size. Their exhortations to economy used only 1102 sq. cm. of a total paper area of 5040 sq. cm. A note from Regional Board used only 140 sq. cm. of a sheet 1200 sq. cm. writing area. Still we receive one sheet in a 27-34 envelope-four times the size needed if folded. What shining examples! What preceptive leadership! 3 Charlton
Road, Sunderland, Co. Durham SR5 1PJ.
T. DOWELL.
LITHIUM IN MANIC-DEPRESSIVE ILLNESS
SIR,-The hypothesis of Dr Glen and Dr Reading
(Dec. 1,
p.
1239) depends
on
four
assumptions
for which
there is little evidence: 1. Therapeutic levels of lithium in the extracellular fluid increase the efflux of sodium from cells. Though Glen et al.l showed that, in the presence of 2 mM potassium, 3 mM lithium increased the efflux of sodium from erythrocytes, in our laboratories L. J. Boardman (unpublished results) has found no effect of 1 mM lithium at 5 mM potassium concentration. 2. Therapeutic levels of intracellular lithium decrease the efflux of sodium from cells. This claim is based on the report of Keynes and Swan,2 but they used highly unphysiological frog muscles in which " a large part of their potassium had been replaced by lithium ". 3. In-vivo increases in cellular sodium are accompanied by significant decreases in cellular lithium. If the lithium ion is actively transported by the same mechanism as sodium (an essential part of Glen and Reading’s hypothesis), then any change affecting the active expulsion of sodium would presumably affect lithium expulsion similarly, so that both concentrations should change in the same way. 4. Changes in ouabain-insensitive magnesium A.T.P.ase are directly related to changes in ouabain-insensitive membrane transport of sodium and potassium. Since much of the latter is due to passive diffusion, this seems unlikely.
We and
colleagues3 have shown that erythrocyte sodium-potassium A.T.P.ase and ouabain-sensitive potassium influx increase on recovery from a depressive psychosis. We have also found that lithium treatment causes an increase in erythrocyte sodium-potassium A.T.P.ase (unpublished results). It thus seems possible that, at therapeutic levels, lithium may act in part by increasing the amount of cation carrier in cells. GRAHAM J. NAYLOR D. A. T. DICK.
Dundee.
Glen,
10 Kingswood Drive, London SE19 1UT.
1505)
concern-
D. F. ELLISON NASH
AWARENESS DURING ANÆSTHESIA
SIR Your editorial of Dec. 8 (p. 1305) properly pointed
inadvisability of the use of muscle relaxants with inadequate doses of anaathetic agents in the operatingroom. However, it should additionally be pointed out that in the medical intensive-care unit patients on mechaniout
the
cal ventilators may receive muscle relaxants to allow the to be " in phase " with the ventilator, especially with the current frequent use of positive end-expiratory pressure. If these drugs are administered without adequate the patient may experience the sensation of hypnotics " being paralysed and unable to breathe " which you have described for anæsthetised patients. It is therefore recommended that small doses of hypnotic agents almost always be used to render the patient unconscious concurrently with muscle relaxants when the patient is on assisted ventilation.
patient
Cornell University Medical College, North Shore University Hospital, 300 Community Drive, Manhasset, New York 11030, U.S.A.
DANIEL
J. NICOLL.
REACTIONS TO ALCLOFENAC
SIR,-The Committee on Safety of Medicines is currently adverse reactions to the anti-rheumatic drug alclofenac (’ Prinalgin ’), as its use appears to be associated with a relatively high incidence of adverse effects. The reports we have received are, in summary, as follows:
reviewing
Types of reaction
No.
%
Rash without systemic disturbance.... Rash with systemic disturbance.... Gastrointestinal hæmorrhage or other symptoms Other reactions (cedema, vasculitis, &c.) Total ............
168 34 7 21 230
74 14 3 9 100
..
A. I.
M., Bradbury, M.
W.
B., Wilson, J. Nature, 1972, 239,
Some skin reactions were associated with systemic disturbances severe enough to prevent the patients from pursuing their normal daily activities. To enable us to assess the importance of this problem the Committee invites information regarding any instance of serious adverse reactions suspected to be due to alcloIt may be convenient to use the Committee’s fenac. pre-paid yellow card for this purpose. Department of Health and Social Security, Medicines Division, Finsbury Square House, 33-37A Finsbury Square, London EC2A 1PP.
339. 2. 3.
p.
of carbolic to remove powder from operatingThe method which is being adopted increasingly is to have two bowls available, one containing water and A " green " swab is one containing dilute cetrimide. moistened with cetrimide and used to wipe the gloves, particularly between the fingers. It is folded over after wiping the first glove, and used for the second glove and then discarded. A second swab is dipped in water and the same procedure adopted. Dipping the hands in a bowl of water is useless, as friction is needed to remove the ingrained powder. It is regrettable that, in spite of the many warnings that have now been given to the Press about the dangers of corn starch reactions,’2 many surgeons are failing to take this precaution. use
our
Departments of Psychiatry and Anatomy, The University, 1.
SIR,—Mr Lynn Evans writes (Dec. 29,
ing the gloves.
Keynes, R. D., Swan, R. C. J. Physiol., Lond. 1959, 147, 626. Naylor, G. J., Dick, D. A. T., Dick, E. G., Le Poidevin, D., Whyte, S. F. Psychol. Med. 1973, 3, 502.
1. 2.
D.
MANSEL-JONES,
Medical Assessor to the Committee on Safety of Medicines.
Nash, D. F. E. N. Br. med. J. 1971, iii, 183; ibid. 1973, i, 485. Neely, J., Davies, J. D. ibid. 1971, iii, 625.