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GASTROINTESTINAL BLEEDING: A POSSIBLE ASSOCIATION WITH IBUPROFEN
541
believe that such " prophylaxis " is valueless and often
dangerous, and it is
in our patients. Our are: (1) Isolameasures to infection prevent prophylactic tion in single rooms which are plenum-ventilated with air filtered to remove particles down to 5 [L diameter; (2) reverse barrier-nursing procedures for patients with neutropenia of less than 200 per ml.; (3) topical antiseptic agents; (4) sterile food; (5) nursing in plastic film isolators in selected cases; (6) sterilisation of the gut by orally administered non-absorbable antibiotics. The employment and evaluation of these measures is the subject of a controlled clinical trial. Thus, we have no disagreement with Dr. Smith in his condemnation of systemic antibiotic prophylaxis. Concerning the frequency with which blind antibiotic therapy (as against prophylaxis) is indicated, we may differ, but we believe that both our own resultsand those of Schimpff and his colleagues3 amply justify our readiness to embark at an early stage upon empirical antibiotic therapy in clinically diagnosed infections without awaiting bacteriological confirmation. not
practised
Royal Postgraduate Medical School London W.12.
A. S. D. SPIERS M. H. N. TATTERSALL J. H. DARRELL.
GASTROINTESTINAL BLEEDING: A POSSIBLE ASSOCIATION WITH IBUPROFEN SIR,—Ibuprofen (’ Brufen ’) is said to be well tolerated by patients who experience gastric irritation with other anti-inflammatory drugs.4This may well lead to its being widely prescribed to patients with both peptic ulceration and rheumatic conditions, and I therefore report a case of fatal gastrointestinal bleeding after this drug had been given to a patient with duodenal ulcer. A 69-year-old man had had symptoms of duodenal ulcer for 25 years, but with no complications. In 1957 he had a myocardial infarct, followed by persistent angina, and for about 4 years had had mild prostatic symptoms. The prostate was hard
rectal examination, but the serum-acid-phosphatase level was normal. For several months he had complained of back pain; radiological examination showed minor osteoarthritic changes and he Later ibuprofen (200 mg. was treated with dihydrocodeine. three times daily) was also given; one week after this was started he passed a melasna stool and was admitted to hospital. After admission meleana continued and the haemoglobin level fell in spite of transfusion, and emergency laparotomy was performed by Mr. R. T. Burkitt. A large posterior duodenal ulcer was found and a Polya partial gastrectomy performed. Initially he did well after operation, but on the second postoperative day he collapsed with left ventricular failure and he died next day. Necropsy (Dr. M. R. Crompton) showed the cause of death to be rupture of an aneurysm of the splenic artery; there was a carcinoma of the prostate with pulmonary metastases. on
The fatal outcome of the bleed from this patient’s duodenal ulcer is clearly due to multiple factors; however, the onset of this complication within a week of the start of treatment with ibuprofen, after many years during which there had been no complications from the ulcer, is striking. It seems that ibuprofen, like other anti-rheumatic drugs, should be avoided in patients with dyspeptic symptoms or known ulcers, and paracetamol remains the analgesic of choice in such patients. Ashford Hospital,
Ashford, Middlesex.
D.
J. HOLOSTOCK.
Preisler, H. D., Goldstein, I. M., Henderson, E. S. Cancer, 1970, 26, 1076. 3. Schimpff, S., Satterlee, W., Young, V. M., Serpick, A. New Engl. J. Med. 1971, 284, 1061. 4. MIMS Annual Compendium, section 3, p. 86. London, 1971. 2.
ACCOMMODATION FOR MEDICAL VISITORS SiR,-Few would dispute that for a young doctor in training a period of work overseas is of inestimable value, whether this is spent, depending upon his, specialty and intended career, in a research laboratory, in a clinical department of a university hospital, in an under-doctored area of a developing country, or in general practice. Many of us in Britain have been fortunate in having had such opportunities and, in turn, we are also fortunate in being invited to act as hosts to increasing numbers of colleagues from other countries, of various ages, qualifications, and
experience, who come to work for varying periods in our clinics and departments. Some such individuals place a considerable strain on postgraduate teaching and research facilities, but they are nevertheless very welcome because of the contributions they make to the work of the host department; while most come to learn from us, some come to teach, and there can be few from whom we do not learn something new, whether related to scientific medicine or research or to patterns of medical practice in the countries from which they have come. This flow of visitors, then, is one which few would wish to check, despite its apparent increase (which will surely continue when we are a part of the European community), because of the valuable cross-fertilisation which it engenders. But there is an important practical problem which is giving increasing concern-namely, that of accommodation. Many of these visitors are married, with young families, and, at a time when our hospitals are generally incapable of accommodating their own married junior medical staff, they have as a rule no room to spare for foreign visitors, especially when they are coming to do research or on clinical attachment and are not holding salaried posts in the hospital service. Those of us who have been fortunate enough to travel extensively have been impressed to note the accommodation for visiting fellows and their families in many American centres and the guest flats for short-term (and sometimes long-term) visitors in many European centres (particularly Western Germany), in Australia, and even in some centres in less highly developed countries such as India. It is a never-ending source of concern to us to note the difficulty experienced by many of our visitors in the Provinces in finding suitable furnished accommodation to rent, and then to note the often spartan conditions in which they are compelled to live, so very different from those in the climatic and cultural setting from which they have come. My wife and I particularly recall spending a snowy New Year’s Eve 1970 with a distressed American couple and their two young children, attempting to reassure them that the unfamiliar coke-burning stove would eventually heat the pleasant and clean (to an Englishman) but cold and forbidding (to an American) semi-detached house which they had rented. We could quote many more such examples, and one other visitor who came for a month left after four days after a series of minor catastrophes. The time and effort spent by medical, scientific, secretarial, and administrative staff of our hospitals and departments in trying to find congenial living quarters for such individuals could be spent more profitably, and even the efforts of such agencies as the British Council and the university accommodation officer do not as a rule ease the burden of responsibility which we in the host departments feel towards our guests. At present the Health Department will not allow hospital boards or boards of governors to allocate funds for the provision of residential accommodation which could be used by postgraduate students and overseas visitors and their families. Surely the new hospitals now being designed and built in major centres must have such facilities. If we are to continue in this country to attract some of these people who contribute so much to our medical life and
believe that such " prophylaxis " is valueless and often
dangerous, and it is
in our patients. Our are: (1) Isolameasures to infection prevent prophylactic tion in single rooms which are plenum-ventilated with air filtered to remove particles down to 5 [L diameter; (2) reverse barrier-nursing procedures for patients with neutropenia of less than 200 per ml.; (3) topical antiseptic agents; (4) sterile food; (5) nursing in plastic film isolators in selected cases; (6) sterilisation of the gut by orally administered non-absorbable antibiotics. The employment and evaluation of these measures is the subject of a controlled clinical trial. Thus, we have no disagreement with Dr. Smith in his condemnation of systemic antibiotic prophylaxis. Concerning the frequency with which blind antibiotic therapy (as against prophylaxis) is indicated, we may differ, but we believe that both our own resultsand those of Schimpff and his colleagues3 amply justify our readiness to embark at an early stage upon empirical antibiotic therapy in clinically diagnosed infections without awaiting bacteriological confirmation. not
practised
Royal Postgraduate Medical School London W.12.
A. S. D. SPIERS M. H. N. TATTERSALL J. H. DARRELL.
GASTROINTESTINAL BLEEDING: A POSSIBLE ASSOCIATION WITH IBUPROFEN SIR,—Ibuprofen (’ Brufen ’) is said to be well tolerated by patients who experience gastric irritation with other anti-inflammatory drugs.4This may well lead to its being widely prescribed to patients with both peptic ulceration and rheumatic conditions, and I therefore report a case of fatal gastrointestinal bleeding after this drug had been given to a patient with duodenal ulcer. A 69-year-old man had had symptoms of duodenal ulcer for 25 years, but with no complications. In 1957 he had a myocardial infarct, followed by persistent angina, and for about 4 years had had mild prostatic symptoms. The prostate was hard
rectal examination, but the serum-acid-phosphatase level was normal. For several months he had complained of back pain; radiological examination showed minor osteoarthritic changes and he Later ibuprofen (200 mg. was treated with dihydrocodeine. three times daily) was also given; one week after this was started he passed a melasna stool and was admitted to hospital. After admission meleana continued and the haemoglobin level fell in spite of transfusion, and emergency laparotomy was performed by Mr. R. T. Burkitt. A large posterior duodenal ulcer was found and a Polya partial gastrectomy performed. Initially he did well after operation, but on the second postoperative day he collapsed with left ventricular failure and he died next day. Necropsy (Dr. M. R. Crompton) showed the cause of death to be rupture of an aneurysm of the splenic artery; there was a carcinoma of the prostate with pulmonary metastases. on
The fatal outcome of the bleed from this patient’s duodenal ulcer is clearly due to multiple factors; however, the onset of this complication within a week of the start of treatment with ibuprofen, after many years during which there had been no complications from the ulcer, is striking. It seems that ibuprofen, like other anti-rheumatic drugs, should be avoided in patients with dyspeptic symptoms or known ulcers, and paracetamol remains the analgesic of choice in such patients. Ashford Hospital,
Ashford, Middlesex.
D.
J. HOLOSTOCK.
Preisler, H. D., Goldstein, I. M., Henderson, E. S. Cancer, 1970, 26, 1076. 3. Schimpff, S., Satterlee, W., Young, V. M., Serpick, A. New Engl. J. Med. 1971, 284, 1061. 4. MIMS Annual Compendium, section 3, p. 86. London, 1971. 2.
ACCOMMODATION FOR MEDICAL VISITORS SiR,-Few would dispute that for a young doctor in training a period of work overseas is of inestimable value, whether this is spent, depending upon his, specialty and intended career, in a research laboratory, in a clinical department of a university hospital, in an under-doctored area of a developing country, or in general practice. Many of us in Britain have been fortunate in having had such opportunities and, in turn, we are also fortunate in being invited to act as hosts to increasing numbers of colleagues from other countries, of various ages, qualifications, and
experience, who come to work for varying periods in our clinics and departments. Some such individuals place a considerable strain on postgraduate teaching and research facilities, but they are nevertheless very welcome because of the contributions they make to the work of the host department; while most come to learn from us, some come to teach, and there can be few from whom we do not learn something new, whether related to scientific medicine or research or to patterns of medical practice in the countries from which they have come. This flow of visitors, then, is one which few would wish to check, despite its apparent increase (which will surely continue when we are a part of the European community), because of the valuable cross-fertilisation which it engenders. But there is an important practical problem which is giving increasing concern-namely, that of accommodation. Many of these visitors are married, with young families, and, at a time when our hospitals are generally incapable of accommodating their own married junior medical staff, they have as a rule no room to spare for foreign visitors, especially when they are coming to do research or on clinical attachment and are not holding salaried posts in the hospital service. Those of us who have been fortunate enough to travel extensively have been impressed to note the accommodation for visiting fellows and their families in many American centres and the guest flats for short-term (and sometimes long-term) visitors in many European centres (particularly Western Germany), in Australia, and even in some centres in less highly developed countries such as India. It is a never-ending source of concern to us to note the difficulty experienced by many of our visitors in the Provinces in finding suitable furnished accommodation to rent, and then to note the often spartan conditions in which they are compelled to live, so very different from those in the climatic and cultural setting from which they have come. My wife and I particularly recall spending a snowy New Year’s Eve 1970 with a distressed American couple and their two young children, attempting to reassure them that the unfamiliar coke-burning stove would eventually heat the pleasant and clean (to an Englishman) but cold and forbidding (to an American) semi-detached house which they had rented. We could quote many more such examples, and one other visitor who came for a month left after four days after a series of minor catastrophes. The time and effort spent by medical, scientific, secretarial, and administrative staff of our hospitals and departments in trying to find congenial living quarters for such individuals could be spent more profitably, and even the efforts of such agencies as the British Council and the university accommodation officer do not as a rule ease the burden of responsibility which we in the host departments feel towards our guests. At present the Health Department will not allow hospital boards or boards of governors to allocate funds for the provision of residential accommodation which could be used by postgraduate students and overseas visitors and their families. Surely the new hospitals now being designed and built in major centres must have such facilities. If we are to continue in this country to attract some of these people who contribute so much to our medical life and