- Email: [email protected]
JOINT SYMPTOMS IN GIARDIASIS
1010
MICROFILTRATION OF STORED BLOOD REGARDLESS OF AGE OF STORAGE SIR,-Our data, which will be published in full elsewhere are at variance with a comment in your editorial on blood filters.’ You stated that "blood less than 48 hours old should not be microfiltered since the number of particles is small". We have found significant numbers of microaggregates in fresh, unfiltered whole blood even shortly after collection (see table). Larger aggregates (10 lim and larger) were more common in 0-3 h blood than in blood which was 24-48 h postcollection. It has been established that c.P.D.-preserved blood develops greater numbers of aggregrates than does acid-citrate/ dextrose preserved blood.2 These data, with ours, suggest that if C.P.D. blood less than 7 days old is used for transfusion, microfiltration is even more necessary than it is for freshly collected whole blood We also disagree with your statement that the loss of platelets in a micropore filter is serious. Platelets in fresh, whole
probably
QUANTITY
AND SIZE OF MICROAGGREGATES IN C.P.D.-PRESERVED
WHOLE BLOOD DURING FIRST
48
H POST COLLECTION
I conclude from these data and the review by Bischel et a1.9 that all blood should be microfiltered, regardless of age, if the purpose of transfusion is to increase the haematocrit without producing pulmonary hypoxxmia. As your editorial stated "most of the circulating aggregates are removed by the pulmonary circulation during the first circuit through the body," but we would stress that the patient with pre-existing pulmonary disease and/or arteriosclerosis is more likely to be at risk from microembolisation and needs protection from the aggregates in blood of all ages. I recommend further, that if platelets are needed for the restoration of the platelet-count, they should be given as fresh concentrates by centrifugation techniques from a single ABOcompatible donor. Blood Bank and Department of Hahnemann Medical College and Hospital of Philadelphia,
Pathology,
Philadelphia, Pennsylvania 19102, U.S.A.
ELEANOR M. GRIFFITH*
*1’resent address’ Laboratory Service, Veterans Administration Hospital, Providence, Rhode Island 02908, U.S.A.
JOINT SYMPTOMS IN GIARDIASIS
Table shows average number of
microaggregates 3-50
fJ.Il1 in dia-
meter/ml whole blood in eight units of c.r.D.-preserved whole blood collected by standard phlebotomy technique within 8-12 min. The total number of microaggregates in a specific size range can be estimated by multiplication of the total volume of the unit (usually 450-525 ml), times the number of microaggregates/ml blood. 6 units tested at 0-3 h, 2 units at 24 and 48 h.
blood adhere to the collection pack3 and micropore filter bed at the rate of 10% loss in the polyvinyl-chloride collection bag at 22"C (greater than 32% loss in collection bag3) and a 10-25% loss in either the Pall, Bentley, or Fenwal micropore filters.’ The transfusion of the average number of platelets in a single unit of fresh whole blood (about 1011)6 is too small to increase the whole-body platelet-count to haemostatic levels. In our experience with massive transfusion and dilutional thrombocytopenia in patients after open-heart surgery, the plateletcount will not increase to haemostatic levels unless many units of fresh, whole blood are transfused within a short period of time. Fresh whole blood is difficult to obtain quickly from safely screened donors, has a low platelet-count if not collected within 8 min,7 loses 50-70% of its platelets in the transfusion apparatus (see above), and most of the platelets in freshly-collected blood are not viable 12 h post-collection.8 1. Lancet, 1976, i, 185. 2. Solis, R. T., Goldfinger,
D., Gibbs, M. B., Feller, J. A. Transfusion, 1974, 14, 544. 3. Perkins, H. A., Robbs, M. R., Hymans, P. G. ibid. 1975, 15, 87. 4. Murphy, S., Gardner, F. H. ibid. 1976, 16, 2. 5. Dunbar, R. W., Price, K. A., Cannarella, C. F. Anesth. Analg. 1974, 53,
SIR,-Several disorders of the small bowel can be associated with arthritis. Giardia lamblia thrives in the small bowel, and it. may cause diarrhoea, often alternating with constipation, steatorrhoea and malabsorption syndrome. G. lamblia infestation might, therefore, be expected to result in joint reactions, I have identified and successfully treated a rheumatic syndrome in children with G. lamblia intestinal parasitism who were attending a rheumatism clinic in C6rdoba, Argentina. There were 66 children (36 males and 30 females) aged two to fifteen years. The knee joint was affected in 42, bilaterally in 20, and of these 42, 24 had mild, recurrent, self-limiting synovitis. Other joint symptoms included ankle and or tarsal joint (13), hip (7), and shoulder, elbow, or wrist (3 each).IIIdefined pain in the hands was recorded in 7 and diffuse pain in the leg in 11. Gastrointestinal symptoms included crampy abdominal pain (27), recurrent diarrhoea (29), constipation (23), diarrhoea and constipation alternating (11), nausea and/or vomiting (11), blood in stools (4), and anorexia (28). Allergic manifestations, recorded in 60% of cases, included nasal itching, pruritus of the skin, and anal itching. Neurological symptoms were common-headache (24), irritability (27), and nocturnal gnashing of the teeth (29). Low-grade fever was present in 9 patients and 2 children had pyrexia. The erythrocyte-sedimentation rate was normal in 43 children and raised in 23. Haemoglobin levels were below 13 g/dl in 22. Latex tests for rheumatoid factor were positive in 3/40, and antistreptolysin 0 titres were significant in 4/40. HLA antigens were not tested. Synovial biopsy in 3 cases of recurrent synovitis of the knee revealed non-specific changes in 2 and "intensive fatty infiltration of the axis of villi" in one. The finding of G. lamblia cysts in stools in 62 cases and trophozoites and cysts in the duodenal juice in 2 confirmed parasitism. Treatment with quinacrine or metronidazole in standard doses for 10 days freed the stools of parasites, and both joint and extra-articular symptoms disappeared in more than 90% of cases. Occasional recurrences required a second course of treatment. Giardiasis in children is common in Argentina (parasites being found in 20-30% of stool specimens),’2 but it is found all over the world and is being reported increasingly often among American and Scandinavian travellers.3It is un-
580. 6.
Huestis, D. W., Bove, J. R., Busch, S. Practical Blood Transfusion; p. 295. Boston, 1969.
7. American Association of Blood Banks. Technical Manual. A.A.B.B. Wash-
ington, D.C., 1976. 8. Huestis, D. W. in Seminar ton,
D.C., 1974.
on
Current Technical
Topics A.A.B.B., Washing-
9. 1.
Bischel, M. D., Scoles, G. G., Mobler, J. G. Chest, 1975, 67, 335. Garaguso, P. Oliveri O. F., De Pierri, O. Revta Asoc. med. argent. 1965, 79,
529. 2. Zamar R., Gerber M. W. Dia méd. 1971, 3. Wolfe, M. S. J. Am med. Ass. 1975, 233, 4. ibid. p. 1393.
43, 1760. 1362.
1011
likely that joint symptoms diasis in Argentina.
are
peculiar
Department of Rheumatology, Children’s Hospital, Córdoba, Argentina *Present address:
Lakegatan 6
to
children with
giar-
JORGE P. GOOBAR*
II tr., 13300
Saltjöbaden, Sweden.
RECURRENCE RISK OF MYOTONIC DYSTROPHY
SIR,-Spence et al.discuss the inclusion of’information provided by family members in the calculation of the risk of myotomc dystrophy to a fetus in a given family (see figure). The myotonic-dystrophy locus is closely linked to the secretor locus, and secretor phenotypes can be detected in utero. Hence,
It is time-consuming to derive and check the formulae used for the tables. We therefore agree with Spence et al. that the risk calculations should be done by a computer program designed to handle arbitrary pedigrees. We derived the formulae both manually and by means of the GENEX computer system based on the algorithms.2 The computer route did not prove much easier, but since a general GENEX program was obtained as a byproduct, new pedigrees will now be very easy to handle. Institute of Medical
Genetics, University of Copenhagen, DK-2200 Copenhagen N, Denmark
*** 0-01 was, indeed, a misprint, for which Spence and her colleagues.-ED. L.
KIRSTEN FENGER J. HILDEN we
apologise
to
Dr
P.T.H., iP.T.H., P.T.E., AND PARATHORMONE SIR, Terminological inaccuracy is the hallmark of ignor-
the calculation has
to be based on the various family members’ myotonic-dystrophy phenotypes and secretor types, including the secretor type of the fetus. Spence et al. tabulate the pre-
dicted risk to the fetus for different values of the recombination, (8) both when the fetus is secretor and when it is a nonsecretor. The calculation is based on the assumption that an uncle (II-1 in their figure) is a secretor. For the alternative PREDICTED RISK TO INDIVIDUAL
111-2
WHEN THE UNCLE IS
NON-SECRETOR
ance. The non-expert follows the example of the expert; and inaccuracies are often perpetuated in teaching and may even appear in print. There is, in papers, considerable misuse of terms in respect of the polypeptide hormone secreted by the parathyroid glands, its name, and what is measured in the circulation. Some investigators measure one thing, discuss another, and use the abbreviation of something else. The hormone secreted by the parathyroid glands is parathyroid hormone (P.T.H.). In the circulation the hormone undergoes cleavage into at least three distinct fragments, differing in molecular weight and biological activity. Different radioimmunoassay techniques use different antisera and detect different fragments; the results obtained are correctly reported as the concentration of immunoreactive-p.T.H. (iP.T.H.). Parathyroid glands from human or animal species can be extracted, and the parathyroid extract (P.T.E.) obtained can be used in diagnostic procedures. P.T.E. from beef glands is available commercially from Eli Lilly under the trade name ’Para-thormone’. This particular brand of P.T.E. does not circulate in human plasma. The production-rate of P.T.H. is influenced by several factors, foremost amongst which is the circulating calcium-ion concentration. The production-rate of para-thormone would appear to be influenced mainly by the availability of beef parathyroid glands and industrial relationships at the Eli Lilly factory. Now that we have to be concerned with the minutiae of the interrelations between the cholecalciferol (vitamin D3) metabolites and parathyroid hormone, and now have to include the pituitary, use of the correct terminology is essential.
Metabolic Unit, Royal Free Hospital, London NW3 2QG
M. R. WILLS
WHAT’S IN BREAST MILK?
a non-secretor, they report the risk for there seems to be a misprint, 6=0-01 However, (0 88) only. since 6=0.01 gives the risk 0.99, whereas the risk 0.88 corresponds to 6=0-10. The predicted risk to the individual 111-2 is given in the table for this and other recombination fractions, the table being identical with that of Spence et al., except that the uncle is now a non-secretor. Spence et al. wanted to emphasise that the uncle’s secretor type ought to be taken into account. This point is brought out very clearly by the two tables. The uncle’s secretor type may well decide the question of abortion, especially if the fetus is
case, where the uncle is
secretor. 1
Spence, M. A., Lange, K., Crandall,
B.F. Lancet, 1976, n, 1198.
S!R,—The Department of Health working-party, whose thorough analytical survey of five pooled samples of human milk you noted on April 23 (p. 918), recommend that the composition of artificial feeds for babies should, as far as possible, resemble their estimated average composition for mature human milk. Since the report will be regarded by many as a definitive statement about the way in which baby foods should be
constituted, we feel that the conclusions should be examined
carefully. The entire expressed contents of one breast were analysed. normal breast feeding, the infant frequently does not empty the breast, and because the composition of milk changes throughout the feed the average composition of the entire contents of one breast may not be the same as the average composition of milk that a baby may have obtained by being suckled.
During
2. Hilden,
J.Clin. Genet. 1971, 1, 319.
MICROFILTRATION OF STORED BLOOD REGARDLESS OF AGE OF STORAGE SIR,-Our data, which will be published in full elsewhere are at variance with a comment in your editorial on blood filters.’ You stated that "blood less than 48 hours old should not be microfiltered since the number of particles is small". We have found significant numbers of microaggregates in fresh, unfiltered whole blood even shortly after collection (see table). Larger aggregates (10 lim and larger) were more common in 0-3 h blood than in blood which was 24-48 h postcollection. It has been established that c.P.D.-preserved blood develops greater numbers of aggregrates than does acid-citrate/ dextrose preserved blood.2 These data, with ours, suggest that if C.P.D. blood less than 7 days old is used for transfusion, microfiltration is even more necessary than it is for freshly collected whole blood We also disagree with your statement that the loss of platelets in a micropore filter is serious. Platelets in fresh, whole
probably
QUANTITY
AND SIZE OF MICROAGGREGATES IN C.P.D.-PRESERVED
WHOLE BLOOD DURING FIRST
48
H POST COLLECTION
I conclude from these data and the review by Bischel et a1.9 that all blood should be microfiltered, regardless of age, if the purpose of transfusion is to increase the haematocrit without producing pulmonary hypoxxmia. As your editorial stated "most of the circulating aggregates are removed by the pulmonary circulation during the first circuit through the body," but we would stress that the patient with pre-existing pulmonary disease and/or arteriosclerosis is more likely to be at risk from microembolisation and needs protection from the aggregates in blood of all ages. I recommend further, that if platelets are needed for the restoration of the platelet-count, they should be given as fresh concentrates by centrifugation techniques from a single ABOcompatible donor. Blood Bank and Department of Hahnemann Medical College and Hospital of Philadelphia,
Pathology,
Philadelphia, Pennsylvania 19102, U.S.A.
ELEANOR M. GRIFFITH*
*1’resent address’ Laboratory Service, Veterans Administration Hospital, Providence, Rhode Island 02908, U.S.A.
JOINT SYMPTOMS IN GIARDIASIS
Table shows average number of
microaggregates 3-50
fJ.Il1 in dia-
meter/ml whole blood in eight units of c.r.D.-preserved whole blood collected by standard phlebotomy technique within 8-12 min. The total number of microaggregates in a specific size range can be estimated by multiplication of the total volume of the unit (usually 450-525 ml), times the number of microaggregates/ml blood. 6 units tested at 0-3 h, 2 units at 24 and 48 h.
blood adhere to the collection pack3 and micropore filter bed at the rate of 10% loss in the polyvinyl-chloride collection bag at 22"C (greater than 32% loss in collection bag3) and a 10-25% loss in either the Pall, Bentley, or Fenwal micropore filters.’ The transfusion of the average number of platelets in a single unit of fresh whole blood (about 1011)6 is too small to increase the whole-body platelet-count to haemostatic levels. In our experience with massive transfusion and dilutional thrombocytopenia in patients after open-heart surgery, the plateletcount will not increase to haemostatic levels unless many units of fresh, whole blood are transfused within a short period of time. Fresh whole blood is difficult to obtain quickly from safely screened donors, has a low platelet-count if not collected within 8 min,7 loses 50-70% of its platelets in the transfusion apparatus (see above), and most of the platelets in freshly-collected blood are not viable 12 h post-collection.8 1. Lancet, 1976, i, 185. 2. Solis, R. T., Goldfinger,
D., Gibbs, M. B., Feller, J. A. Transfusion, 1974, 14, 544. 3. Perkins, H. A., Robbs, M. R., Hymans, P. G. ibid. 1975, 15, 87. 4. Murphy, S., Gardner, F. H. ibid. 1976, 16, 2. 5. Dunbar, R. W., Price, K. A., Cannarella, C. F. Anesth. Analg. 1974, 53,
SIR,-Several disorders of the small bowel can be associated with arthritis. Giardia lamblia thrives in the small bowel, and it. may cause diarrhoea, often alternating with constipation, steatorrhoea and malabsorption syndrome. G. lamblia infestation might, therefore, be expected to result in joint reactions, I have identified and successfully treated a rheumatic syndrome in children with G. lamblia intestinal parasitism who were attending a rheumatism clinic in C6rdoba, Argentina. There were 66 children (36 males and 30 females) aged two to fifteen years. The knee joint was affected in 42, bilaterally in 20, and of these 42, 24 had mild, recurrent, self-limiting synovitis. Other joint symptoms included ankle and or tarsal joint (13), hip (7), and shoulder, elbow, or wrist (3 each).IIIdefined pain in the hands was recorded in 7 and diffuse pain in the leg in 11. Gastrointestinal symptoms included crampy abdominal pain (27), recurrent diarrhoea (29), constipation (23), diarrhoea and constipation alternating (11), nausea and/or vomiting (11), blood in stools (4), and anorexia (28). Allergic manifestations, recorded in 60% of cases, included nasal itching, pruritus of the skin, and anal itching. Neurological symptoms were common-headache (24), irritability (27), and nocturnal gnashing of the teeth (29). Low-grade fever was present in 9 patients and 2 children had pyrexia. The erythrocyte-sedimentation rate was normal in 43 children and raised in 23. Haemoglobin levels were below 13 g/dl in 22. Latex tests for rheumatoid factor were positive in 3/40, and antistreptolysin 0 titres were significant in 4/40. HLA antigens were not tested. Synovial biopsy in 3 cases of recurrent synovitis of the knee revealed non-specific changes in 2 and "intensive fatty infiltration of the axis of villi" in one. The finding of G. lamblia cysts in stools in 62 cases and trophozoites and cysts in the duodenal juice in 2 confirmed parasitism. Treatment with quinacrine or metronidazole in standard doses for 10 days freed the stools of parasites, and both joint and extra-articular symptoms disappeared in more than 90% of cases. Occasional recurrences required a second course of treatment. Giardiasis in children is common in Argentina (parasites being found in 20-30% of stool specimens),’2 but it is found all over the world and is being reported increasingly often among American and Scandinavian travellers.3It is un-
580. 6.
Huestis, D. W., Bove, J. R., Busch, S. Practical Blood Transfusion; p. 295. Boston, 1969.
7. American Association of Blood Banks. Technical Manual. A.A.B.B. Wash-
ington, D.C., 1976. 8. Huestis, D. W. in Seminar ton,
D.C., 1974.
on
Current Technical
Topics A.A.B.B., Washing-
9. 1.
Bischel, M. D., Scoles, G. G., Mobler, J. G. Chest, 1975, 67, 335. Garaguso, P. Oliveri O. F., De Pierri, O. Revta Asoc. med. argent. 1965, 79,
529. 2. Zamar R., Gerber M. W. Dia méd. 1971, 3. Wolfe, M. S. J. Am med. Ass. 1975, 233, 4. ibid. p. 1393.
43, 1760. 1362.
1011
likely that joint symptoms diasis in Argentina.
are
peculiar
Department of Rheumatology, Children’s Hospital, Córdoba, Argentina *Present address:
Lakegatan 6
to
children with
giar-
JORGE P. GOOBAR*
II tr., 13300
Saltjöbaden, Sweden.
RECURRENCE RISK OF MYOTONIC DYSTROPHY
SIR,-Spence et al.discuss the inclusion of’information provided by family members in the calculation of the risk of myotomc dystrophy to a fetus in a given family (see figure). The myotonic-dystrophy locus is closely linked to the secretor locus, and secretor phenotypes can be detected in utero. Hence,
It is time-consuming to derive and check the formulae used for the tables. We therefore agree with Spence et al. that the risk calculations should be done by a computer program designed to handle arbitrary pedigrees. We derived the formulae both manually and by means of the GENEX computer system based on the algorithms.2 The computer route did not prove much easier, but since a general GENEX program was obtained as a byproduct, new pedigrees will now be very easy to handle. Institute of Medical
Genetics, University of Copenhagen, DK-2200 Copenhagen N, Denmark
*** 0-01 was, indeed, a misprint, for which Spence and her colleagues.-ED. L.
KIRSTEN FENGER J. HILDEN we
apologise
to
Dr
P.T.H., iP.T.H., P.T.E., AND PARATHORMONE SIR, Terminological inaccuracy is the hallmark of ignor-
the calculation has
to be based on the various family members’ myotonic-dystrophy phenotypes and secretor types, including the secretor type of the fetus. Spence et al. tabulate the pre-
dicted risk to the fetus for different values of the recombination, (8) both when the fetus is secretor and when it is a nonsecretor. The calculation is based on the assumption that an uncle (II-1 in their figure) is a secretor. For the alternative PREDICTED RISK TO INDIVIDUAL
111-2
WHEN THE UNCLE IS
NON-SECRETOR
ance. The non-expert follows the example of the expert; and inaccuracies are often perpetuated in teaching and may even appear in print. There is, in papers, considerable misuse of terms in respect of the polypeptide hormone secreted by the parathyroid glands, its name, and what is measured in the circulation. Some investigators measure one thing, discuss another, and use the abbreviation of something else. The hormone secreted by the parathyroid glands is parathyroid hormone (P.T.H.). In the circulation the hormone undergoes cleavage into at least three distinct fragments, differing in molecular weight and biological activity. Different radioimmunoassay techniques use different antisera and detect different fragments; the results obtained are correctly reported as the concentration of immunoreactive-p.T.H. (iP.T.H.). Parathyroid glands from human or animal species can be extracted, and the parathyroid extract (P.T.E.) obtained can be used in diagnostic procedures. P.T.E. from beef glands is available commercially from Eli Lilly under the trade name ’Para-thormone’. This particular brand of P.T.E. does not circulate in human plasma. The production-rate of P.T.H. is influenced by several factors, foremost amongst which is the circulating calcium-ion concentration. The production-rate of para-thormone would appear to be influenced mainly by the availability of beef parathyroid glands and industrial relationships at the Eli Lilly factory. Now that we have to be concerned with the minutiae of the interrelations between the cholecalciferol (vitamin D3) metabolites and parathyroid hormone, and now have to include the pituitary, use of the correct terminology is essential.
Metabolic Unit, Royal Free Hospital, London NW3 2QG
M. R. WILLS
WHAT’S IN BREAST MILK?
a non-secretor, they report the risk for there seems to be a misprint, 6=0-01 However, (0 88) only. since 6=0.01 gives the risk 0.99, whereas the risk 0.88 corresponds to 6=0-10. The predicted risk to the individual 111-2 is given in the table for this and other recombination fractions, the table being identical with that of Spence et al., except that the uncle is now a non-secretor. Spence et al. wanted to emphasise that the uncle’s secretor type ought to be taken into account. This point is brought out very clearly by the two tables. The uncle’s secretor type may well decide the question of abortion, especially if the fetus is
case, where the uncle is
secretor. 1
Spence, M. A., Lange, K., Crandall,
B.F. Lancet, 1976, n, 1198.
S!R,—The Department of Health working-party, whose thorough analytical survey of five pooled samples of human milk you noted on April 23 (p. 918), recommend that the composition of artificial feeds for babies should, as far as possible, resemble their estimated average composition for mature human milk. Since the report will be regarded by many as a definitive statement about the way in which baby foods should be
constituted, we feel that the conclusions should be examined
carefully. The entire expressed contents of one breast were analysed. normal breast feeding, the infant frequently does not empty the breast, and because the composition of milk changes throughout the feed the average composition of the entire contents of one breast may not be the same as the average composition of milk that a baby may have obtained by being suckled.
During
2. Hilden,
J.Clin. Genet. 1971, 1, 319.