ECTOPIC GESTATION AND HYDATIDIFORM MOLE IN CLOMIPHENE-INDUCED PREGNANCIES

1094

repair (see table). Since the amount of bound caralso rose, the high N.A.-A.A.F. repair values must have resulted from increased repair stimulation due to more damaged D.N.A. sites and not from more active repair-synthe-

tients recumbent for 30 minutes after the intravenous administration of labetalol and measure standing blood-pressure under supervision before allowing them to become fully ambulant. The effect of a single injection lasted up to 24 hours in some

induced

patients.

sising enzymes. The potential for increased accumulation of genetic damage in high-blood-pressure individuals was supported by our cytogenetic study, which showed an increased level of chromosome aberrations correlated with high blood-pressure after carcinogen treatment. Together, these results have convinced us that there is an increased genetic risk, probably expressed through an increased mutational frequency, associated with the lymphocytes from hypertensive individuals. Therefore, we can answer "yes" to the question posed by Dyer and his colleagues: "Are there bio-

In this initial small trial, intravenous labetalol has been satisfactory for the rapid reduction of blood-pressure in severely hypertensive patients. We are also continuing treatment with the oral preparation, and, since we have not so far encountered serious side-effects, it seems worthy of more extensive trials. E. AGABITI ROSEI P. M. TRUST M.R.C. Blood Pressure Western Infirmary, Glasgow G11 6NT.

J. J. BROWN

Unit,

A. F. LEVER J. I. S. ROBERTSON

cinogen

chemical variables which are related to both cancer and elevated blood-pressure?". Detailed descriptions of our results are now being prepared for publication. Unit for

Community Care Sciences, Dalby, Sweden, and Department of Medicine, Lund University Hospital.

HYPERTENSION RELATED TO D.N.A. REPAIR SYNTHESIS AND CARCINOGEN UPTAKE

StR,—The genetic aspects of hypertension have, so far, focused mainly on whether hereditary mechanisms are involved in the acquisition of high blood-pressure. We have studied D.N.A. repair synthesis in patients with hypertension (blood-pressure above the 95th percentile and below the 30th percentile), and we have found that subjects with raised bloodpressure are more likely to have D.N.A. damage than subjects with normal or low blood-pressure. Furthermore, the extent of the induced D.N.A. damage in patients with known hypertension could not be distinguished from that in subjects with only slightly elevated blood-pressure. Our results are particularly interesting in the light of a report by Dyer et al.’ pointing out that hypertensive people are at an increased risk of developing cancer.

We have used the carcinogen, N-acetoxy 2-acetylaminofluorene (N.A.-A.A.F.), to induce D.N.A. repair synthesis in lymCOMPARISON OF BLOOD-PRESSURE TO CARCINOGEN INTERACTION IN

Biochemistry 1, University of Lund, Chemical Center.

RONALD W. PERO CARL BRYNGELSSON

Department of Clinical Genetics, Lund University Hospital, Lund, Sweden.

FELIX MITELMAN

ECTOPIC GESTATION AND HYDATIDIFORM MOLE IN CLOMIPHENE-INDUCED PREGNANCIES

SIR,-Dr Berman (Nov. 1, p. 878) pointed to the undesirable consequences of clomiphene-citrate-induced pregnancies, and to the importance of reporting them, because of the widespread use of this drug. We should like to draw attention to the fact that ectopic pregnancy and hydatidiform mole may be other possible, although rare, complications of clomiphene treatment.

During

LYMPHOCYTFSS

AKE NORDÉN BENGT SCHERSTÉN THOMAS THULIN

the past year

we

have

seen

21

cases

of tubal ges-

tation, of which 3 were in clomiphene-induced pregnancies. All 3 patients suffered from sterility (primary or secondary) and,

clomiphene therapy (50-100 mg daily for five to seven all days), investigations indicated that no tubal factor was present ; and in all these cases the diagnosis of anovulatory cycles was confirmed by dilatation and curettage, laparoscopy, and hormonal assessment. During the same period we also saw 2 cases of hydatidiform mole in the group of clomiphene-induced

before

*Incorporation of (3H)dT due to background replicative synthesis in

was

the

same

both groups.

92 individuals with diastolic blood-pressures from 65 to 120 mm Hg. After 1 h exposure to 10 N.A.-A.A.F., the lymphocytes were cultured for 17 h in fresh medium containing 10 mM hydroxyurea to suppress replicative synthesis and 3H-thymidine (10 uCi/ml, 20 Ci/mmol), which was a measure of the degree of repair-synthesis stimulation. Both the incorporated radioactivity and the amount of D.N.A. were measured, so that the method could be reproduced within an experiment to +9.0%. The amount of D.N.A.-bound carcinogen remaining after induction of repair synthesis by 3H-7,12-dimethylbenz(a)anthracene (D.M.B.A.) was used to measure potential differences in carcinogen uptake. Cytogenetic confirmation of D.N.A. damage was also carried out, following phytohaemagglutinin stimulation of cell-division and collection of lymphocytes in metaphase with a colchicine block. The normal number of chromosome aberrations without N.A.-A.A.F. treatment was subtracted from the number of aberrations induced by 1 jAf N.A.-A.A.F. after 17 h repair synthesis. As the diastolic blood-pressure increased, so did N.A.-A.A.F.-

ranging

cet,

reporting the outcome of clomiphene-induced do not refer to these complications, but study of pregnancies the literature revealed some reports confirming our findings. Karow and Payne’ reported an incidence of tubal gestation in clomiphene-treated women of 1/70. Macgregor et a1.2 reported an incidence of 1/90; and in a study by Merrell National Laboratories in the United States (personal communication) the incidence was 28 in 2369 pregnancies (1/84). The overall incidence is therefore approximately 1.25% of the induced pregnancies, much higher than the 0’3-0’7% incidence of ectopic pregnancy in the general population.3 The reported incidence of hydatidiform mole in clomipheneinduced pregnancies in the United States (where control of the drug and registration of its side-effects are of paramount importance) is much higher than that accepted for the untreated general population, ands varies between 1.350 pregnancies to an incidence of 1 - 592/ The incidence of spontaneous abortion in women with cloMost papers

phocytes from

1. Dyer, A. R.,

pregnancies.

Stamler, J., Berkson,

1975, i, 1051.

D.

M., Lindberg, H A , Stevens, E., Lan-

1. Karow, W. G., Payne, S. H. Fertil Steril. 1968, 19, 351. 2. Macgregor, A. H., Johnson, J. E., Bunde, C. A. ibid. p. 616. 3. Lehfeldt, H., Tietze, C, Gorstein, F. Am. J. Obstet. Gynec 1970, 4. Erving, H. W., Bower, J. E. Int. Surg. 1967, 47, 493. 5. Shneiderman, C. I., Waxman, B. Obstet Gynec 1972, 39, 787

108, 1005

1095 is much higher than in non-induced. Since the incidence of ectopic pregnancy and hydatidiform mole in this group may also be higher and since there might be a cause-and-effect relationship, each possible instance of these complications should be carefully documented.

miphene-induced pregnancies

Shaare Zedek

Hospital,

Jerusalem 91000, Israel.

"Present address:

remain "not proven" while other workers examine deviations from accuracy of gentamicin assays in uraemic sera.

Southmead Bristol.

Hospital,

J. M. BROUGHALL D. J. PUGSLEY D. S. REEVES

DAVID B. WEISS* YESHAYA ABOULAFIA

GLUTEN CONTENT OF CEREALS

Upton Hospital, Slough, Berkshire SL1 2BJ.

SIR,-For many years there has been confusion about the content of cereals other than wheat. Oats, barley, and

gluten POTENTIAL PITFALL IN BIOASSAY OF

SERUM-GENTAMICIN

findings of Dr Stessman and his colleagues (Sept. 20, p. 563), regarding the assay of gentamicin in serum from uraemic patients. The reported underestimate of the serum-concentration by 30-50% could clearly lead to serious overdosing. Since we have had some experience of assessment of gentamicin assays,’ we performed several recovery experiments on sera collected from paSIR,-We read with interest and

concern

the

ERROR-RATES OF SERUM-GENTAMICIN ASSAYS

rye are known to contain some is not clearly established to our

gluten, but the knowledge.

amount

in each

Various authorities differ in their advice to patients about the dietary allowance of products made from non-wheat cereals. Our current practice is to avoid wheat, barley, and rye, but to allow oats. However, we are concerned about malted corn and rice cereals which may retain minimal amounts of barley gluten after manufacture. There are some advantages in allowing breakfast cereals. Apart from the fact that they are almost a universal food in Western societies, they provide significant amounts of thiamine, which may be low in the "gluten-free" diet. If coeliac disease is due to an enzyme defect, presumably gluten tolerance is variable. Certainly, we have seen our patients respond clinically to "gluten-free" diets containing oats and malted corn and rice cereals, and, in all cases where a follow-up biopsy has been taken, there has been histological response. What facts

tients before routine

hsemodialysis. The urea content of these samples ranged from 120 to 256 mg/dI. No other biochemical analyses were performed on the sera. Concentrated gentamicin solution, at 1000 mg/l, was added to each serum sample to give final concentrations in the range 2.0-12.2 mg/1. These sera were then assayed by four methods. Three were microbiological large-plate diffusion assays using different indicator organisms. The fourth method was a radioisotope acetyltransferase technique.2 For each assay the percentage error (i.e., recovery) for individual samples was calculated and the 6 serum

standard deviation of these errors determined. The accuracy of each assay method may be judged by both the overall mean percentage error and the standard deviation of these errors. Two of the microbiological assay methods gave mean underestimates by 5% and 6% (see table). However, these were within the overall error of the assay, and we would not consider them significant deviations in this series of experiments. This contention is supported by the Bacillus pumilis assay results, where the mean error was 3.6%. Our results, therefore, have not demonstrated the serious underrating of gentamicin concentration in the sera of ur2emic patients, but there is no ready explanation for the difference between these results and those reported by Dr Stessman and his colleagues. The assay method used by them, that of Sabath et aI.,3 has an accuracy comparable with the technique used in this laboratory. Calculation of the standard deviation and mean percentage error from Sabath’s original published results for kanamycin assay gives values similar to those obtained with the Klebsiella spp., Bacillus subtilis, and B. pumilis assays in this study. Possible interference by bile constituents has been suggested,3 but this observation was not reproduced in another investigation.’ While not denying the possibility that the observations are correct, we suggest that the large deviations reported 1. Reeves, D. S., Bywater, M. J. J. antimicrob. Chemother. 1975, 1, 103 2. Broughall, J. M., Reeves, D. S. J. clin. Path. 1975, 28, 140. 3. Sabath, L. D., Casey, J. I., Ruch, P. A., Stumpf, L. L., Finland, M. Antimicrob. Agents Chemother. 1970, p. 83. 4. McDonald, D.R., Waterworth, P. M. ibid. 1974, 5, 562

are known about the gluten content of oats, rye, and barley and the malted corn and rice cereals? What influence does a minimal amount of gluten have on the risks of chronic anaemia and malignancy? We suspect that many others are as perplexed by this problem as we are ourselves, and hope that this letter may stimulate discussion.

Department of Gastroenterology, Department of Dietetics,

GRAEME BARNES

BETTY C. LYNCH

Royal Children’s Hospital, Melbourne, Flemington Road, Parkville, Victoria 3052, Australia.

ADRIAMYCIN IN ADVANCED BREAST CANCER

SIR,-Combination chemotherapy as commonly used in advanced breast cancer, produces objective remission-rates of 60-65%.’ These regimens comprise agents which, used singly, produce only 20-25% response-rates. The new agent, adriamycin, has been claimed to produce up to a 50% responseand its inclusion in a multidrug regimen is therefore of great interest. We describe a pilot study of this agent in advanced breast cancer. Patients included in this study all had progressive incurable breast The patients were assessed before and after treatment. The treatment pattern used was based on the two-day system developed by the multi-centre breast-chemotherapy group.’ Chemotherapy was given on day 1 and day 8 of the cycle, followed by a 3-week interval. The drug combination used was a slightly modified version of that previously reported, with the addition of adriamycin. Precise dose details are as follows: days 1 and 8, cyclophosphamide, 300 mg, vincristine 1 mg, adriamycin 25 mg; day 1 only, 5-fluorouracil 500 mg; day 8 only, methotrexate 30 mg. All agents were administered intravenously one at a time, and treatment was accompanied by an antiemetic. Treatment response was defined as either complete remission or regression of at least 50% 3 months after start of therapy. cancer.

G. A., Bates, T. D., Brinkley, D., MacRae, K. D., Spittle, M. F., Wheeler, T. Lancet, 1975, ii, 209. 2. Bonadonna, G., Monfardini, S., De Lena, N., Fossati-Bellani, F., Beretti, G. 1.

Edelstyn,

Cancer Res. 1970, 30, 2572.