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Erythema annulare centrifugum and Escherichia coli urinary infection
Letters to the Editor
The Internet:
a
global coffee
room
StR-There has been an unprecedented explosion of interest in the Internet: an estimated 30 million people now have access to this network of computers. Anaesthetists, in common with many other medical groups, have also shown enthusiasm for the resource and, as a result, there are already more than 134 worldwide web sites devoted to anaesthesia and intensive care topics. The New England Journal of Medicine has announced that material previously released on the Internet will not be accepted for publication.’ Therefore, at a time when anaesthetists are beginning to explore possibilities of the Internet, they are being actively discouraged from using it for presentation and discussion of research before journal publication. This "publish (electronically) and be dammed" policy seems to contrast strikingly with the spirit of free exchange of ideas on the information "superhighway". We wondered to what extent the New England Journal of Medicine’s editorial policy reflected the views of other major journals of interest to anaesthetists. We therefore put the issue to the editors of 24 such journals. We received replies from 19 editors. Of these, nine had a defined editorial policy and six of these policies were against publication. Six journals were in the process of policy formulation, and of these only one would decline to publish. Four journals had not yet considered the matter, and none of these regarded previous publications on the Internet as a barrier to journal publication. In total, seven of the 19 would not publish data that had previously appeared on the Internet. Six editors mentioned the policy of the New England Journal of Medicine and, of these, two agreed with it, two were against it, and two were undecided. The policy has not therefore gained universal acceptance among journal editors. Some editors considered that the major concern with material published on the Internet was that it had not. undergone peer review, and that it was therefore of unchecked originality, importance, and validity. One editor went so far as to say that such information was scientifically worthless. The problem of copyright was frequently mentioned, although the legal position seemed to be unclear. Some expressed concern about the continued viability of traditional journals should the role of the Internet increase. As doctors we have a professional duty to disseminate new knowledge and ideas as quickly and widely as possible, and computers obviously facilitate this. However, we also have a duty to avoid creating false hope, confusion, or panic caused by disseminating misleading or flawed data. This consideration is particularly relevant with regard to the Internet. Medical information differs from other scientific data-it is personal, and to place such data in a public forum in which critical analysis could be difficult and many would accept conclusions at face value would not be in keeping with the spirit of free exchange of ideas and information. The Internet might best be compared to a "global coffee room"-a place for news, views, and gossip, where most things should probably be taken with a pinch of salt (and where valuables should not be left unattended). Regarded as
such, the Internet obviously is of value
to doctors. Journals should therefore accept that the Internet will be increasingly used by doctors and they should attempt to develop it in such a way that its advantages can be exploited and the difficulties minimised.
*Mark W Davies, Richard Wenstone *Department of Anaesthesia, Royal Liverpool University Hospital, Liverpool L7 8XP, UK 1
Kassirer JP, Angell M. The Internet and the Journal. N Engl 1995; 332: 1709-10.
J Med
Erythema annulare centrifugum and Escherichia coli urinary infection SIR-Erythema annulare centrifugum (EAC),’ described by Darier in 1916, is an uncommon eruption (one case per 100 000 population per year2). The ringed patterns migrate slowly (2-3 mm/day), reaching up to 10 cm in diameter with central clearing. Old lesions may resolve in several days to a few weeks while new eruptions develop. This process may continue for several years.’ A 59-year-old man with non-insulin-dependent diabetes mellitus and non-proliferative diabetic retinopathy was referred in August, 1993, and in July, 1994, to the dermatology outpatient clinic with similar episodes of migratory erythema of 2 weeks duration. Several annular erythematous and polycyclic plaques with a well-defined scaly border, of different sizes, growing in an eccentric way and slightly itchy were seen on both legs and on the trunk (figure). The patient complained of dysuria and thirst on both occasions. Urine culture showed Escherichia coli. Chest and abdominal radiographs, abdominal and prostate gland ecography, and tests for immunoglobulins, complement, antinuclear antibody, and thyroid function were normal. Histological examination showed a lymphocytic infiltrate around vessels in the dermis compatible with EAC. He was treated with oral antibiotics; the lesions stopped growing and
Figure: Rash
on
thigh 897
disappeared on both occasions after 3 weeks. Although the pathogenesis of EAC is unknown,’ EAC is considered to be a hypersensitivity reaction to bacterial, viral, mycobacterial, parasitic, or fungal infections; drugs (salicylates and antimalarials); or tumour proteins.4 Other processes reported include food ingestion (blue cheeses), thyroid diseases, and autoimmune disturbances. It may also be familial or follow the menstrual cycle.5 In this case, correlation between the development of the rash and the positive urine culture, as well as its resolution during antibiotic therapy on two occasions, suggests a causal association. Urinary infection with E coli should be
splenius capitais", he would probably have been horrified by the pronunciation, or contractions. However, I do not wish to condemn the Greek-Latin crasis. After all I have used it to mould my surname (Latro=thief [Latin], Nike=victory [Greek]) into a more palatable form (victory over the thieves) than might be inferred from its slanderous (for me) Latin stem!
considered in EAC.
2
Nicola Latronico Istituto di Anestesia
1 3
*J Borbujo, C de Miguel, A Lopez, R de Lucas, M Casado Dermatology Department, Hospital General de Mostoles, Mostoles, Madrid 9, Spain
4 5
1 2
3
4
Tyring SK. Reactive erythemas: erythema annulare centrifugum and erythema gyratum repens. Clin Dermatol 1993; 11: 135-39. Mahood JM. Erythema annulare centrifugum: a review of 24 cases with special reference to its association with underlying disease. Clin Exp Dermatol 1983; 8: 383-87. Furure M, Akasu R, Ohtake N, Tamaki K. Erythema annulare centrifugum induced by molluscum contagiosum. Br J Dermatol 1993; 128: 646-47. Betlloch I, Amador C, Chiner E, Varona C, Carbonell C, Vilar A. Erythema annulare centrifugum in Q fever. J Exp Clin Dermatol 1991; 30: 502.
5
Yaniv R, Spielberg O, Shapiro D, Feinstein A, Ben-Bassat I. Erythema annulare centrifugum as the presenting sign of Hodgkin’s disease. Int J Dermatol 1993; 32: 59-61.
Making
sense
SiR-To the arguments of Jeffcoate for proper use of words in medicine (Feb 17, p 451)’would add a few comments. The term "vasospasm", often used to describe the delayed in cerebral ischaemia patients with subarachnoid haemorrhage, is probably one of the best examples of a misleading medical word (complete Socrates’ syndrome). The Shorter Oxford English Dictionary defines vasospasm as a "sudden and violent muscular contraction", an event that does not take place at all in the pathophysiology of delayed cerebral ischaemia. The term also implies that drugs such as nimodipine are beneficial because they relax the vascular wall, whereas, once again, the real explanation, although incompletely understood, is certainly far from this.2 TRH (thyrotropin-releasing hormone) is a good example of nomenclature that can limit our understanding (incomplete Socrates’ syndrome). TRH is classically described as the hypothalamic hormone regulating the hypophyseal release of TSH, which in turn acts on the thyroid gland. However, the TRH tripeptide has been found throughout the central nervous system, as well as in other and placental, gastrointestinal, tissues-pancreatic, TRH several man. has reproductive-of species, including also been found in species lacking TSH, or the thyroid, and even in plants.3 Among the reported physiological effects of TRH are the ability to "reverse the effects of CNS depression whether due to physiological (hibernation), behavioural (learned immobility), or chemical (narcotic drugs and alcohol) means",4 and to cause hyperthermia, increased gastrointestinal contractility, changes in blood pressure,3 and maturation of premature lungs.5 When these findings are considered, we can no longer tolerate the simplistic designation thyrotropin-releasing hormone for a molecule with such an extraordinary array of physiological
properties. Finally, I agree with Jeffcoate that ancient languages face a crisis of neglect. Had Cicero heard (as I have) doctors referring to "the substantia naigra" and "the [muscle] 898
e
Rianimazione, Spedali Civili, 25125 Brescia, Italy
Jeffcoate W. Making sense. Lancet 1996; 347: 451-52. Van Gijn J. Subarachnoid haemorrhage. Lancet 1992; 339: 653-61. Jackson IMD. Thyrotropin-releasing hormone. N Engl J Med 1982; 306: 145-55. Metcalf G, Dettmar PW. Is thyrotropin releasing hormone an endogenous ergotropic substance in the brain? Lancet 1981; i: 586-89. Ballard RA, Ballard PL, Creasy RK, et al. Respiratory disease in verylow-birthweight infants after prenatal thyrotropin-releasing hormone and glucocorticoid. Lancet 1992; 339: 510-15.
SIR-Jeffcoate1 pleads for a name for the neurological test in which the patient is asked to hold his or her arms outstretched. The Netherlands has the opposite problemtoo many names. Some call it "Wartenberg’s test" while others prefer "Mingazzini I" or "Barre I" (the corresponding test for central weakness of the leg being "Mingazzini II" or "Barre II"). The more prosaic among us simply speak of "the test of the outstretched arms". In this confusion there is one positive aspect. The results of this useful test are almost always recorded in the notes. In answer to Jeffcoate’s plea, may I suggest the "manna-manoeuvre"? When patients stand in this fashion and with their eyes closed, it seems as if they are awaiting the biblical falling of manna from Heaven. The term is easily remembered because of the alliteration. The muddling of Greek and Latin in medical language, another topic in Jeffcoate’s essay, is not easily circumvented. Jeffcoate himself does it with "transient (Latin), benign (Latin), pleurisy (Greek)" and whether it is within one word (hyperreflexia) or two (dissecting aneurysm) it may not be so reprehensible. The number of other examples is probably
myriad (Greek), or legion (Latin). Why condemn? In Roman times Latin was much influenced by Greek and many Greek words were superficially latinised. As Horace puts it in his Epistles (II, i, 156) "Graecia capta ferum victorem cepit, et artes intulit agresti Latio" ("When Greece had been enslaved she made a slave of her rough conqueror, and introduced the arts into Latium, still rude", in Wickham’s translation). The Roman Empire, through which Europe’s classical heritage comes Graeco-Roman in culture and later centuries saw a further amalgamation of Greek and Latin in scientific terminology (eg, automobile and television). We can try to avoid words such as homolateral and quadriplegia because we have the correct forms ipsilateral and tetraplegia but it will prove to be impossible to purge medical language completely of Leek and Gratin terms. was
R F
Duyff
Department of Neurology, Lucas Andreas Ziekenhuis, 1061AE Amsterdam, Netherlands
1
Jeffcoate W. Making sense. Lancet 1996; 347: 451-52.
SiR Jeffcoate’ rightly decries the Editors
can
acronyms
thinking. Jeffcoate
help
lessen
current
"acronymous age".
this aspect of poor writingcomprehension and diminish critical correct
also pleads for the naming of a neurological test. But this is not possible: motor system analysis includes looking for wasting and involuntary movements, testing for
The Internet:
a
global coffee
room
StR-There has been an unprecedented explosion of interest in the Internet: an estimated 30 million people now have access to this network of computers. Anaesthetists, in common with many other medical groups, have also shown enthusiasm for the resource and, as a result, there are already more than 134 worldwide web sites devoted to anaesthesia and intensive care topics. The New England Journal of Medicine has announced that material previously released on the Internet will not be accepted for publication.’ Therefore, at a time when anaesthetists are beginning to explore possibilities of the Internet, they are being actively discouraged from using it for presentation and discussion of research before journal publication. This "publish (electronically) and be dammed" policy seems to contrast strikingly with the spirit of free exchange of ideas on the information "superhighway". We wondered to what extent the New England Journal of Medicine’s editorial policy reflected the views of other major journals of interest to anaesthetists. We therefore put the issue to the editors of 24 such journals. We received replies from 19 editors. Of these, nine had a defined editorial policy and six of these policies were against publication. Six journals were in the process of policy formulation, and of these only one would decline to publish. Four journals had not yet considered the matter, and none of these regarded previous publications on the Internet as a barrier to journal publication. In total, seven of the 19 would not publish data that had previously appeared on the Internet. Six editors mentioned the policy of the New England Journal of Medicine and, of these, two agreed with it, two were against it, and two were undecided. The policy has not therefore gained universal acceptance among journal editors. Some editors considered that the major concern with material published on the Internet was that it had not. undergone peer review, and that it was therefore of unchecked originality, importance, and validity. One editor went so far as to say that such information was scientifically worthless. The problem of copyright was frequently mentioned, although the legal position seemed to be unclear. Some expressed concern about the continued viability of traditional journals should the role of the Internet increase. As doctors we have a professional duty to disseminate new knowledge and ideas as quickly and widely as possible, and computers obviously facilitate this. However, we also have a duty to avoid creating false hope, confusion, or panic caused by disseminating misleading or flawed data. This consideration is particularly relevant with regard to the Internet. Medical information differs from other scientific data-it is personal, and to place such data in a public forum in which critical analysis could be difficult and many would accept conclusions at face value would not be in keeping with the spirit of free exchange of ideas and information. The Internet might best be compared to a "global coffee room"-a place for news, views, and gossip, where most things should probably be taken with a pinch of salt (and where valuables should not be left unattended). Regarded as
such, the Internet obviously is of value
to doctors. Journals should therefore accept that the Internet will be increasingly used by doctors and they should attempt to develop it in such a way that its advantages can be exploited and the difficulties minimised.
*Mark W Davies, Richard Wenstone *Department of Anaesthesia, Royal Liverpool University Hospital, Liverpool L7 8XP, UK 1
Kassirer JP, Angell M. The Internet and the Journal. N Engl 1995; 332: 1709-10.
J Med
Erythema annulare centrifugum and Escherichia coli urinary infection SIR-Erythema annulare centrifugum (EAC),’ described by Darier in 1916, is an uncommon eruption (one case per 100 000 population per year2). The ringed patterns migrate slowly (2-3 mm/day), reaching up to 10 cm in diameter with central clearing. Old lesions may resolve in several days to a few weeks while new eruptions develop. This process may continue for several years.’ A 59-year-old man with non-insulin-dependent diabetes mellitus and non-proliferative diabetic retinopathy was referred in August, 1993, and in July, 1994, to the dermatology outpatient clinic with similar episodes of migratory erythema of 2 weeks duration. Several annular erythematous and polycyclic plaques with a well-defined scaly border, of different sizes, growing in an eccentric way and slightly itchy were seen on both legs and on the trunk (figure). The patient complained of dysuria and thirst on both occasions. Urine culture showed Escherichia coli. Chest and abdominal radiographs, abdominal and prostate gland ecography, and tests for immunoglobulins, complement, antinuclear antibody, and thyroid function were normal. Histological examination showed a lymphocytic infiltrate around vessels in the dermis compatible with EAC. He was treated with oral antibiotics; the lesions stopped growing and
Figure: Rash
on
thigh 897
disappeared on both occasions after 3 weeks. Although the pathogenesis of EAC is unknown,’ EAC is considered to be a hypersensitivity reaction to bacterial, viral, mycobacterial, parasitic, or fungal infections; drugs (salicylates and antimalarials); or tumour proteins.4 Other processes reported include food ingestion (blue cheeses), thyroid diseases, and autoimmune disturbances. It may also be familial or follow the menstrual cycle.5 In this case, correlation between the development of the rash and the positive urine culture, as well as its resolution during antibiotic therapy on two occasions, suggests a causal association. Urinary infection with E coli should be
splenius capitais", he would probably have been horrified by the pronunciation, or contractions. However, I do not wish to condemn the Greek-Latin crasis. After all I have used it to mould my surname (Latro=thief [Latin], Nike=victory [Greek]) into a more palatable form (victory over the thieves) than might be inferred from its slanderous (for me) Latin stem!
considered in EAC.
2
Nicola Latronico Istituto di Anestesia
1 3
*J Borbujo, C de Miguel, A Lopez, R de Lucas, M Casado Dermatology Department, Hospital General de Mostoles, Mostoles, Madrid 9, Spain
4 5
1 2
3
4
Tyring SK. Reactive erythemas: erythema annulare centrifugum and erythema gyratum repens. Clin Dermatol 1993; 11: 135-39. Mahood JM. Erythema annulare centrifugum: a review of 24 cases with special reference to its association with underlying disease. Clin Exp Dermatol 1983; 8: 383-87. Furure M, Akasu R, Ohtake N, Tamaki K. Erythema annulare centrifugum induced by molluscum contagiosum. Br J Dermatol 1993; 128: 646-47. Betlloch I, Amador C, Chiner E, Varona C, Carbonell C, Vilar A. Erythema annulare centrifugum in Q fever. J Exp Clin Dermatol 1991; 30: 502.
5
Yaniv R, Spielberg O, Shapiro D, Feinstein A, Ben-Bassat I. Erythema annulare centrifugum as the presenting sign of Hodgkin’s disease. Int J Dermatol 1993; 32: 59-61.
Making
sense
SiR-To the arguments of Jeffcoate for proper use of words in medicine (Feb 17, p 451)’would add a few comments. The term "vasospasm", often used to describe the delayed in cerebral ischaemia patients with subarachnoid haemorrhage, is probably one of the best examples of a misleading medical word (complete Socrates’ syndrome). The Shorter Oxford English Dictionary defines vasospasm as a "sudden and violent muscular contraction", an event that does not take place at all in the pathophysiology of delayed cerebral ischaemia. The term also implies that drugs such as nimodipine are beneficial because they relax the vascular wall, whereas, once again, the real explanation, although incompletely understood, is certainly far from this.2 TRH (thyrotropin-releasing hormone) is a good example of nomenclature that can limit our understanding (incomplete Socrates’ syndrome). TRH is classically described as the hypothalamic hormone regulating the hypophyseal release of TSH, which in turn acts on the thyroid gland. However, the TRH tripeptide has been found throughout the central nervous system, as well as in other and placental, gastrointestinal, tissues-pancreatic, TRH several man. has reproductive-of species, including also been found in species lacking TSH, or the thyroid, and even in plants.3 Among the reported physiological effects of TRH are the ability to "reverse the effects of CNS depression whether due to physiological (hibernation), behavioural (learned immobility), or chemical (narcotic drugs and alcohol) means",4 and to cause hyperthermia, increased gastrointestinal contractility, changes in blood pressure,3 and maturation of premature lungs.5 When these findings are considered, we can no longer tolerate the simplistic designation thyrotropin-releasing hormone for a molecule with such an extraordinary array of physiological
properties. Finally, I agree with Jeffcoate that ancient languages face a crisis of neglect. Had Cicero heard (as I have) doctors referring to "the substantia naigra" and "the [muscle] 898
e
Rianimazione, Spedali Civili, 25125 Brescia, Italy
Jeffcoate W. Making sense. Lancet 1996; 347: 451-52. Van Gijn J. Subarachnoid haemorrhage. Lancet 1992; 339: 653-61. Jackson IMD. Thyrotropin-releasing hormone. N Engl J Med 1982; 306: 145-55. Metcalf G, Dettmar PW. Is thyrotropin releasing hormone an endogenous ergotropic substance in the brain? Lancet 1981; i: 586-89. Ballard RA, Ballard PL, Creasy RK, et al. Respiratory disease in verylow-birthweight infants after prenatal thyrotropin-releasing hormone and glucocorticoid. Lancet 1992; 339: 510-15.
SIR-Jeffcoate1 pleads for a name for the neurological test in which the patient is asked to hold his or her arms outstretched. The Netherlands has the opposite problemtoo many names. Some call it "Wartenberg’s test" while others prefer "Mingazzini I" or "Barre I" (the corresponding test for central weakness of the leg being "Mingazzini II" or "Barre II"). The more prosaic among us simply speak of "the test of the outstretched arms". In this confusion there is one positive aspect. The results of this useful test are almost always recorded in the notes. In answer to Jeffcoate’s plea, may I suggest the "manna-manoeuvre"? When patients stand in this fashion and with their eyes closed, it seems as if they are awaiting the biblical falling of manna from Heaven. The term is easily remembered because of the alliteration. The muddling of Greek and Latin in medical language, another topic in Jeffcoate’s essay, is not easily circumvented. Jeffcoate himself does it with "transient (Latin), benign (Latin), pleurisy (Greek)" and whether it is within one word (hyperreflexia) or two (dissecting aneurysm) it may not be so reprehensible. The number of other examples is probably
myriad (Greek), or legion (Latin). Why condemn? In Roman times Latin was much influenced by Greek and many Greek words were superficially latinised. As Horace puts it in his Epistles (II, i, 156) "Graecia capta ferum victorem cepit, et artes intulit agresti Latio" ("When Greece had been enslaved she made a slave of her rough conqueror, and introduced the arts into Latium, still rude", in Wickham’s translation). The Roman Empire, through which Europe’s classical heritage comes Graeco-Roman in culture and later centuries saw a further amalgamation of Greek and Latin in scientific terminology (eg, automobile and television). We can try to avoid words such as homolateral and quadriplegia because we have the correct forms ipsilateral and tetraplegia but it will prove to be impossible to purge medical language completely of Leek and Gratin terms. was
R F
Duyff
Department of Neurology, Lucas Andreas Ziekenhuis, 1061AE Amsterdam, Netherlands
1
Jeffcoate W. Making sense. Lancet 1996; 347: 451-52.
SiR Jeffcoate’ rightly decries the Editors
can
acronyms
thinking. Jeffcoate
help
lessen
current
"acronymous age".
this aspect of poor writingcomprehension and diminish critical correct
also pleads for the naming of a neurological test. But this is not possible: motor system analysis includes looking for wasting and involuntary movements, testing for