- Email: [email protected]
Hiking sticks in mountaineering
be discussed from the start of the disease. A shorter life expectancy, but being at home, might be preferred to a small chance of a longer life at the cost of a sometimes long hospital stay and considerable morbidity. The patient should have an important (and final) vote in the choice of therapy and the choice of what he considers important for his life. Since the ideal drug for the treatment of CHF that prolongs life and increases the quality of life, together with increased exercise tolerance is still a remote possibility, such discussions will probably be impossible for the CHF patient, especially since mortality outcome only seems to be the important issue-which is not justified in our view.
follow-up of at least 14 months, neurological abnormalities (hemiparesis three cases, pharmacoresistant
After
epilepsy in disturbance
3
4
5
together
polyneuropathy
movement
in
2,
case
*G Kluger, A Schöttler, K Waldvogel, D Nadal, W Hinrichs, G F Wündisch, M C Laub
The CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure. N Engl J Med 1987; 316: 1429-35. Promise Study Research Group. Effect of oral milrinone on mortality in severe chronic heart failure. N Engl J Med 1991; 325: 1468-75. Jondeau G, Dubourg O, Delorme G, et al. Oral enoximone as a substitute for intravenous catecholamine support in end-stage congestive heart failure. Eur Heart J 1994; 15: 242-46. The SOLVD investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med 1991; 325: 293-302. Cohn JN, Johnson G, Ziesche S, et al. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med 1991; 325: 303-10.
*Neuropaediatric Department, Behandlungszentrum, Krankenhausstrasse 20, D-83569 Vogtareuth, Germany; Intensive Care and Infectious Diseases Units, Children’s Hospital, Zürich, Switzerland; Cnopf’sche Kinderklinik, Nurnberg, Germany; Children’s Hospital, Bayreuth, Germany 1
Zoulek G, Roggendorf M, Deinhardt F, Kunz C. Different immune responses after intradermal and intramuscular administration of vaccine against tick-borne encephalitis virus. J Med Virol 1986; 19:
2
Kunz C, Hofmann H, Kundi M, Mayer K. Zur Wirksamkeit von FSME—Immunglobulin. Wien Klin Wochenschr 1981; 93: 665-67. Morens DM. Antibody-dependent enhancement of infection and the pathogenesis of viral disease. Clin Infect Dis 1994; 19: 500-12.
55-61.
3
in
Hiking sticks Tickborne
encephalitis despite specific immunoglobulin prophylaxis
SiR-Tickborne Europe. Severe
2, and extrapyramidal
with
All three patients developed severe TBE despite passive immunisation after exposure at doses and within the time frame recommended by the manufacturer. In the last 10 years we have not observed severe TBE in children not passively immunised. Administration of hyperimmune globulin after a tick bite may have had a detrimental effect on the course of the illness in our patients. This would be in agreement with the notion of antibody-dependent enhancement of infection and contribution to pathogenesis in other arboviral diseases.3
Netherlands
2
1 and
remained.
*Armand R J Girbes, Joost Th M de Wolf Surgical Intensive Care Unit, University Hospital Groningen, 9713 EZ Groningen,
1
cases
(TBE) is widespread in of TBE with permanent neurological damage are rare, especially in children. Active immunisation with a killed-virus vaccine is recommended in endemic areas, and offers 90% protection.’ Passive immunisation before or after exposure with a specific immunoglobulin is available but little information exists as to the efficacy of this treatment." According to the manufacturer’s recommendation, the dosage of immunoglobulin should vary according to the time since exposure, and be administered no longer than 4 days after the tick bite. We report on three girls who had severe TBE with residual symptoms despite passive immunisation (table). In all three cases, intrathecal TBE virus-specific antibody was detected and immunodeficiency was ruled out. In cases 1 and 2 TBE-specific IgM was still found in cerebrospinal fluid after 8 months and in one case TBE-PCR was also positive. During the acute-phase of the encephalitis, enhanced signals in T2-weighted magnetic resonance imaging in the thalamus were demonstrated in all cases.
encephalitis
cases
mountaineering
SiR-Many hikers, mountaineers, and climbers use telescopic sticks, because these aid walking uphill or downhill and ease the strain of the spine and the leg joints, especially the knee.’ Telescopic sticks, however, must be used with the correct technique. Two sticks should always be used, and should be height-adjustable and have handles that
are
constructed in
a
way that the user’s hands-when
firm
support. pressing down-gain importance to use two sticks as close body’s line of fall.
It as
is
of
utmost
possible
to
the
1
To test whether hikers follow this advice by the Unione Internazionale delle Associazioni Alpinistiche Medical Commission we observed 860 hikers who used telescopic sticks. This study was undertaken in the Austrian Alps near Innsbruck during the summer of 1995. We found that more than 95% of our participants did not use telescopic sticks with the correct technique. Therefore, ways have to be found to pass down the correct advice’ to hikers and mountaineers. *Christian Haid, Arnold Koller Departments of *Orthopaedic Surgery, and Sports and Circulatory Medicine, University Hospital, A-6020 Innsbruck, Austria 1
Official Standards of the UIAA Medical Commission. Hiking sticks in vol 3. Medical Commission of UIAA, 1994.
mountaineering,
DEPARTMENT OF ERROR Tackling liver cancer with mterferon (Oct 21, p 1049)-In this Commentary by Schluger and Bodenheimer, the authors incorrectly stated that Nishiguchi and colleagues in the accompanying article (p 1051) used interferon CX2b’ which is recombinant mterferon, when the human lymphoblastoid interferon.
preparation used
was
Pertussis
Table: Severe tickborne
immunisation
1502
encephalitis after passive
in adults: frequency of transmission after household exposure-In this article by Wirsing von König and colleagues (Nov 18, p 1326), the two sex ratios in table 2 should be replaced by, respectively, 2-3 (41/18) and 1-1 (13/12).
follow-up of at least 14 months, neurological abnormalities (hemiparesis three cases, pharmacoresistant
After
epilepsy in disturbance
3
4
5
together
polyneuropathy
movement
in
2,
case
*G Kluger, A Schöttler, K Waldvogel, D Nadal, W Hinrichs, G F Wündisch, M C Laub
The CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure. N Engl J Med 1987; 316: 1429-35. Promise Study Research Group. Effect of oral milrinone on mortality in severe chronic heart failure. N Engl J Med 1991; 325: 1468-75. Jondeau G, Dubourg O, Delorme G, et al. Oral enoximone as a substitute for intravenous catecholamine support in end-stage congestive heart failure. Eur Heart J 1994; 15: 242-46. The SOLVD investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med 1991; 325: 293-302. Cohn JN, Johnson G, Ziesche S, et al. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med 1991; 325: 303-10.
*Neuropaediatric Department, Behandlungszentrum, Krankenhausstrasse 20, D-83569 Vogtareuth, Germany; Intensive Care and Infectious Diseases Units, Children’s Hospital, Zürich, Switzerland; Cnopf’sche Kinderklinik, Nurnberg, Germany; Children’s Hospital, Bayreuth, Germany 1
Zoulek G, Roggendorf M, Deinhardt F, Kunz C. Different immune responses after intradermal and intramuscular administration of vaccine against tick-borne encephalitis virus. J Med Virol 1986; 19:
2
Kunz C, Hofmann H, Kundi M, Mayer K. Zur Wirksamkeit von FSME—Immunglobulin. Wien Klin Wochenschr 1981; 93: 665-67. Morens DM. Antibody-dependent enhancement of infection and the pathogenesis of viral disease. Clin Infect Dis 1994; 19: 500-12.
55-61.
3
in
Hiking sticks Tickborne
encephalitis despite specific immunoglobulin prophylaxis
SiR-Tickborne Europe. Severe
2, and extrapyramidal
with
All three patients developed severe TBE despite passive immunisation after exposure at doses and within the time frame recommended by the manufacturer. In the last 10 years we have not observed severe TBE in children not passively immunised. Administration of hyperimmune globulin after a tick bite may have had a detrimental effect on the course of the illness in our patients. This would be in agreement with the notion of antibody-dependent enhancement of infection and contribution to pathogenesis in other arboviral diseases.3
Netherlands
2
1 and
remained.
*Armand R J Girbes, Joost Th M de Wolf Surgical Intensive Care Unit, University Hospital Groningen, 9713 EZ Groningen,
1
cases
(TBE) is widespread in of TBE with permanent neurological damage are rare, especially in children. Active immunisation with a killed-virus vaccine is recommended in endemic areas, and offers 90% protection.’ Passive immunisation before or after exposure with a specific immunoglobulin is available but little information exists as to the efficacy of this treatment." According to the manufacturer’s recommendation, the dosage of immunoglobulin should vary according to the time since exposure, and be administered no longer than 4 days after the tick bite. We report on three girls who had severe TBE with residual symptoms despite passive immunisation (table). In all three cases, intrathecal TBE virus-specific antibody was detected and immunodeficiency was ruled out. In cases 1 and 2 TBE-specific IgM was still found in cerebrospinal fluid after 8 months and in one case TBE-PCR was also positive. During the acute-phase of the encephalitis, enhanced signals in T2-weighted magnetic resonance imaging in the thalamus were demonstrated in all cases.
encephalitis
cases
mountaineering
SiR-Many hikers, mountaineers, and climbers use telescopic sticks, because these aid walking uphill or downhill and ease the strain of the spine and the leg joints, especially the knee.’ Telescopic sticks, however, must be used with the correct technique. Two sticks should always be used, and should be height-adjustable and have handles that
are
constructed in
a
way that the user’s hands-when
firm
support. pressing down-gain importance to use two sticks as close body’s line of fall.
It as
is
of
utmost
possible
to
the
1
To test whether hikers follow this advice by the Unione Internazionale delle Associazioni Alpinistiche Medical Commission we observed 860 hikers who used telescopic sticks. This study was undertaken in the Austrian Alps near Innsbruck during the summer of 1995. We found that more than 95% of our participants did not use telescopic sticks with the correct technique. Therefore, ways have to be found to pass down the correct advice’ to hikers and mountaineers. *Christian Haid, Arnold Koller Departments of *Orthopaedic Surgery, and Sports and Circulatory Medicine, University Hospital, A-6020 Innsbruck, Austria 1
Official Standards of the UIAA Medical Commission. Hiking sticks in vol 3. Medical Commission of UIAA, 1994.
mountaineering,
DEPARTMENT OF ERROR Tackling liver cancer with mterferon (Oct 21, p 1049)-In this Commentary by Schluger and Bodenheimer, the authors incorrectly stated that Nishiguchi and colleagues in the accompanying article (p 1051) used interferon CX2b’ which is recombinant mterferon, when the human lymphoblastoid interferon.
preparation used
was
Pertussis
Table: Severe tickborne
immunisation
1502
encephalitis after passive
in adults: frequency of transmission after household exposure-In this article by Wirsing von König and colleagues (Nov 18, p 1326), the two sex ratios in table 2 should be replaced by, respectively, 2-3 (41/18) and 1-1 (13/12).