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Cigarette smoking in the next world
Diphtheria In
Russia
world" for smoking betrays the friend and kills.1 And talking of the next world-a survey by a Japanese life-insurance company revealed that 27 5% of its 30 000 female employees smoked.2 According to the Japan Tobacco Corporation, the prevalence of smoking among women throughout the country in 1993 was 13-8%. The workers thus smoke twice as much as average. Are they really selling life insurance?
next
SIR-Rich (Jan 15, p 169) asserts that the current epidemic of diphtheria in Russia reflects poor immunisation uptake because of a lack of disposable needles and public concern about contracting blood-borne disease. Disposable syringes and needles are widely available and are used for immunisation. Until recently, I was a specialist in paediatric diphtheria at Tushinskaya Children’s Hospital, Moscow. Most children with diphtheria had not been immunised for medical reasons. Russian doctors are often reluctant to immunise children, including their own, because many medical conditions are considered contraindications. I know of a doctor who falsified her daughter’s immunisation card so that the girl could enter school. I understand that until recently British doctors also believed there were many contraindications. Last summer my British colleagues and I studied the immunisation rate of a group of Moscow children and our report will include the reasons for non-immunisation. Immunisation is compulsory in Russia for school entry but, because of the fear of side-effects of vaccine, children can easily escape protection. Better medical and public education will improve uptake in Russian children as it has in British children. As Rich’s figures show, it is the adult population which is most at risk. That is so not just in Russia but also in western countries
generally.
Hiroshi Kawane Department of Medicine, Kawasaki 1 2
Medical School, Kurashiki City 701-01, Japan
Kawane H. Smoking betrays the friend. Lancet 1993; 342: 1120. Anon. Lifestyles among female employees in a life insurance company.
Yomiuri Shimbun, Jan 13, 1994: 16.
Screening for coeliac disease SIR—Catassi and colleagues (Jan 22, p 200) report on the of subclinical coeliac disease in children. We agree with Challacombe (commentary, p 188) that delayed diagnosis is common in adults. We have diagnosed and treated 17 adults in whom we diagnosed coeliac disease. The patients were referred to the gastroenterology or medical outpatient clinics of our hospital. The diagnosis was made on the basis of two biopsies-at presentation and after a gluten-free diet-
diagnosis
and histological improvement. 6 men and 11 women (average age 43, range 18-69). 3 had a childhood history of coeliac disease (subsequently forgotten); symptoms in the others were diarrhoea (8), weight loss (5), and polymyositis (1). We found iron deficiency (mean serum iron 45 moljL) in all 9 patients tested, folate deficiency (average 2-52 nmol/L) in 9 out of 10, and vitamin B12 deficiency in 1. Coeliac disease may present unusually (eg, at age 69 or with symptoms that included polymyositis and severe
showing clinical, biochemical,
There were
VA Ivanov Queen Elizabeth Hospital for Children, London E2 8PS, UK
Compulsory treatment for Infectious disease SiR-Morton and Campbell (Feb 5, p 359) are correct in their section 37 of the UK’s Public Health (Control of 1984 contains no power for compulsory treatment Disease) Act of patients. However, many of the powers of this Act stem from the 1988 regulations, and this applies to tuberculosis. Section 37 only allows for removal to a suitable hospital; the person is free to walk out of the hospital immediately. Section 38 allows for detention but it can only be used if the person is already in hospital. A justice of the peace has to follow the vehicle being used to convey a person under section 37 so that a section 38 order can be served to prevent that person walking out. The view that treatment can be compulsory may thus arise from this compulsory detention. If the patient refuses treatment the section 38 order can be continued and when he or she complies the order can be lifted. The situation may arise in which patients can only leave hospital if they take adequate treatment-not technically compulsory treatment but the same thing. A combination of removal and essentially detention (sections 37 and 38) should be considered in the long overdue review of the law on communicable diseases, as should the ethical and legal problems arising from the public health threat of multi-drug resistant tuberculosis. comment that
proteinuria). We noted raised levels of anti-gliadin IgA in all 4 patients tested. The possibility of screening for coeliac disease by non-invasive serological testing in adults has been addressed previously.1.2 Of 25 patients with positive serum reticulin or gliadin antibody titres but normal small bowel on biopsy, 7 were found to develop villous atrophy during median followup of 5 years.3 Coeliac disease is underdiagnosed and a raised level of awareness could result in an increase in diagnosis-by noninvasive serological testing or by more duodenal biopsies during endoscopy for non-specific complaints. S D H Malnick, Y Lurie, D D Bass, D Geltner Department of Internal Medicine C and Division of Gastroenterology, Kaplan Hospital, Rehovot, Israel 1
2
Keith Neal
Watson EGP, McMillan SA, Dickey W, Biggart JD, Porter KG. Detection of undiagnosed coeliac disease with atypical features using antireticulin and antigliadin antibodies. Q J Med 1992; 84: 713-18. Carroccio A, Tacono G, Montalto G, et al. Immunologic and absorptive tests in celiac disease: can they replace intestinal biopsies? Scand J Gastroenterol 1993; 28: 673-76. Collin P, Helin M, Maki M, Hallstrom O, Karvonen A-L. Follow-up of patients positive in reticulin and gliadin antibody tests with normal small-bowel biopsy findings. Scand J Gastroenterol 1993; 28: 595-98.
Department of Public Health Medicine and Epidemiology, University Hospital, Queen’s Medical Centre, Nottingham NG7 2UH, UK
3
Cigarette smoking in the next world
SiR-Challacombe stresses the importance of reliable noninvasive screening tests for coeliac disease. I wish to report a clinical observation which may be a first step towards such a
mx-1 was asnamea to
see tne
pnotograpn presented by
Nussenzweig and Biggs (Feb 5, p 365). However, the message in English displayed on that cigarette vending machine must be for foreign visitors. There are no Japanese words there with the same meaning: the part in Japanese simply tells people how to use the machine and warns that underage smoking is prohibited by law. "... over there" says the message "Cigarettes are offered
to
express friendliness". Over there may
mean
"the
test.
A boy now aged 8 years presented at the age of 3 years with steatorrhoea, irritability, distension of the abdomen, and
growth failure. A jejunal biopsy showed mucosal atrophy. He was put on a gluten-free diet; all clinical manifestations cleared and reappeared on rechallenge with gluten. Ever since, he has been on a gluten-free diet and symptom-free. 675
Russia
world" for smoking betrays the friend and kills.1 And talking of the next world-a survey by a Japanese life-insurance company revealed that 27 5% of its 30 000 female employees smoked.2 According to the Japan Tobacco Corporation, the prevalence of smoking among women throughout the country in 1993 was 13-8%. The workers thus smoke twice as much as average. Are they really selling life insurance?
next
SIR-Rich (Jan 15, p 169) asserts that the current epidemic of diphtheria in Russia reflects poor immunisation uptake because of a lack of disposable needles and public concern about contracting blood-borne disease. Disposable syringes and needles are widely available and are used for immunisation. Until recently, I was a specialist in paediatric diphtheria at Tushinskaya Children’s Hospital, Moscow. Most children with diphtheria had not been immunised for medical reasons. Russian doctors are often reluctant to immunise children, including their own, because many medical conditions are considered contraindications. I know of a doctor who falsified her daughter’s immunisation card so that the girl could enter school. I understand that until recently British doctors also believed there were many contraindications. Last summer my British colleagues and I studied the immunisation rate of a group of Moscow children and our report will include the reasons for non-immunisation. Immunisation is compulsory in Russia for school entry but, because of the fear of side-effects of vaccine, children can easily escape protection. Better medical and public education will improve uptake in Russian children as it has in British children. As Rich’s figures show, it is the adult population which is most at risk. That is so not just in Russia but also in western countries
generally.
Hiroshi Kawane Department of Medicine, Kawasaki 1 2
Medical School, Kurashiki City 701-01, Japan
Kawane H. Smoking betrays the friend. Lancet 1993; 342: 1120. Anon. Lifestyles among female employees in a life insurance company.
Yomiuri Shimbun, Jan 13, 1994: 16.
Screening for coeliac disease SIR—Catassi and colleagues (Jan 22, p 200) report on the of subclinical coeliac disease in children. We agree with Challacombe (commentary, p 188) that delayed diagnosis is common in adults. We have diagnosed and treated 17 adults in whom we diagnosed coeliac disease. The patients were referred to the gastroenterology or medical outpatient clinics of our hospital. The diagnosis was made on the basis of two biopsies-at presentation and after a gluten-free diet-
diagnosis
and histological improvement. 6 men and 11 women (average age 43, range 18-69). 3 had a childhood history of coeliac disease (subsequently forgotten); symptoms in the others were diarrhoea (8), weight loss (5), and polymyositis (1). We found iron deficiency (mean serum iron 45 moljL) in all 9 patients tested, folate deficiency (average 2-52 nmol/L) in 9 out of 10, and vitamin B12 deficiency in 1. Coeliac disease may present unusually (eg, at age 69 or with symptoms that included polymyositis and severe
showing clinical, biochemical,
There were
VA Ivanov Queen Elizabeth Hospital for Children, London E2 8PS, UK
Compulsory treatment for Infectious disease SiR-Morton and Campbell (Feb 5, p 359) are correct in their section 37 of the UK’s Public Health (Control of 1984 contains no power for compulsory treatment Disease) Act of patients. However, many of the powers of this Act stem from the 1988 regulations, and this applies to tuberculosis. Section 37 only allows for removal to a suitable hospital; the person is free to walk out of the hospital immediately. Section 38 allows for detention but it can only be used if the person is already in hospital. A justice of the peace has to follow the vehicle being used to convey a person under section 37 so that a section 38 order can be served to prevent that person walking out. The view that treatment can be compulsory may thus arise from this compulsory detention. If the patient refuses treatment the section 38 order can be continued and when he or she complies the order can be lifted. The situation may arise in which patients can only leave hospital if they take adequate treatment-not technically compulsory treatment but the same thing. A combination of removal and essentially detention (sections 37 and 38) should be considered in the long overdue review of the law on communicable diseases, as should the ethical and legal problems arising from the public health threat of multi-drug resistant tuberculosis. comment that
proteinuria). We noted raised levels of anti-gliadin IgA in all 4 patients tested. The possibility of screening for coeliac disease by non-invasive serological testing in adults has been addressed previously.1.2 Of 25 patients with positive serum reticulin or gliadin antibody titres but normal small bowel on biopsy, 7 were found to develop villous atrophy during median followup of 5 years.3 Coeliac disease is underdiagnosed and a raised level of awareness could result in an increase in diagnosis-by noninvasive serological testing or by more duodenal biopsies during endoscopy for non-specific complaints. S D H Malnick, Y Lurie, D D Bass, D Geltner Department of Internal Medicine C and Division of Gastroenterology, Kaplan Hospital, Rehovot, Israel 1
2
Keith Neal
Watson EGP, McMillan SA, Dickey W, Biggart JD, Porter KG. Detection of undiagnosed coeliac disease with atypical features using antireticulin and antigliadin antibodies. Q J Med 1992; 84: 713-18. Carroccio A, Tacono G, Montalto G, et al. Immunologic and absorptive tests in celiac disease: can they replace intestinal biopsies? Scand J Gastroenterol 1993; 28: 673-76. Collin P, Helin M, Maki M, Hallstrom O, Karvonen A-L. Follow-up of patients positive in reticulin and gliadin antibody tests with normal small-bowel biopsy findings. Scand J Gastroenterol 1993; 28: 595-98.
Department of Public Health Medicine and Epidemiology, University Hospital, Queen’s Medical Centre, Nottingham NG7 2UH, UK
3
Cigarette smoking in the next world
SiR-Challacombe stresses the importance of reliable noninvasive screening tests for coeliac disease. I wish to report a clinical observation which may be a first step towards such a
mx-1 was asnamea to
see tne
pnotograpn presented by
Nussenzweig and Biggs (Feb 5, p 365). However, the message in English displayed on that cigarette vending machine must be for foreign visitors. There are no Japanese words there with the same meaning: the part in Japanese simply tells people how to use the machine and warns that underage smoking is prohibited by law. "... over there" says the message "Cigarettes are offered
to
express friendliness". Over there may
mean
"the
test.
A boy now aged 8 years presented at the age of 3 years with steatorrhoea, irritability, distension of the abdomen, and
growth failure. A jejunal biopsy showed mucosal atrophy. He was put on a gluten-free diet; all clinical manifestations cleared and reappeared on rechallenge with gluten. Ever since, he has been on a gluten-free diet and symptom-free. 675