- Email: [email protected]
Control of bleeding in advanced cancer
1290
such a programme for one year, we want to re-emphasise our call for international effort to continue to stop the further spread of bloodbome diseases among children in Romania. an
University Children’s Hospital, University of Basel,
CH. RUDIN
CH-4058 Basel, Switzerland
P. W. NARS
AIDS in
Nicaragua
SIR,-Dr Summerfield (April 20, p 967) reports on the ending of the "Contra" war and the AIDS situation in Nicaragua, and we welcome the attention given to this issue. The source of this item seems to be a report that we wrote for the Nicaragua Health Fund newsletter.1 Since then information on HIV infection amongst returnees from Honduras has revealed a different situation. Summerfield suggests that the return of Contra troops and refugees from Honduras has had a significant impact on the small number of Nicaraguans identified as seropositive. In an earlier letter to The Lancec2 we showed that this concern was largely unfounded. Only 1 Contra and 4 refugees, out of more than 12 000 people tested, were HIV antibody positive, the apparent explanation being that Nicaraguans who lived in Honduras during the war stayed in the border region with little contact with urban areas in the centre and north of the country where two-thirds of the people with AIDS in Honduras have been identified. Whilst it is true that 47 people had been identified as HIV seropositive (up to Sept 30,1990), only 26 are Nicaraguan and the remainder have left the country. Injecting of illegal drugs is not a problem in Nicaragua, as implied by Summerfield, but the frequency of intramuscular injections of antibiotics and vitamins bought over the counter would be a potential route of transmission if the availability of sterile needles and syringes cannot be guaranteed. Social dislocation and poverty due to war are thought to be factors facilitating the spread of sexually transmitted diseases. Low intensity wars leading to destabilisation, especially in rural areas, are also seen as creating conditions for HIV transmission in countries such as Mozambique.3 The paradoxical situation of Nicaragua derives from the observation that ten years of this type of warfare seem to have protected the country from AIDS by limiting contact with the aggressor. The Fundación Nimehuatzin is a European Community Task Force on AIDS funded project, which was founded in collaboration with a group of gay health educators (CEP-SIDA) who instigated AIDS prevention in 1986. Its objectives are not confined to epidemiological surveillance of HIV but aim to develop a culturally appropriate programme of education and condom promotion to reduce the incidence of sexually transmitted diseases and population risk of AIDS in Nicaragua. RITA ARAUZ NICOLA LOW ANNA GORTER GEORGE DAVEY SMITH
Fundación Nimehuatzin, Casa 68,
Managua, Nicaragua 1. Low N. Is AIDS
a problem in Nicaragua? Nicaragua Health Fund Newsl 1990 (autumn). 2. Low N, Davey Smith G, Gorter A, Arauz R AIDS and migrant populations m Nicaragua. Lancet 1990; 336: 1593-94. 3. Baldo M, Cabral AJ. Low intensity wars and social determination of the HIV transmission: the search for a new paradigm to guide research and control of the HIV-AIDS pandemic. In: Proceedings of Maputo Conference on Health in Transition in Southern Africa (April 9-16, 1990). New York: CHISA, 1990.
Control of
bleeding
in advanced
cancer
SIR,-Mrs McElligot and her colleagues (Feb 16, p 431) and Dr Regnard (April 20, p 974) describe the use of topical medication, including tranexamic acid, alum, and sucralfate, for haemorrhage in patients with locally advanced malignant tumours. Although these approaches are of interest, their place in the management of haemorrhage in such patients remains unclear. In most patients, definitive palliative local treatment with radiotherapy will provide effective control of bleeding for the lifespan of the patient without the need for continued medication. Published data show that haemoptysis,l rectal bleeding,2 and
haematuria3are controlled after only short palliative courses of irradiation in most patients. We have reviewed our experience of palliative irradiation in the treatment of relapsed ovarian cancer after chemotherapy. In a consecutive series of 54 patients, 8 were treated for vaginal haemorrhage from pelvic tumour invading the vaginal vault. Complete resolution of bleeding was seen in all 8 patients after a short course of irradiation; our standard dose in this situation was only 2 doses of 4 Gy on consecutive days. Such treatment is accompanied by few if any side-effects and causes minimum disruption to the patient; it may also be given after previous irradiation. At present topical therapy should be reserved for those few patients in whom local irradiation is not effective or feasible and preferably should be given in the context of a clinical trial to evaluate its true efficacy. Department of Radiotherapy and Oncology, Royal Marsden Hospital,
P. J. HOSKIN
London SW3 6JJ, UK
P. R. BLAKE
1. Collins
TM, Ash DV, Close HJ, Thorogood J. An evaluation of the palliative role of in inoperable carcinoma of the bronchus. Clin Radiol 1989; 39:
radiotherapy 284-86.
Kerr GR, Amott SJ. External beam radiotherapy for rectal adenocarcinoma. Br J Surg 1987; 74: 455-59. 3. Green M, George FW. Radiotherapy of advanced localised bladder cancer. J Urol 1974; 111: 611-12. 2.
Taylor RE,
Man-to-man transmission of melioidosis SIR,-Melioidosis, a highly fatal infectious disease of South-East Asia, is caused by Pseudomonaspseudomallei, a free-living bacterium widely found in soil and surface water in endemic areas.’ The disease is most common during the rainy seasonMost cases arise through soil contact or occupations such as farming. However, laboratory accidents have been reported,3,4 as has contamination of fluids or equipment.s We are aware of only one report of man-to-man transmission, this being from a man with chronic prostatitis whose wife had a raised haemagglutination titre.1 In June, 1990, a Thai man, aged 45, was referred from southern Thailand to this hospital in Bangkok. He had been a tin miner and he cleaned soil by high-pressure hosing. 10 years previously he began to experience periodic pain in his left shoulder, ascribed to physical effort. In May, 1990, he was referred for physiotherapy but after a few days of deep-heat therapy, the pain increased and fever developed. Incision at the left shoulder joint yielded purulent discharge. Amoxycillin/clavulanic acid and aztreonam had little effect and the patient was referred to Ramathibodi Hospital, Bangkok. He had arthritis of left elbow, knees, right ankle, and left shoulder, and an X-ray of the shoulder revealed bony destruction with
a
dense sclerotic border
at
the humeral head. A chest
radiograph showed bilateral diffuse patchy infiltration, reflecting bloodbome pneumonia. The diagnosis of disseminated septicaemic melioidosis was confirmed by the presence of P pseudomallei on culture of blood, discharge, and aspirates. Ceftazidime and co-trimoxazole were given. When sensitivity tests indicated resistance to co-trimoxazole, only ceftazidime was maintained. The patient recovered after 6 weeks. While he was in hospital, previously undetected diabetes mellitus was found. A 53-year-old woman, the patient’s sister, lived in north-eastern Thailand. In June, 1990, she visited her sick brother and nursed him devotedly, staying in hospital with her brother’s wife. 10 days later, she had pain in the right inguinal canal that was referred to the right hip. No bone or joint abnormalities were demonstrated by X-ray. She had hepatosplenomegaly and abdominal tenderness. Appendiceal abscess was diagnosed but at laparotomy the appendix was normal. Appendectomy was done. Because of worsening fever and pain she was referred here. She had a history of diabetes with irregular follow-up. Examination revealed tachypnea, crackles in the right lower lung, and swelling and tenderness of the right groin. No evidence of any abscess was found by ultrasonography. Groin aspiration yielded only a small amount of blood from which no organism could be isolated. Chest films showed interstitial and patchy infiltration. Blood cultures grew P pseudomallei. After
such a programme for one year, we want to re-emphasise our call for international effort to continue to stop the further spread of bloodbome diseases among children in Romania. an
University Children’s Hospital, University of Basel,
CH. RUDIN
CH-4058 Basel, Switzerland
P. W. NARS
AIDS in
Nicaragua
SIR,-Dr Summerfield (April 20, p 967) reports on the ending of the "Contra" war and the AIDS situation in Nicaragua, and we welcome the attention given to this issue. The source of this item seems to be a report that we wrote for the Nicaragua Health Fund newsletter.1 Since then information on HIV infection amongst returnees from Honduras has revealed a different situation. Summerfield suggests that the return of Contra troops and refugees from Honduras has had a significant impact on the small number of Nicaraguans identified as seropositive. In an earlier letter to The Lancec2 we showed that this concern was largely unfounded. Only 1 Contra and 4 refugees, out of more than 12 000 people tested, were HIV antibody positive, the apparent explanation being that Nicaraguans who lived in Honduras during the war stayed in the border region with little contact with urban areas in the centre and north of the country where two-thirds of the people with AIDS in Honduras have been identified. Whilst it is true that 47 people had been identified as HIV seropositive (up to Sept 30,1990), only 26 are Nicaraguan and the remainder have left the country. Injecting of illegal drugs is not a problem in Nicaragua, as implied by Summerfield, but the frequency of intramuscular injections of antibiotics and vitamins bought over the counter would be a potential route of transmission if the availability of sterile needles and syringes cannot be guaranteed. Social dislocation and poverty due to war are thought to be factors facilitating the spread of sexually transmitted diseases. Low intensity wars leading to destabilisation, especially in rural areas, are also seen as creating conditions for HIV transmission in countries such as Mozambique.3 The paradoxical situation of Nicaragua derives from the observation that ten years of this type of warfare seem to have protected the country from AIDS by limiting contact with the aggressor. The Fundación Nimehuatzin is a European Community Task Force on AIDS funded project, which was founded in collaboration with a group of gay health educators (CEP-SIDA) who instigated AIDS prevention in 1986. Its objectives are not confined to epidemiological surveillance of HIV but aim to develop a culturally appropriate programme of education and condom promotion to reduce the incidence of sexually transmitted diseases and population risk of AIDS in Nicaragua. RITA ARAUZ NICOLA LOW ANNA GORTER GEORGE DAVEY SMITH
Fundación Nimehuatzin, Casa 68,
Managua, Nicaragua 1. Low N. Is AIDS
a problem in Nicaragua? Nicaragua Health Fund Newsl 1990 (autumn). 2. Low N, Davey Smith G, Gorter A, Arauz R AIDS and migrant populations m Nicaragua. Lancet 1990; 336: 1593-94. 3. Baldo M, Cabral AJ. Low intensity wars and social determination of the HIV transmission: the search for a new paradigm to guide research and control of the HIV-AIDS pandemic. In: Proceedings of Maputo Conference on Health in Transition in Southern Africa (April 9-16, 1990). New York: CHISA, 1990.
Control of
bleeding
in advanced
cancer
SIR,-Mrs McElligot and her colleagues (Feb 16, p 431) and Dr Regnard (April 20, p 974) describe the use of topical medication, including tranexamic acid, alum, and sucralfate, for haemorrhage in patients with locally advanced malignant tumours. Although these approaches are of interest, their place in the management of haemorrhage in such patients remains unclear. In most patients, definitive palliative local treatment with radiotherapy will provide effective control of bleeding for the lifespan of the patient without the need for continued medication. Published data show that haemoptysis,l rectal bleeding,2 and
haematuria3are controlled after only short palliative courses of irradiation in most patients. We have reviewed our experience of palliative irradiation in the treatment of relapsed ovarian cancer after chemotherapy. In a consecutive series of 54 patients, 8 were treated for vaginal haemorrhage from pelvic tumour invading the vaginal vault. Complete resolution of bleeding was seen in all 8 patients after a short course of irradiation; our standard dose in this situation was only 2 doses of 4 Gy on consecutive days. Such treatment is accompanied by few if any side-effects and causes minimum disruption to the patient; it may also be given after previous irradiation. At present topical therapy should be reserved for those few patients in whom local irradiation is not effective or feasible and preferably should be given in the context of a clinical trial to evaluate its true efficacy. Department of Radiotherapy and Oncology, Royal Marsden Hospital,
P. J. HOSKIN
London SW3 6JJ, UK
P. R. BLAKE
1. Collins
TM, Ash DV, Close HJ, Thorogood J. An evaluation of the palliative role of in inoperable carcinoma of the bronchus. Clin Radiol 1989; 39:
radiotherapy 284-86.
Kerr GR, Amott SJ. External beam radiotherapy for rectal adenocarcinoma. Br J Surg 1987; 74: 455-59. 3. Green M, George FW. Radiotherapy of advanced localised bladder cancer. J Urol 1974; 111: 611-12. 2.
Taylor RE,
Man-to-man transmission of melioidosis SIR,-Melioidosis, a highly fatal infectious disease of South-East Asia, is caused by Pseudomonaspseudomallei, a free-living bacterium widely found in soil and surface water in endemic areas.’ The disease is most common during the rainy seasonMost cases arise through soil contact or occupations such as farming. However, laboratory accidents have been reported,3,4 as has contamination of fluids or equipment.s We are aware of only one report of man-to-man transmission, this being from a man with chronic prostatitis whose wife had a raised haemagglutination titre.1 In June, 1990, a Thai man, aged 45, was referred from southern Thailand to this hospital in Bangkok. He had been a tin miner and he cleaned soil by high-pressure hosing. 10 years previously he began to experience periodic pain in his left shoulder, ascribed to physical effort. In May, 1990, he was referred for physiotherapy but after a few days of deep-heat therapy, the pain increased and fever developed. Incision at the left shoulder joint yielded purulent discharge. Amoxycillin/clavulanic acid and aztreonam had little effect and the patient was referred to Ramathibodi Hospital, Bangkok. He had arthritis of left elbow, knees, right ankle, and left shoulder, and an X-ray of the shoulder revealed bony destruction with
a
dense sclerotic border
at
the humeral head. A chest
radiograph showed bilateral diffuse patchy infiltration, reflecting bloodbome pneumonia. The diagnosis of disseminated septicaemic melioidosis was confirmed by the presence of P pseudomallei on culture of blood, discharge, and aspirates. Ceftazidime and co-trimoxazole were given. When sensitivity tests indicated resistance to co-trimoxazole, only ceftazidime was maintained. The patient recovered after 6 weeks. While he was in hospital, previously undetected diabetes mellitus was found. A 53-year-old woman, the patient’s sister, lived in north-eastern Thailand. In June, 1990, she visited her sick brother and nursed him devotedly, staying in hospital with her brother’s wife. 10 days later, she had pain in the right inguinal canal that was referred to the right hip. No bone or joint abnormalities were demonstrated by X-ray. She had hepatosplenomegaly and abdominal tenderness. Appendiceal abscess was diagnosed but at laparotomy the appendix was normal. Appendectomy was done. Because of worsening fever and pain she was referred here. She had a history of diabetes with irregular follow-up. Examination revealed tachypnea, crackles in the right lower lung, and swelling and tenderness of the right groin. No evidence of any abscess was found by ultrasonography. Groin aspiration yielded only a small amount of blood from which no organism could be isolated. Chest films showed interstitial and patchy infiltration. Blood cultures grew P pseudomallei. After