- Email: [email protected]
Diphtheria after visit to Russia
grounds "that the nearest relative of the patient unreasonably objects to the making of an application for admission for treatment... in respect of the patient". In practice, this is a complicated, time-consuming, and expensive procedure. Not surprisingly, social workers are very hesitant to use this section and patients do, albeit rather infrequently, continue to deteriorate in the community because of their nearest relatives’ wishes. If the Law Commission avoids creating similar pitfalls for medical treatment, it can only be in the mentally incapacitated patient’s best interests. Naresh Gandhi Academic Department of Psychiatry, St Mary’s Hospital Medical School, London W2 1NY, UK
Martin Lock North West Thames Southall
Regional Forensic Services, Three Bridges Regional Secure Unit,
Alcuin Wilkie Department of Psychiatry, St Mary’s Hospital
Noel Kennedy Westminster Social Services, St Mary’s Hospital
1 Peckham D. Emergency treatment against a patient’s wishes. BMJ 1992; 305: 478-79. 2 Atkins M, Riccio M. Treating physical illness without consent. Psychiat Bull 1992; 16: 444-45. 3 Mental Health Act 1983. London: HM Stationery Office, 1983.
SIR—Your conclusions about the Law Commission recommendations are timely, because the House of Lords Select Committee on medical ethics will soon comment inter alia on this issue. In response to repeated pleas not to use life-
sustaining and life-prolonging technology inappropriately to extend the process of dying, doctors are learning to say no. It is important for lawyers and others considering this issue to realise how frequently such decisions are now made informally as part of good practice, outside the controversy with respect to vegetative patients. A report from two intensive care units from San Francisco found that almost half the deaths followed a decision to limit treatment.1 Only 5% of patients were competent, and only 12% of the incompetent had living wills. Most decisions were therefore reached informally in consultation with families. We have reported that half the deaths in the Glasgow neurosurgical unit followed a written note in the medical record to limit treatmentand audit of perioperative deaths in all Glasgow hospitals showed that 41 % followed such a decision. When intensive care or emergency surgery are used inappropriately doctors sometimes offer as an excuse their uncertainty about the law. It is to be hoped therefore that those considering these matters will be able to reassure doctors about the propriety and legality of withholding or withdrawing nonbeneficial or unwanted treatment, so that they can continue to act in their patients’ best interests without the need for the kind of bureaucracy feared by The Lancet. That some formality may continue to be required for certain controversial treatments should not be allowed to complicate the much more commonplace decisions that have to be made many times every day in acute
hospitals.
Bryan Jennett Department of Neurosurgery, Institute of Neurological Sciences, Southern General Hospital, Glasgow G51 4TF, UK 1
Smedira NG, Evans BH, Grais LS, et al. Withholding and withdrawal of life support from the critically ill. N Engl JMed 1990; 322: 309-14. 2 Barlow P, Jennett B. Decisions to limit treatment in a neurosurgical unit: an aspect of audit of mortality. Scott Med J 1991; 36: 109-11.
Diphtheria after visit to Russia SIR-A 43-year-old healthy Finnish man visited St Petersburg in Russia for 3 days during Easter, 1993. 12 h after he returned he became acutely ill with a sore throat. He contacted a doctor and was given oral penicillin. The next day he felt worse and was sent to
Tampere Univeristy Hospital.
On admission he had an extremely sore throat and could not eat or speak. There were large greyish membranes on the hypopharynx and the right tonsil, which was necrotic. The pharynx and right side of the neck were heavily swollen. The patient had a slight fever (37-4° C), moderate leucocytosis (15-5x 109/L), and high C-reactive protein (240 mg/L). On the day of admission, after an unsuccessful attempt to draw pus from the right peritonsillar tissue, a bilateral tonsillectomy was done. No abscess was found in the operation. Parenteral clindamycin was started. On the fourth day after the operation gram-positive rods were seen in a bacterial culture from the tonsil tissue. The next day the rods were identified as Corynebacterium diphtheriae var gravis, and were shown to produce toxin. No other pathogens were found. The culture has been sent to the Diphtheria (WHO) Reference Unit, Colindale, UK, for further typing. A throat culture taken on the day of microbiological diagnosis was negative. Because of the delayed diagnosis no antitoxin was given. After 4 days of clindamycin with a clear clinical benefit, the treatment was changed to oral erythromycin acistrate (0-4 g three times a day). 9 days after his first symptoms there was an increase in creatine kinase (1281 U/L), a high proportion of which was isoenzyme B (97 U/L), indicating myocardial origin. The electrocardiogram showed a prolongation of the QT interval and ST wave changes in the anterolateral recordings. In two-dimensional echo-
cardiographic recordings anteroseptal myocardial hypokinesia detected. 30 days after the sore throat neurological symptoms appeared: paraesthesia of the right mandibular area
was
and decreased muscular power on all four extremities. On the second week of neurological disease, weakness of the pharyngeal musculature developed. 2 months after falling ill he is still in hospital. There were no records available on the patient’s possible childhood diphtheria vaccinations. He had one dose of diphtheria vaccine during military service in 1970. A serum sample for diphtheria toxoid antibodies was negative
day 7. During his stay in St Petersburg the patient had taken part in a birthday party where drinks were taken from shared unwashed glasses and the patient kissed his local girlfriend. It was later confirmed that she has remained healthy. No throat on
culture from her is available. 33 health-care workers, who had a confirmed or probable contact with the patient’s saliva were screened for diphtheria. All the cultures were negative. 35 travellers on the same trip to St Petersburg were also screened, and 1 middle-aged healthy man was shown to harbour a toxin-producing strain in his throat. This traveller had no contact with the patient during the trip, but he too, had a local intimate contact in St Petersburg. In Finland large scale vaccination against diphtheria was started in the early 1950s. The most recent diphtheria epidemic was in 1947, and no case of endemic disease has occurred since 1961.1 Since then, despite over 50 000 Finnish citizens travelling each year to tropical countries alone, only 1 case of imported pharyngeal diphtheria has been diagnosed and that was nearly 30 years ago (1965). During the past 3 years, the incidence of diphtheria has increased sharply in Russia.2 The situation is worst in St Petersburg, where 845 cases (17 cases/100 000 inhabitants) were reported in 1992, and 498 cases from January to April, 1993 (Dr Yuri Rikushin, Pasteur Institute of St Petersburg,
personal communication). To our knowledge this is the first case of imported diphtheria acquired by a western tourist on a short trip to Russia, although 53
each year over 400 000 Finnish citizens travel each year to Russia and about 200 000 Russians visit Finland. The patient described here and the fellow traveller with a positive throat culture both had a contact with a local inhabitant, during which exchange of saliva occurred. Although diphtheria is endemic in Russia, the risk for an average traveller is not very big. However, a booster of diphtheria vaccine is recommended, even for a short trip to Russia, if the traveller is not vaccinated or has not had a booster dose within 10 years. The risk of spread of diphtheria in Finland, where the coverage of childhood vaccination is good, is improbable. However, in several countries of western Europe, surveys have shown that immunity to diphtheria is poor, especially among women over 40.3 Male individuals are better protected because they are given an additional booster dose during military service. There have been small outbreaks of diphtheria in Sweden and Denmark recently.4 With increasing travel to and from countries endemic for diphtheria, booster vaccinations of the adult population in western European countries may have to be reconsidered; and health care workers, who are at greatest risk of exposure to the saliva of diphtheria patients, should be adequately immunised. Jukka Lumio, Matti Jahkola, Risto Vuento, Olli Haikala, Juhani Eskola Departments of Internal Medicine and Clinical Microbiology, Tampere University Hospital, 33521 Tampere, Finland; and Department of Infectious Disease Epidemiology, National Public Health Institute, Helsinki, Finland
Figure: &bgr;-hCG after falloposcopic prostaglandin
Falloposcopy by means of LEC may lead to a new approach in the non-surgical management of unruptured tubal pregnancies. Repeated injections of PGF2a via LEC may allow adequate doses, depending on initial &bgr;-hCG. However, PGF2lX is not necessarily the only drug to be used in this indication; methotrexateor even hypertonic glucose solution’ could also be used. H Kiss, Ch
1 1
2 3 4
The Official Statistics of Finland XI:72,73. Helsinki: Public Health and Medical Care, 1974: 125. WHO. Expanded program of immunization: outbreak of diphtheria, update. Wkly Epidemiol Rec 1993; 68: 134-38. Christensson B, Böttiger M. Serological immunity to diphtheria in Sweden in 1978 and 1984. Scand J Infect Dis 1986; 18: 227-33. Karzon DT, Edwards KM. Editorial: diphtheria outbreaks in immunized population. N Engl J Med 1988; 318: 41-43.
2
3 4 5
Falloposcopic instillation of prostaglandin in tubal pregnancy SIR—Falloposcopy, the transcervical endoscopic examination fallopian tube by a linear everting catheter (LEC), was reported in 1990.1 It has been used diagnostically in infertile patients. Visualisation of the tubal lumen may assist in planning rational treatment of infertility, permitting surgery or tubal transfer of embryos or gametes if the mucosa is normal. A further possible application is the diagnosis of tubal pregnancy. The LEC may also be useful in the non-surgical treatment of unruptured tubal pregnancies. We tried to manage an unruptured tubal pregnancy with high initial beta-human chorionic gonadotropin (&bgr;-hCG) levels by prolonged prostaglandin (PG) F2&agr; application via LEC. Previously, non-surgical treatment of tubal pregnancy by local PGF21X instillation had been limited to cases with initial &bgr;-hCG under 2500 mIU/mL serum; higher concentrations were correlated with unfavou-
Egarter, R Wenzl, P Husslein
Department of Gynecology and Obstetrics I, University of Vienna, A-1090 Vienna, Austria
Kerin J, Daykhovsky L, Grundfest W,
Surrey E. Falloposcopy, a microendoscopic, transvaginal technique for diagnosis and treating endotubal disease incorporating guide wire cannulation and direct balloon tuboblasty. J Reprod Med 1990; 35: 606-12. Egarter Ch, Fitz R, Spona J, Vavra N, Husslein P. Treatment of tubal pregnancy with prostaglandins: correlation between hormone profile and success. J Obstet Gynecol 1991; 11: 119-22. Egarter Ch, Husslein P. Treatment of tubal pregnancy by prostaglandins. Lancet 1988; i: 1104-05. Pansky M, Bukovsky I, Golan A, et al. Tubal patency after local methotrexate injection for tubal pregnancy. Lancet 1989; ii: 967-68. Lang PF, Tamussino K, Hönigl W, Ralph G. Treatment of unruptured tubal pregnancy by laparoscopic instillation of hyperosmolar glucose solution. Am J Obstet Gynecol 1992; 166: 1378-81.
of the
Non-invasive antenatal
rable outcome.2,3 In a 25-year-old patient with a 3-year history of infertility, tubal pregnancy was diagnosed by vaginal ultrasound. &bgr;-hCG was 4506 mIU/mL. Under general anaesthesia and laparoscopic control, the LEC was introduced into the relevant tube. The tip of the catheter was positioned directly on the gestational sac. After visualising the lumen of the fallopian tube and the tubal gestation, 10 mg PGF21X was injected. Laparoscopy was ended with the LEC left in place. 3 hours later, a second dose of 5 mg was injected with no adverse effects and the catheter was removed. The patient was discharged the next day. Serial &bgr;-hCG rapidly fell, and was undetctable after 4 weeks (figure). Vaginal ultrasound revealed that the tubal pregnancy had disappeared.
SiR-Lo and colleagues (May 1, p 1147) attempt to determine the rhesus status of fetuses in utero by non-invasive means. They admit that this method has not reached the precision required for routine application (because a 20% false negative and almost 20% false positive rate is too high), but it shows great promise. Furthermore, it will contribute to a better understanding of normal fetomaternal physiology and to the quest for a non-invasive but definitive antenatal diagnostic procedure that would carry no risk to the fetus. Research into the isolation and genetic analysis of fetal nucleated cells in the maternal circulation is gaining momentum, and three types of cell—trophoblast,1 lymphocytes,2 and nucleated fetal erythrocytes (NFEs)3—are the main focus of attention. For several reasons the first and last of these are the most likely candidates and each has its proponents. Trophoblast is physiologically shed into the maternal circulation, whereas, in early pregnancy, NFEs are the most common type of nucleated fetal cell in the fetal circulation.4 However, there is a growing opinion favouring NFEs.5 Because Lo et al did not use any relative enrichment techniques, it is not known if they analysed one particular type of cell or a combination of types. However, from their polymerase chain reaction results, it seems that in most cases there is 1 fetal cell for every 105-106 maternal cells. These workers clearly demonstrate the ability to detect signals in patients with substantial antibody concentrations, but do not
54
diagnosis
Martin Lock North West Thames Southall
Regional Forensic Services, Three Bridges Regional Secure Unit,
Alcuin Wilkie Department of Psychiatry, St Mary’s Hospital
Noel Kennedy Westminster Social Services, St Mary’s Hospital
1 Peckham D. Emergency treatment against a patient’s wishes. BMJ 1992; 305: 478-79. 2 Atkins M, Riccio M. Treating physical illness without consent. Psychiat Bull 1992; 16: 444-45. 3 Mental Health Act 1983. London: HM Stationery Office, 1983.
SIR—Your conclusions about the Law Commission recommendations are timely, because the House of Lords Select Committee on medical ethics will soon comment inter alia on this issue. In response to repeated pleas not to use life-
sustaining and life-prolonging technology inappropriately to extend the process of dying, doctors are learning to say no. It is important for lawyers and others considering this issue to realise how frequently such decisions are now made informally as part of good practice, outside the controversy with respect to vegetative patients. A report from two intensive care units from San Francisco found that almost half the deaths followed a decision to limit treatment.1 Only 5% of patients were competent, and only 12% of the incompetent had living wills. Most decisions were therefore reached informally in consultation with families. We have reported that half the deaths in the Glasgow neurosurgical unit followed a written note in the medical record to limit treatmentand audit of perioperative deaths in all Glasgow hospitals showed that 41 % followed such a decision. When intensive care or emergency surgery are used inappropriately doctors sometimes offer as an excuse their uncertainty about the law. It is to be hoped therefore that those considering these matters will be able to reassure doctors about the propriety and legality of withholding or withdrawing nonbeneficial or unwanted treatment, so that they can continue to act in their patients’ best interests without the need for the kind of bureaucracy feared by The Lancet. That some formality may continue to be required for certain controversial treatments should not be allowed to complicate the much more commonplace decisions that have to be made many times every day in acute
hospitals.
Bryan Jennett Department of Neurosurgery, Institute of Neurological Sciences, Southern General Hospital, Glasgow G51 4TF, UK 1
Smedira NG, Evans BH, Grais LS, et al. Withholding and withdrawal of life support from the critically ill. N Engl JMed 1990; 322: 309-14. 2 Barlow P, Jennett B. Decisions to limit treatment in a neurosurgical unit: an aspect of audit of mortality. Scott Med J 1991; 36: 109-11.
Diphtheria after visit to Russia SIR-A 43-year-old healthy Finnish man visited St Petersburg in Russia for 3 days during Easter, 1993. 12 h after he returned he became acutely ill with a sore throat. He contacted a doctor and was given oral penicillin. The next day he felt worse and was sent to
Tampere Univeristy Hospital.
On admission he had an extremely sore throat and could not eat or speak. There were large greyish membranes on the hypopharynx and the right tonsil, which was necrotic. The pharynx and right side of the neck were heavily swollen. The patient had a slight fever (37-4° C), moderate leucocytosis (15-5x 109/L), and high C-reactive protein (240 mg/L). On the day of admission, after an unsuccessful attempt to draw pus from the right peritonsillar tissue, a bilateral tonsillectomy was done. No abscess was found in the operation. Parenteral clindamycin was started. On the fourth day after the operation gram-positive rods were seen in a bacterial culture from the tonsil tissue. The next day the rods were identified as Corynebacterium diphtheriae var gravis, and were shown to produce toxin. No other pathogens were found. The culture has been sent to the Diphtheria (WHO) Reference Unit, Colindale, UK, for further typing. A throat culture taken on the day of microbiological diagnosis was negative. Because of the delayed diagnosis no antitoxin was given. After 4 days of clindamycin with a clear clinical benefit, the treatment was changed to oral erythromycin acistrate (0-4 g three times a day). 9 days after his first symptoms there was an increase in creatine kinase (1281 U/L), a high proportion of which was isoenzyme B (97 U/L), indicating myocardial origin. The electrocardiogram showed a prolongation of the QT interval and ST wave changes in the anterolateral recordings. In two-dimensional echo-
cardiographic recordings anteroseptal myocardial hypokinesia detected. 30 days after the sore throat neurological symptoms appeared: paraesthesia of the right mandibular area
was
and decreased muscular power on all four extremities. On the second week of neurological disease, weakness of the pharyngeal musculature developed. 2 months after falling ill he is still in hospital. There were no records available on the patient’s possible childhood diphtheria vaccinations. He had one dose of diphtheria vaccine during military service in 1970. A serum sample for diphtheria toxoid antibodies was negative
day 7. During his stay in St Petersburg the patient had taken part in a birthday party where drinks were taken from shared unwashed glasses and the patient kissed his local girlfriend. It was later confirmed that she has remained healthy. No throat on
culture from her is available. 33 health-care workers, who had a confirmed or probable contact with the patient’s saliva were screened for diphtheria. All the cultures were negative. 35 travellers on the same trip to St Petersburg were also screened, and 1 middle-aged healthy man was shown to harbour a toxin-producing strain in his throat. This traveller had no contact with the patient during the trip, but he too, had a local intimate contact in St Petersburg. In Finland large scale vaccination against diphtheria was started in the early 1950s. The most recent diphtheria epidemic was in 1947, and no case of endemic disease has occurred since 1961.1 Since then, despite over 50 000 Finnish citizens travelling each year to tropical countries alone, only 1 case of imported pharyngeal diphtheria has been diagnosed and that was nearly 30 years ago (1965). During the past 3 years, the incidence of diphtheria has increased sharply in Russia.2 The situation is worst in St Petersburg, where 845 cases (17 cases/100 000 inhabitants) were reported in 1992, and 498 cases from January to April, 1993 (Dr Yuri Rikushin, Pasteur Institute of St Petersburg,
personal communication). To our knowledge this is the first case of imported diphtheria acquired by a western tourist on a short trip to Russia, although 53
each year over 400 000 Finnish citizens travel each year to Russia and about 200 000 Russians visit Finland. The patient described here and the fellow traveller with a positive throat culture both had a contact with a local inhabitant, during which exchange of saliva occurred. Although diphtheria is endemic in Russia, the risk for an average traveller is not very big. However, a booster of diphtheria vaccine is recommended, even for a short trip to Russia, if the traveller is not vaccinated or has not had a booster dose within 10 years. The risk of spread of diphtheria in Finland, where the coverage of childhood vaccination is good, is improbable. However, in several countries of western Europe, surveys have shown that immunity to diphtheria is poor, especially among women over 40.3 Male individuals are better protected because they are given an additional booster dose during military service. There have been small outbreaks of diphtheria in Sweden and Denmark recently.4 With increasing travel to and from countries endemic for diphtheria, booster vaccinations of the adult population in western European countries may have to be reconsidered; and health care workers, who are at greatest risk of exposure to the saliva of diphtheria patients, should be adequately immunised. Jukka Lumio, Matti Jahkola, Risto Vuento, Olli Haikala, Juhani Eskola Departments of Internal Medicine and Clinical Microbiology, Tampere University Hospital, 33521 Tampere, Finland; and Department of Infectious Disease Epidemiology, National Public Health Institute, Helsinki, Finland
Figure: &bgr;-hCG after falloposcopic prostaglandin
Falloposcopy by means of LEC may lead to a new approach in the non-surgical management of unruptured tubal pregnancies. Repeated injections of PGF2a via LEC may allow adequate doses, depending on initial &bgr;-hCG. However, PGF2lX is not necessarily the only drug to be used in this indication; methotrexateor even hypertonic glucose solution’ could also be used. H Kiss, Ch
1 1
2 3 4
The Official Statistics of Finland XI:72,73. Helsinki: Public Health and Medical Care, 1974: 125. WHO. Expanded program of immunization: outbreak of diphtheria, update. Wkly Epidemiol Rec 1993; 68: 134-38. Christensson B, Böttiger M. Serological immunity to diphtheria in Sweden in 1978 and 1984. Scand J Infect Dis 1986; 18: 227-33. Karzon DT, Edwards KM. Editorial: diphtheria outbreaks in immunized population. N Engl J Med 1988; 318: 41-43.
2
3 4 5
Falloposcopic instillation of prostaglandin in tubal pregnancy SIR—Falloposcopy, the transcervical endoscopic examination fallopian tube by a linear everting catheter (LEC), was reported in 1990.1 It has been used diagnostically in infertile patients. Visualisation of the tubal lumen may assist in planning rational treatment of infertility, permitting surgery or tubal transfer of embryos or gametes if the mucosa is normal. A further possible application is the diagnosis of tubal pregnancy. The LEC may also be useful in the non-surgical treatment of unruptured tubal pregnancies. We tried to manage an unruptured tubal pregnancy with high initial beta-human chorionic gonadotropin (&bgr;-hCG) levels by prolonged prostaglandin (PG) F2&agr; application via LEC. Previously, non-surgical treatment of tubal pregnancy by local PGF21X instillation had been limited to cases with initial &bgr;-hCG under 2500 mIU/mL serum; higher concentrations were correlated with unfavou-
Egarter, R Wenzl, P Husslein
Department of Gynecology and Obstetrics I, University of Vienna, A-1090 Vienna, Austria
Kerin J, Daykhovsky L, Grundfest W,
Surrey E. Falloposcopy, a microendoscopic, transvaginal technique for diagnosis and treating endotubal disease incorporating guide wire cannulation and direct balloon tuboblasty. J Reprod Med 1990; 35: 606-12. Egarter Ch, Fitz R, Spona J, Vavra N, Husslein P. Treatment of tubal pregnancy with prostaglandins: correlation between hormone profile and success. J Obstet Gynecol 1991; 11: 119-22. Egarter Ch, Husslein P. Treatment of tubal pregnancy by prostaglandins. Lancet 1988; i: 1104-05. Pansky M, Bukovsky I, Golan A, et al. Tubal patency after local methotrexate injection for tubal pregnancy. Lancet 1989; ii: 967-68. Lang PF, Tamussino K, Hönigl W, Ralph G. Treatment of unruptured tubal pregnancy by laparoscopic instillation of hyperosmolar glucose solution. Am J Obstet Gynecol 1992; 166: 1378-81.
of the
Non-invasive antenatal
rable outcome.2,3 In a 25-year-old patient with a 3-year history of infertility, tubal pregnancy was diagnosed by vaginal ultrasound. &bgr;-hCG was 4506 mIU/mL. Under general anaesthesia and laparoscopic control, the LEC was introduced into the relevant tube. The tip of the catheter was positioned directly on the gestational sac. After visualising the lumen of the fallopian tube and the tubal gestation, 10 mg PGF21X was injected. Laparoscopy was ended with the LEC left in place. 3 hours later, a second dose of 5 mg was injected with no adverse effects and the catheter was removed. The patient was discharged the next day. Serial &bgr;-hCG rapidly fell, and was undetctable after 4 weeks (figure). Vaginal ultrasound revealed that the tubal pregnancy had disappeared.
SiR-Lo and colleagues (May 1, p 1147) attempt to determine the rhesus status of fetuses in utero by non-invasive means. They admit that this method has not reached the precision required for routine application (because a 20% false negative and almost 20% false positive rate is too high), but it shows great promise. Furthermore, it will contribute to a better understanding of normal fetomaternal physiology and to the quest for a non-invasive but definitive antenatal diagnostic procedure that would carry no risk to the fetus. Research into the isolation and genetic analysis of fetal nucleated cells in the maternal circulation is gaining momentum, and three types of cell—trophoblast,1 lymphocytes,2 and nucleated fetal erythrocytes (NFEs)3—are the main focus of attention. For several reasons the first and last of these are the most likely candidates and each has its proponents. Trophoblast is physiologically shed into the maternal circulation, whereas, in early pregnancy, NFEs are the most common type of nucleated fetal cell in the fetal circulation.4 However, there is a growing opinion favouring NFEs.5 Because Lo et al did not use any relative enrichment techniques, it is not known if they analysed one particular type of cell or a combination of types. However, from their polymerase chain reaction results, it seems that in most cases there is 1 fetal cell for every 105-106 maternal cells. These workers clearly demonstrate the ability to detect signals in patients with substantial antibody concentrations, but do not
54
diagnosis