- Email: [email protected]
EPIDEMIC OF FATAL RESPIRATORY DISEASE IN WOLVERHAMPTON
277 RESULTS OF ATTEMPTED IVF IN GROUPS WITH TREATED OR UNTREATED MINOR ENDOMETRIOSIS AND GROUP WITH
INFLAMMATORY TUBAL OCCLUSION
comparing the outcome in children whose drugs assigned to be given in the morning or evening.
are
randomly
Department of Haematology and Oncology, Hospitals for Sick Children, London WC1N 3JH
JUDITH M. CHESSELLS
EPIDEMIC OF FATAL RESPIRATORY DISEASE IN WOLVERHAMPTON
Percentages are (a) ofoocytes, (b) of patients, (c) of embryos transferred, (d) of patients with embryos. *p<0’001 (vs tubal damage). tNot significant.
The endometriosis was still present although of reduced severity in all cases. The results ofIVF are given in the table. Results in cases of inflammatory tubal damage have been included as normal reference. The groups of patients are comparable by age and duration of infertility. Whilst the IVF rates are nearly halved in women with untreated endometriosis they are normal in women who had been treated. Most of the women with treated endometriosis were different from those with untreated endometriosis. Proof of the benefit, for IVF, of treatment is now being sought in a study of results in the same women before and after treatment. Nevertheless, our findings raise intriguing questions about the relation between minor endometriosis and infertility and the effect of treatment on the chance of natural conception. Proper epidemiological studies are still awaited to decide the true relation to infertility, and the results of published therapeutic studies are conflicting. 6,7 Nevertheless, we have demonstrated an ovarian disorder with endometriosis that can be overcome by suppression of the disease without the need to eradicate it.
SiR.—Dr Griffiths (Nov 23, p 1194), noting 460 deaths from pneumococcal pneumonia in Wolverhampton in 1969-73, thought it unlikely that this unusually high figure could be ascribed to vagaries in death certification. With the permission of HM Coroner I examined the
causes
of death for
one
of these years and found
a
simple explanation for these extraordinary statistics. In 1973 323 post mortems were done by a general practitioner in Wolverhampton, who was not a pathologist, and in 129 he diagnosed lobar pneumonia. In a further 34 cases his diagnosis was influenzal pneumonia. During the same year 226 post mortems were done by four consultant pathologists and they diagnosed 2 cases of lobar pneumonia, 30 cases of bronchopneumonia, and 2 cases of influenzal pneumonia. It would therefore seem that this "epidemic" in Wolverhampton was due to a preference in death certification diagnosis by one practitioner and that there was a gross disparity between his diagnoses and those of the pathologists working in the same city. There is no record of any histological or bacteriological confirmation of these diagnoses of pneumonia. Department of Pathology, Royal Hospital, Wolverhampton WV2 1BT
K. W. M. SCOTT
’
Bristol Maternity Bristol BS2 8EG
P. G. WARDLE P. A. FOSTER J. D. MITCHELL E. A. MCLAUGHLIN J. A. C. SYKES E. CORRIGAN M. G. R. HULL
Regional Cytogenetics Centre, Hospital, Bristol
B. D. RAY A. MCDERMOTT
Department of Obstetrics and Gynaecology,
University of Bristol, Hospital,
Southmead
1. Wardle PG, Mitchell JD, McLaughlin EA, Ray BD, McDermott A, Hull MGR. Endometriosis and ovulatory disorder: Reduced fertilisation in vitro compared with tubal and unexplained infertility. Lancet 1985; ii: 236-39 2 Yovich JL, Yovich JM, Tuvik AI, Matson PL, Willcox DL. In-vitro fertilisation for endometriosis. Lancet 1985; ii: 552 3 O’Shea RT, Chen C, Weiss T, Jones WR. Endometriosis and in-vitro fertilisation. Lancet 1985; ii: 723. 4 Mahadevan MM, Trounson AO, Leeton JF. The relationship of tubal blockage, infertility of unknown cause, suspected male infertility and endometriosis to success of in-vitro fertilisation and embryo transfer. Fertil Steril 1983; 40: 755-62. 5. Jones HW, Acosta AA, Andrews MC, et al. Three years of in-vitro fertilisation at Norfolk. Fertil Steril 1984; 42: 826-34. 6 Starks GC, Grimes EM. Clinical significance of focal pelvic endometriosis. J Reprod Med 1985; 30: 481-84. 7 Siebel MM, Berger MJ, Weinstein FG, Taymor ML. The effectiveness of danazol on subsequent fertility in minimal endometriosis. Fertil Steril 1982; 38: 534-37.
TIMING OF MAINTENANCE THERAPY FOR LEUKAEMIA
SiR,-Dr Rivard and colleagues (Dec 7, p 1264) noted improved survival for evening administration of maintenance chemo herapy (loosely defined as any time after 1700 hours) compandwith survival when treatment was given before 1000 hour:. This difference may be related to mealtimes as much as to ci ’cadian rhythm. It is surely unwise to draw any assumptions from.i retrospective survey of parents’ recollections of the time of giving drugs. The only way to test such a hypothesis is by a prospective randomised clinical trial, standardised with respect to meals and
NEURALGIA AFTER CRYOANALGESIA FOR THORACOTOMY
SIR,-Since cryoprobes for intercostal
nerve
blockade
at
thoracotomyl were routinely adopted in this unit three years ago an increase in patients complaining at follow-up of suggesting post-thoracotomy neuralgia. In our experience 1-3% of thoracotomy patients had symptoms disabling enough for them to seek a cure. Further evidence that cryoprobes may result in nerve irritation
there has been
symptoms
comes from a study in which cryoanalgesia was used in patients who already had post-thoracotomy neuralgia. Although half of the patients had temporary pain relief from the technique, one-third
found that their symptoms worsened.4 Under clinical conditions, when it may be difficult to site the cryoprobe accurately and when the iceball may be too small, freezing of an intercostal nerve may be inadequate. Cold has a differential effect on nerve fibre function; large myelinated fibres are most susceptible while small fibre activity may be unchecked. This undesirable effect, postulated by Barnard in 1980,5 may explain the observation that some patients complain of dysaesthesia after the cryoprobe has been used. It remains to be seen if this effect is temporary or not, but for the time being we have stopped the routine use of the cryoprobe for producing postoperative analgesia for thoracotomy patients. I. D. CONACHER T. LOCKE C. HILTON
Regional Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NE7 7DN
1 Katz J, Nelson W, Forest R, Bruce D Cryoanalgesia for post-thoracotomy pain. Lancet 1980, i
512-13.
O, Makey AR. Cryoanalgesia for relief of pain after thoracotomy. Br Med J 1981, 282: 1749-50
2 Maiwand
DJM, Dundee DW Improved pain relief after thoracotomy use of and morphine infusion. Br Med J 1981; 283: 945-48. 4 Conacher ID. Percutaneous cryotherapy for post-thoracotomy neuralgia. Pain (in 3 Orr IA, Keenan
cryoprobe press)
5 Barnard D The effects of extreme cold
180-87.
on sensory nerves
Ann
Roy Coll Surg 1980, 62:
INFLAMMATORY TUBAL OCCLUSION
comparing the outcome in children whose drugs assigned to be given in the morning or evening.
are
randomly
Department of Haematology and Oncology, Hospitals for Sick Children, London WC1N 3JH
JUDITH M. CHESSELLS
EPIDEMIC OF FATAL RESPIRATORY DISEASE IN WOLVERHAMPTON
Percentages are (a) ofoocytes, (b) of patients, (c) of embryos transferred, (d) of patients with embryos. *p<0’001 (vs tubal damage). tNot significant.
The endometriosis was still present although of reduced severity in all cases. The results ofIVF are given in the table. Results in cases of inflammatory tubal damage have been included as normal reference. The groups of patients are comparable by age and duration of infertility. Whilst the IVF rates are nearly halved in women with untreated endometriosis they are normal in women who had been treated. Most of the women with treated endometriosis were different from those with untreated endometriosis. Proof of the benefit, for IVF, of treatment is now being sought in a study of results in the same women before and after treatment. Nevertheless, our findings raise intriguing questions about the relation between minor endometriosis and infertility and the effect of treatment on the chance of natural conception. Proper epidemiological studies are still awaited to decide the true relation to infertility, and the results of published therapeutic studies are conflicting. 6,7 Nevertheless, we have demonstrated an ovarian disorder with endometriosis that can be overcome by suppression of the disease without the need to eradicate it.
SiR.—Dr Griffiths (Nov 23, p 1194), noting 460 deaths from pneumococcal pneumonia in Wolverhampton in 1969-73, thought it unlikely that this unusually high figure could be ascribed to vagaries in death certification. With the permission of HM Coroner I examined the
causes
of death for
one
of these years and found
a
simple explanation for these extraordinary statistics. In 1973 323 post mortems were done by a general practitioner in Wolverhampton, who was not a pathologist, and in 129 he diagnosed lobar pneumonia. In a further 34 cases his diagnosis was influenzal pneumonia. During the same year 226 post mortems were done by four consultant pathologists and they diagnosed 2 cases of lobar pneumonia, 30 cases of bronchopneumonia, and 2 cases of influenzal pneumonia. It would therefore seem that this "epidemic" in Wolverhampton was due to a preference in death certification diagnosis by one practitioner and that there was a gross disparity between his diagnoses and those of the pathologists working in the same city. There is no record of any histological or bacteriological confirmation of these diagnoses of pneumonia. Department of Pathology, Royal Hospital, Wolverhampton WV2 1BT
K. W. M. SCOTT
’
Bristol Maternity Bristol BS2 8EG
P. G. WARDLE P. A. FOSTER J. D. MITCHELL E. A. MCLAUGHLIN J. A. C. SYKES E. CORRIGAN M. G. R. HULL
Regional Cytogenetics Centre, Hospital, Bristol
B. D. RAY A. MCDERMOTT
Department of Obstetrics and Gynaecology,
University of Bristol, Hospital,
Southmead
1. Wardle PG, Mitchell JD, McLaughlin EA, Ray BD, McDermott A, Hull MGR. Endometriosis and ovulatory disorder: Reduced fertilisation in vitro compared with tubal and unexplained infertility. Lancet 1985; ii: 236-39 2 Yovich JL, Yovich JM, Tuvik AI, Matson PL, Willcox DL. In-vitro fertilisation for endometriosis. Lancet 1985; ii: 552 3 O’Shea RT, Chen C, Weiss T, Jones WR. Endometriosis and in-vitro fertilisation. Lancet 1985; ii: 723. 4 Mahadevan MM, Trounson AO, Leeton JF. The relationship of tubal blockage, infertility of unknown cause, suspected male infertility and endometriosis to success of in-vitro fertilisation and embryo transfer. Fertil Steril 1983; 40: 755-62. 5. Jones HW, Acosta AA, Andrews MC, et al. Three years of in-vitro fertilisation at Norfolk. Fertil Steril 1984; 42: 826-34. 6 Starks GC, Grimes EM. Clinical significance of focal pelvic endometriosis. J Reprod Med 1985; 30: 481-84. 7 Siebel MM, Berger MJ, Weinstein FG, Taymor ML. The effectiveness of danazol on subsequent fertility in minimal endometriosis. Fertil Steril 1982; 38: 534-37.
TIMING OF MAINTENANCE THERAPY FOR LEUKAEMIA
SiR,-Dr Rivard and colleagues (Dec 7, p 1264) noted improved survival for evening administration of maintenance chemo herapy (loosely defined as any time after 1700 hours) compandwith survival when treatment was given before 1000 hour:. This difference may be related to mealtimes as much as to ci ’cadian rhythm. It is surely unwise to draw any assumptions from.i retrospective survey of parents’ recollections of the time of giving drugs. The only way to test such a hypothesis is by a prospective randomised clinical trial, standardised with respect to meals and
NEURALGIA AFTER CRYOANALGESIA FOR THORACOTOMY
SIR,-Since cryoprobes for intercostal
nerve
blockade
at
thoracotomyl were routinely adopted in this unit three years ago an increase in patients complaining at follow-up of suggesting post-thoracotomy neuralgia. In our experience 1-3% of thoracotomy patients had symptoms disabling enough for them to seek a cure. Further evidence that cryoprobes may result in nerve irritation
there has been
symptoms
comes from a study in which cryoanalgesia was used in patients who already had post-thoracotomy neuralgia. Although half of the patients had temporary pain relief from the technique, one-third
found that their symptoms worsened.4 Under clinical conditions, when it may be difficult to site the cryoprobe accurately and when the iceball may be too small, freezing of an intercostal nerve may be inadequate. Cold has a differential effect on nerve fibre function; large myelinated fibres are most susceptible while small fibre activity may be unchecked. This undesirable effect, postulated by Barnard in 1980,5 may explain the observation that some patients complain of dysaesthesia after the cryoprobe has been used. It remains to be seen if this effect is temporary or not, but for the time being we have stopped the routine use of the cryoprobe for producing postoperative analgesia for thoracotomy patients. I. D. CONACHER T. LOCKE C. HILTON
Regional Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NE7 7DN
1 Katz J, Nelson W, Forest R, Bruce D Cryoanalgesia for post-thoracotomy pain. Lancet 1980, i
512-13.
O, Makey AR. Cryoanalgesia for relief of pain after thoracotomy. Br Med J 1981, 282: 1749-50
2 Maiwand
DJM, Dundee DW Improved pain relief after thoracotomy use of and morphine infusion. Br Med J 1981; 283: 945-48. 4 Conacher ID. Percutaneous cryotherapy for post-thoracotomy neuralgia. Pain (in 3 Orr IA, Keenan
cryoprobe press)
5 Barnard D The effects of extreme cold
180-87.
on sensory nerves
Ann
Roy Coll Surg 1980, 62: