- Email: [email protected]
EXCHANGE TRANSFUSION IN ANÆMIA
441
lagged miserably behind Canada, United States of America, and the Scandinavian countries in providing the necessary funds. Cancer has an emotional appeal, and vocal members of our
Women’s Institutes and Members of Parliament have
supported the provision of funds for this excellent scheme. But hypochromic anaemia has not got the same emotional appeal, and we cannot expect the same enthusiastic support. Perhaps we could stretch a point in stating that the atrophic lesions seen in iron deficiency are considered premalignant in the Plummer-Vinson syndrome, and perhaps we can encourage the support of the same body of people, so that funds can be detect anxmia in the adolescent. The and the Ministry of Health should long boards regional hospital have the stimulus and the funds which are provided ago necessary for this investigation.
made available
to
Pathological Laboratory, Derbyshire Royal Infirmary, Derby.
BRIAN
J. LEONARD.
(July 30) that the method works very well, as would be expected with the circulating volume being kept virtually intact. In the interests of " blood economy " I have also found it useful to " pack " the admittedly small volume of red cells recovered from the venesection and return them to the patient. Middlesex Hospital, R. J. GREGORY. London, W.1. INACTIVATION OF METRONIDAZOLE
SIR,-We have reported1 that in some 200 cultures of trichomonads examined for sensitivity to metronidazole, no resistant strains were found. The few patients who did not respond to 200 mg. t.i.d. all responded to a double dose (400 mg. t.i.d. for seven days). We now report a patient who failed to respond to metronidazole in whom laboratory studies showed the primary isolate of the trichomonads to have normal
sensitivity to the drug. This patient was referred to St. Thomas’s Hospital because of a history of vaginal discharge for some 11 years, and apparent SIR,-Dr. Shearman and Dr. Delamore (Aug. 6) disagree repeated failure of metronidazole to clear the trichomonal with the definition of chronic idiopathic iron-deficiency infection. Absorption of the drug was shown to be satisfactory anoemia in our article, but they offer no alternative definition. by serum and urine concentrations determined after a standard We consider idiopathic iron-deficiency anaemia to be a dose. The patient’s husband received the standard course of convenient clinical term to describe those patients in whom metronidazole (200 mg. t.i.d. for seven days), with unknown the cause of the anaemia is not apparent. It should not be used after which sexual intercourse was denied. results, to imply a specific xtiology. Most of these patients are women, f Investigation before admission to hospital had led to the and the iron deficiency is usually the result of excessive blood- I isolation of the parasite, which was found to be sensitive to loss, or dietary deficiency, or both these factors. The most 1-0 {jt.g. per ml. of metronidazole. Examination of vaginal important source of blood-loss in normal women is menstrua- smears and cultures also showed gross multiple bacterial tion, but menorrhagia cannot be diagnosed or excluded with infection, including a heavy growth of Proteus spp. Growth certainty except by direct measurement. Dietary intake of iron of these organisms inactivated metronidazole in vitro. The is even more difficult to assess, but indirect evidence from the patient was given a course of neomycin pessaries concurrently Nadonal Food Survey shows that many women in this country with the oral administration of metronidazole, 200 mg. t.i.d. probably have an inadequate intake. Dr. Shearman and Dr. for seven days, but the trichomonads were still present at the Delamorehave studied 17 patients with iron-deficiency end of this treatment. mmia and allocated them to two groups according to whether On admission microscopical examination confirmed the or not they were achlorhydric. In the achlorhydric group the of trichomonads in both vagina and urethra, but diagnosis most common probable cause of the anaemia was classified as tests were not carried out. In view of the past sensitivity "idiopathic ", and in the acid-secreting group the most common history, metronidazole 400 mg. t.i.d. was given for seven days. cause was menorrhagia. Unfortunately they do not state Trichomonads were still found at the end of this course in the whether they measured menstrual loss or dietary iron intake vagina but not the urethra. Examination of the bacterial flora these patients. The evidence so far produced does not of the vagina showed an organism provisionally identified as justify a revised definition of idiopathic iron deficiency as belonging to the genus Mimae which, when incubated with the achlorhydric iron deficiency with the implication that the drug, was able to inactivate metronidazole (assayed biologically gastric defect is the primary lesion. and polarographically). Primary atrophic gastritis with secondary iron deficiency may Clearance of the trichomonal infection was obtained by a well occur, but we do not know how frequently. The ability combination of metronidazole 400 mg. t.i.d., and acetarsol of most of our younger patients to increase acid secretion after vaginal compound pessaries (’ S.V.C.’) b.d. for 14 days. To treatment with iron makes it unlikely that they had a primary date (after six weeks) the patient has remained symptomless, gastric mucosal defect. Those older patients whose acid did and repeated examination has shown no evidence of trichonot increase may have included some with primary gastric moniasis. atrophy, but they may equally well have progressed from the C. S. NICOL St. Thomas’s Hospital, untreated earlier stage seen in the younger group. A. J. EVANS. London S.E.1. We should like to point out that our statement that the Research Laboratories, presence of circulating parietal-cell antibody was not related to J. A. MCFADZEAN May & Baker, Ltd., S. L. SQUIRES. age or gastric acidity clearly referred to our own group of Dagenham, Essex. patients, in most of whom gastric-acid secretion was in fact "
"
"
"
"
"
subnormal 44 cases.
Cardiff
or
absent.
Royal Infirmary.
Antibody
was
present in 17
out
of
A. JACOBS J. H. LAWRIE C. C. ENTWISTLE.
EXCHANGE TRANSFUSION IN ANÆMIA
SIR,-Within the past four years I have had occasion to treat several severely anaemic patients in actual or impending cardiac failure. In addition to the standard anti-failure regimen I have used blood-transfusion with simultaneous venesection at a similar rate. I agree with your leading article Jacobs, A., Kilpatrick, G. S., Withey, J. L. Post-Grad. med. J. 1965, 41, 418. 2 Shearman, D. J. C., Delamore, I. W., Gardner, D. L. Lancet, 1966, 1, 845.
B.C.G. AND KELOIDS SIR,-Dr. Kaplan in his letter last week discusses the incidence of keloids after B.c.G. inoculation, and says that he thinks the deltoid region is not the best site. I agree with him, and in this clinic for the past seven years we have given B.c.G. into the back, just below the point of the scapula. Since using this site we have had no trouble with keloids, or with regional adenitis-there is the added advantage in children that it is out of reach of scratching, and less liable to be knocked. The final scar is hardly noticeable, though to find a site which is never visible nowadays is probably impossible. B.C.G. Clinic, Hospital for Sick Children, Great Ormond Street,
MARCIA HALL.
London W.C.1. 1.
Nicol, C. S., McFadzean, J. A., Squires,
S. L.
Lancet, 1966, i,
1100.
lagged miserably behind Canada, United States of America, and the Scandinavian countries in providing the necessary funds. Cancer has an emotional appeal, and vocal members of our
Women’s Institutes and Members of Parliament have
supported the provision of funds for this excellent scheme. But hypochromic anaemia has not got the same emotional appeal, and we cannot expect the same enthusiastic support. Perhaps we could stretch a point in stating that the atrophic lesions seen in iron deficiency are considered premalignant in the Plummer-Vinson syndrome, and perhaps we can encourage the support of the same body of people, so that funds can be detect anxmia in the adolescent. The and the Ministry of Health should long boards regional hospital have the stimulus and the funds which are provided ago necessary for this investigation.
made available
to
Pathological Laboratory, Derbyshire Royal Infirmary, Derby.
BRIAN
J. LEONARD.
(July 30) that the method works very well, as would be expected with the circulating volume being kept virtually intact. In the interests of " blood economy " I have also found it useful to " pack " the admittedly small volume of red cells recovered from the venesection and return them to the patient. Middlesex Hospital, R. J. GREGORY. London, W.1. INACTIVATION OF METRONIDAZOLE
SIR,-We have reported1 that in some 200 cultures of trichomonads examined for sensitivity to metronidazole, no resistant strains were found. The few patients who did not respond to 200 mg. t.i.d. all responded to a double dose (400 mg. t.i.d. for seven days). We now report a patient who failed to respond to metronidazole in whom laboratory studies showed the primary isolate of the trichomonads to have normal
sensitivity to the drug. This patient was referred to St. Thomas’s Hospital because of a history of vaginal discharge for some 11 years, and apparent SIR,-Dr. Shearman and Dr. Delamore (Aug. 6) disagree repeated failure of metronidazole to clear the trichomonal with the definition of chronic idiopathic iron-deficiency infection. Absorption of the drug was shown to be satisfactory anoemia in our article, but they offer no alternative definition. by serum and urine concentrations determined after a standard We consider idiopathic iron-deficiency anaemia to be a dose. The patient’s husband received the standard course of convenient clinical term to describe those patients in whom metronidazole (200 mg. t.i.d. for seven days), with unknown the cause of the anaemia is not apparent. It should not be used after which sexual intercourse was denied. results, to imply a specific xtiology. Most of these patients are women, f Investigation before admission to hospital had led to the and the iron deficiency is usually the result of excessive blood- I isolation of the parasite, which was found to be sensitive to loss, or dietary deficiency, or both these factors. The most 1-0 {jt.g. per ml. of metronidazole. Examination of vaginal important source of blood-loss in normal women is menstrua- smears and cultures also showed gross multiple bacterial tion, but menorrhagia cannot be diagnosed or excluded with infection, including a heavy growth of Proteus spp. Growth certainty except by direct measurement. Dietary intake of iron of these organisms inactivated metronidazole in vitro. The is even more difficult to assess, but indirect evidence from the patient was given a course of neomycin pessaries concurrently Nadonal Food Survey shows that many women in this country with the oral administration of metronidazole, 200 mg. t.i.d. probably have an inadequate intake. Dr. Shearman and Dr. for seven days, but the trichomonads were still present at the Delamorehave studied 17 patients with iron-deficiency end of this treatment. mmia and allocated them to two groups according to whether On admission microscopical examination confirmed the or not they were achlorhydric. In the achlorhydric group the of trichomonads in both vagina and urethra, but diagnosis most common probable cause of the anaemia was classified as tests were not carried out. In view of the past sensitivity "idiopathic ", and in the acid-secreting group the most common history, metronidazole 400 mg. t.i.d. was given for seven days. cause was menorrhagia. Unfortunately they do not state Trichomonads were still found at the end of this course in the whether they measured menstrual loss or dietary iron intake vagina but not the urethra. Examination of the bacterial flora these patients. The evidence so far produced does not of the vagina showed an organism provisionally identified as justify a revised definition of idiopathic iron deficiency as belonging to the genus Mimae which, when incubated with the achlorhydric iron deficiency with the implication that the drug, was able to inactivate metronidazole (assayed biologically gastric defect is the primary lesion. and polarographically). Primary atrophic gastritis with secondary iron deficiency may Clearance of the trichomonal infection was obtained by a well occur, but we do not know how frequently. The ability combination of metronidazole 400 mg. t.i.d., and acetarsol of most of our younger patients to increase acid secretion after vaginal compound pessaries (’ S.V.C.’) b.d. for 14 days. To treatment with iron makes it unlikely that they had a primary date (after six weeks) the patient has remained symptomless, gastric mucosal defect. Those older patients whose acid did and repeated examination has shown no evidence of trichonot increase may have included some with primary gastric moniasis. atrophy, but they may equally well have progressed from the C. S. NICOL St. Thomas’s Hospital, untreated earlier stage seen in the younger group. A. J. EVANS. London S.E.1. We should like to point out that our statement that the Research Laboratories, presence of circulating parietal-cell antibody was not related to J. A. MCFADZEAN May & Baker, Ltd., S. L. SQUIRES. age or gastric acidity clearly referred to our own group of Dagenham, Essex. patients, in most of whom gastric-acid secretion was in fact "
"
"
"
"
"
subnormal 44 cases.
Cardiff
or
absent.
Royal Infirmary.
Antibody
was
present in 17
out
of
A. JACOBS J. H. LAWRIE C. C. ENTWISTLE.
EXCHANGE TRANSFUSION IN ANÆMIA
SIR,-Within the past four years I have had occasion to treat several severely anaemic patients in actual or impending cardiac failure. In addition to the standard anti-failure regimen I have used blood-transfusion with simultaneous venesection at a similar rate. I agree with your leading article Jacobs, A., Kilpatrick, G. S., Withey, J. L. Post-Grad. med. J. 1965, 41, 418. 2 Shearman, D. J. C., Delamore, I. W., Gardner, D. L. Lancet, 1966, 1, 845.
B.C.G. AND KELOIDS SIR,-Dr. Kaplan in his letter last week discusses the incidence of keloids after B.c.G. inoculation, and says that he thinks the deltoid region is not the best site. I agree with him, and in this clinic for the past seven years we have given B.c.G. into the back, just below the point of the scapula. Since using this site we have had no trouble with keloids, or with regional adenitis-there is the added advantage in children that it is out of reach of scratching, and less liable to be knocked. The final scar is hardly noticeable, though to find a site which is never visible nowadays is probably impossible. B.C.G. Clinic, Hospital for Sick Children, Great Ormond Street,
MARCIA HALL.
London W.C.1. 1.
Nicol, C. S., McFadzean, J. A., Squires,
S. L.
Lancet, 1966, i,
1100.