- Email: [email protected]
LONG-TERM FOLLOW-UP AFTER BONE-MARROW TRANSPLANTATION IN ACUTE LYMPHOBLASTIC LEUKAEMIA
380
Rabies was diagnosed in bats only, and all but 2 of the 104 positive bats were E serotinus. No other animal was positive either in FA or by inoculation test even though many of the cats and foxes were sent of bat rabies. in from areas in Jutland with a high FA and inoculation studies on serotine bats are shown in table 11. (Of the 2 FA positive Myotis spp, 1 was confirmed by isolation in mouse brain.) Of the 104 bats positive by FA, material from 101 was available for IFA with monoclonal antibodies. All 101 specimens reacted similarly in IFA, confirming that these strains belonged to the rabies virus group, but not to serotype 1. Bat rabies was concentrated in southern and eastern Jutland: 88 (32 %) of 276 serotine bats sent in from the four counties in this part of Jutland were found positive. Positive bats were found in all months from June to October with a peak in August. Rabies in Danish bats was further studied by neutralisation tests on serum from 10 apparently healthy serotine bats, 9 of them being from a rabies positive colony in south-east Jutland; the other was trapped in a house where bat rabies had been diagnosed previously. FA titres were 100 in 4 bats, 10 in 4 bats, and less than 10 in 2 bats. Thus DBV-antibodies were detected in apparently healthy bats. Findings in Denmark and Germanyl° indicate that bat rabies is more common in Europe than most people think. DBV can infect and kill in the laboratory8 but our field data seem to indicate that bat rabies is rarely transmitted to other mammals. The absence of bat rabies in terrestrial animals from an area of Denmark with a cluster of bat rabies could indicate that an epizootic of bat rabies in terrestrial animals will not be readily established. 11
frequency
National Veterinary Laboratory, PO Box 373, DK-1503 Copenhagen V, Denmark
P. C. GRAUBALLE
Zoological Museum, University of Copenhagen Rabies Laboratory, CDC Center for Infectious Diseases Lawrenceville, Georgia, USA
H.
J. BAAGØE
M. FEKADU
Acute
hepatitis
abusers.
B reports
to
PHLS 1975-86 and numbers in
drug
‘
following changes: fewer new intravenous drug abusers, less use of the intravenous route, less sharing of needles and syringes, or active immunisation. Why should these changes have happened in 1985-86? Hepatitis B is a long-established hazard of unsterile needles and syringes: although public awareness of hepatitis B infection as a risk of intravenous drug abuse may have increased it seems improbable that this alone is sufficient to have reversed the trend. However, public warnings of the risk of acquiring the human immunodeficiency virus may have had a sufficient deterrent effect limiting intravenous drug abuse or persuading abusers not to share equipment. There can be no certainty that fear of AIDS has led to a decrease in acute hepatitis B infections but if it has acute hepatitis B reports would be encouraging evidence of the value of publicity campaigns in curbing practices that favour the spread of AIDS. Hepatitis Epidemiology Unit, Central Public Health Laboratory,
SHEILA POLAKOFF
London NW9 5HT
National
Veterinary Service, Copenhagen
J. M. WESTERGAARD
Department of Epidemiology, Statens Seruminstitut, Copenhagen
H. ZOFFMANN
1. Müller J. The effect of fox reduction on the occurrence of rabies. Observation from two outbreaks of rabies in Denmark. Bull Off Int Epiz 1971; 75: 763-76. 2. Stougaard E. Denmark again free from rabies. Rabies Bull Europe 1983; 1: 4-5. 3. Anon. Rabies Bull Europe 1986; 1: 9-14. 4. Anon. MMWR 1986; 35: 431. 5. WHO. Control of rabies in wildlife bats. In: WHO Expert Committee on Rabies:
Seventh report. Tech Rep Ser WHO 1984; 709: 65-66. MA, et al. To the issue of chiropteric rabic infection. Rabies Inf Exchange
6. Selimou
1986; 14: 9-12. J, et al. Human rabies of bat origin in Europe. Lancet 1986, i: 378. 8. Bitsch V, et al. Bat virus-Europe. MMWR 1986; 35: 430-32. 9. Lafon M, et al. Human rabies vaccine induce neutralising antibodies against the European bat rabies virus (Duvenhage). Lancet 1986; ii: 515. 10. Anon. Rabies Bull Europe 1986; 2: 8-9. 11. Smith JS, et al. Demonstration of antigenic variation among rabies virus isolates by using monoclonal antibodies to nucleo-capsid proteins. J Clin Microbiol 1986; 24: 7. Lumio
LONG-TERM FOLLOW-UP AFTER BONE-MARROW TRANSPLANTATION IN ACUTE LYMPHOBLASTIC LEUKAEMIA
SIR,-A 1986 Lancet article by Chessells et all generated lively correspondence. We wish to emphasise the curative intent of bone-marrow transplantation (BMT) and the need to report data after a follow-up of 5 or more years. We have reported on 21 children with acute lymphoblastic leukaemia (ALL) who relapsed, achieved second remission, and were treated with chemotherapy and a concurrent group of 24 patients who had a donor and were treated with BMT while in a second or subsequent marrow remission.2 Initial induction therapy was given in several institutions but, after first relapse, all patients were treated in a single centre by the same team of physicians. In a follow-up, all children treated with chemotherapy had relapsed and
573-80.
DECREASE IN ACUTE HEPATITIS B INCIDENCE IN ENGLAND AND WALES IN 1985-86
SIR,—The annual total of laboratory reports of acute clinical hepatitis B to the Public Health Laboratory Service, which ranged from about 1000 to 1200 during the years 1975-83, rose sharply to almost 2000 in 1984. Thereafter, however, there has been a sharp fall to about 1300 in 1986. Drug abusers have consistently constituted the largest single group, and fluctuations in the annual totals of acute hepatitis B have been due mainly to changes in numbers of addicts. The number of cases with a history of drug abuse increased from less than 300 in 1983 to about 600 in 1984 and then fell to about 300 in 1986 (figure). Male homosexuals have constituted a smaller portion of the total but their numbers also fell from a peak of 150 in 1984 to less than 100 in 1986, the smallest annual total for this group since 1981. The observed decline in drug abuse associated cases must have been due to one or more of the
YEARS
Kaplan-Meier product limit estimates of disease-free survival for 14 children given BMT for ALL in second remission. . = long-term survivor.
381 died by 3 years while 8 of the marrow-grafted patients continued in untreated remission3 and these 8 are in remission to this day. 14 of the 24 were transplanted in second remission. The figure shows actuarial survival with 4 of the 14 in event-free survival after 7-10 years. In addition to the marrow relapse, 1 of these 4 had a central nervous system (CNS) relapse, and 1 a CNS and ovarian relapse. All 4 surviving patients lead normal lives and attend high school or college. Late effects of transplantation include cataracts in 3 and primary ovarian failure in 1. All had normal growth and the 3 who were prepubertal at transplantation developed normally through puberty. As several of your correspondents say, the results of chemotherapy are improving and the same is true for BMT. However, the optimum age, type and stage of leukaemia, and appropriate prognostic indicators for BMT are controversial.3 The answers will come from prospective studies but "rapid advances in chemotherapy regimens and in marrow grafting regimens are likely to invalidate the results of a prospective study by the time it is completed".4
report here our experience with it during the pilgrimage season of 1406 AH in the muslim calendar (August, 1986). A patient trolley (75 x 180 cm) was constructed (figure) with a stainless steel tray to limit water spillage and to wash away excreta. Two fans with 35 cm diameter blades direct room air over the patient and Extech thermocouples are used to measure core and body surface temperatures. The patient is undressed and covered with a fine gauze sheet soaked in water at 20°C. The maximum speed of airflow, 50 cm below the centre of the fan at the top of the bed, is 2-6 m/s. The skin temperature was kept at 30-32°C, if it fell below 30°C the speed of the fans was reduced. We treated 25 consecutive patients (17 males, 8 females) with heatstroke; cooling was started immediately, using the cooling bed. Other medical problems, such as convulsions, were treated by standard medications.1,6 SUMMARY OF RESULTS
’
Department of Pediatric
Hematology/Oncology, University of Chicago
F. LEONARD
Fred Hutchinson Cancer Research Center and University of Washington, School of Medicine, Seattle, WA 98104, USA
JEAN SANDERS
JOHNSON
E. DONNALL THOMAS
1. Chessells
JM, Rogers DW, Leiper AD, et al. Bone-marrow transplantation has a limited role in prolonging second marrow remission in childhood lymphoblastic leukaemia. Lancet 1986; i: 1239-41. 2. Johnson FL, Thomas ED, Clark BS, Chard RL, Hartmann JR, Storb R. A comparison of marrow transplantation with chemotherapy for children with acute lymphoblastic leukemia in second or subsequent remission. N Engl J Med 1981; 305: 846-51. 3. Johnson FL, Thomas ED. Treatment of relapsed acute lymphoblastic leukemia in childhood. N Enel J Med 1984; 310: 263. 4. Thomas ED. Long-term results of marrow transplantation for leukemia. Bone Marrow Transplantation 1986; 1 (suppl 1): 175-76.
The rectal temperature was reduced to 39°C in 40 min on average, at a rate ofO’087OCjmin, at which point unassisted cooling was resorted to. 19 patients recovered completely within 24 h. The other 6 also recovered, but aspiration pneumonia developed in 3, intubation was required in 2, and 1 patient had low platelet count but no evidence of disseminated vascular coagulopathy or bleeding.
The
cooling
rate
achieved with
our
bed is about twice that
reported for the cooling unit introduced by Weiner and Khogali. 6,7 Another advantage is the cheapness, portability, and simplicity of the unit, so that it can be used at any health centre near the pilgrimage camps and gatherings.
Supported by College of Medicine Research Centre grant 117. We thank Jamjoom and the Ministry of Health for their help.
Dr Adnan
SIMPLIFIED COOLING BED FOR HEATSTROKE
SIR,-Heatstroke is a major hazard of the annual pilgrimage to Mekkah, the Haj, in which some 2 million muslims take part.l,2 For the next fifteen years this pilgrimage will be in the summer months, as high as 48°C in the shade. Rapid cooling has proved helpful in heatstroke,3though immersion of the patient in a tub of iced water has many disadvantages.4 Evaporative cooling has been more effective,2,s,6 and a specially designed body cooling unit was introduced for this purpose? Though effective its practical application on a wide scale has been questioned.2,8The unit is expensive, needs trained personnel, takes up a lot of space, and has to be installed in a special treatment centre. To overcome these difficulties we designed a simple cooling bed, the King Saud University cooling bed, and
Members of the Haj research team are: M. 0. Mekki, R. A. Sulimani, M. S. Noah, S. Kinnani, A. Channa, H. Al-Arfaj, A. Al-Anazi, A. Al-Dalaan, and Ali Saad.
A. K. AL-ASKA H. ABU-AISHA B. YAQUB S. S. AL-HARTHI A. SALLAM,
when the temperature may be
College of Medicine, King Saud University, Riyadh 11461, Saudia Arabia
1.
Project leaders,
King Saud University Haj Research Team: 1406 (1986)
Yaqub B, Al-Harthi S, Al-Orainey I, Laajam M, Obeid M. Heat stroke at the Mekkah pilgrimage: Clinical characteristic and course of 30 patients. Quart Med 1986; 59: J 523-30.
2.
Al-Aska A, Yaqub B, Al-Harthi S, Al-Dalaan A. Rapid cooling in management of heat stroke: Clinical methods and practical implication. Ann Saudi Med (in press). 3. Clowes GMA, Jr, O’Donnel TF, Jr. Heat stroke. N Engl J Med 1974; 291: 564-74. 4. Ferris EB, Jr, Blankenhorn MA, Robmson HW, et al. Heat stroke: clinical and chemical observation on 44 cases. J Clin Invest 1938; 17: 249-64. 5. Wyndham CH, Stryden NB, Cooke MM, et al. Methods of cooling subjects with hyperpyrexia. J Appl Physiol 1959; 771-76. 6. Khogali M, Weiner JS. Heat stroke: Report of 18 cases. Lancet 1980; ii: 276-78. 7. Weiner J, Khogali M. A physiological body-cooling unit for treatment of heat stroke. Lancet 1980; i: 507-09. 8. Al-Harthi S, Yaqub B, Al-Nozha M, Al-Aska A, Seraj M. Management of heat stroke patients by rapid cooling at Mekkah pilgrimage (Haj 1404): Comparing a conventional method with a body cooling unit. Saudi Med J 1986; 7: 369-72.
CONSERVATIVE TREATMENT OF ÉCTOPIC PREGNANCY BY TRANSVAGINAL ASPIRATION UNDER SONOGRAPHIC CONTROL AND METHOTREXATE INJECTION
King Saud University cooling bed. (A) stainless steel pan; (B) drain pipe; (C) rubber strips fixed on steel stretcher; (D and E) electric fans adjustable in three dimensions; (F) panel for temperature probes, and single electricity outlet for whole unit.
SIR,-Methotrexate has been proposed for the treatment of ectopic pregnancy after salpingotomyl or for systemic conservative treatment alone.2 We report a case of local application of methotrexate for tubal pregnancy with a transvaginal puncturing technique originally developed for follicle aspiration.3 For local
Rabies was diagnosed in bats only, and all but 2 of the 104 positive bats were E serotinus. No other animal was positive either in FA or by inoculation test even though many of the cats and foxes were sent of bat rabies. in from areas in Jutland with a high FA and inoculation studies on serotine bats are shown in table 11. (Of the 2 FA positive Myotis spp, 1 was confirmed by isolation in mouse brain.) Of the 104 bats positive by FA, material from 101 was available for IFA with monoclonal antibodies. All 101 specimens reacted similarly in IFA, confirming that these strains belonged to the rabies virus group, but not to serotype 1. Bat rabies was concentrated in southern and eastern Jutland: 88 (32 %) of 276 serotine bats sent in from the four counties in this part of Jutland were found positive. Positive bats were found in all months from June to October with a peak in August. Rabies in Danish bats was further studied by neutralisation tests on serum from 10 apparently healthy serotine bats, 9 of them being from a rabies positive colony in south-east Jutland; the other was trapped in a house where bat rabies had been diagnosed previously. FA titres were 100 in 4 bats, 10 in 4 bats, and less than 10 in 2 bats. Thus DBV-antibodies were detected in apparently healthy bats. Findings in Denmark and Germanyl° indicate that bat rabies is more common in Europe than most people think. DBV can infect and kill in the laboratory8 but our field data seem to indicate that bat rabies is rarely transmitted to other mammals. The absence of bat rabies in terrestrial animals from an area of Denmark with a cluster of bat rabies could indicate that an epizootic of bat rabies in terrestrial animals will not be readily established. 11
frequency
National Veterinary Laboratory, PO Box 373, DK-1503 Copenhagen V, Denmark
P. C. GRAUBALLE
Zoological Museum, University of Copenhagen Rabies Laboratory, CDC Center for Infectious Diseases Lawrenceville, Georgia, USA
H.
J. BAAGØE
M. FEKADU
Acute
hepatitis
abusers.
B reports
to
PHLS 1975-86 and numbers in
drug
‘
following changes: fewer new intravenous drug abusers, less use of the intravenous route, less sharing of needles and syringes, or active immunisation. Why should these changes have happened in 1985-86? Hepatitis B is a long-established hazard of unsterile needles and syringes: although public awareness of hepatitis B infection as a risk of intravenous drug abuse may have increased it seems improbable that this alone is sufficient to have reversed the trend. However, public warnings of the risk of acquiring the human immunodeficiency virus may have had a sufficient deterrent effect limiting intravenous drug abuse or persuading abusers not to share equipment. There can be no certainty that fear of AIDS has led to a decrease in acute hepatitis B infections but if it has acute hepatitis B reports would be encouraging evidence of the value of publicity campaigns in curbing practices that favour the spread of AIDS. Hepatitis Epidemiology Unit, Central Public Health Laboratory,
SHEILA POLAKOFF
London NW9 5HT
National
Veterinary Service, Copenhagen
J. M. WESTERGAARD
Department of Epidemiology, Statens Seruminstitut, Copenhagen
H. ZOFFMANN
1. Müller J. The effect of fox reduction on the occurrence of rabies. Observation from two outbreaks of rabies in Denmark. Bull Off Int Epiz 1971; 75: 763-76. 2. Stougaard E. Denmark again free from rabies. Rabies Bull Europe 1983; 1: 4-5. 3. Anon. Rabies Bull Europe 1986; 1: 9-14. 4. Anon. MMWR 1986; 35: 431. 5. WHO. Control of rabies in wildlife bats. In: WHO Expert Committee on Rabies:
Seventh report. Tech Rep Ser WHO 1984; 709: 65-66. MA, et al. To the issue of chiropteric rabic infection. Rabies Inf Exchange
6. Selimou
1986; 14: 9-12. J, et al. Human rabies of bat origin in Europe. Lancet 1986, i: 378. 8. Bitsch V, et al. Bat virus-Europe. MMWR 1986; 35: 430-32. 9. Lafon M, et al. Human rabies vaccine induce neutralising antibodies against the European bat rabies virus (Duvenhage). Lancet 1986; ii: 515. 10. Anon. Rabies Bull Europe 1986; 2: 8-9. 11. Smith JS, et al. Demonstration of antigenic variation among rabies virus isolates by using monoclonal antibodies to nucleo-capsid proteins. J Clin Microbiol 1986; 24: 7. Lumio
LONG-TERM FOLLOW-UP AFTER BONE-MARROW TRANSPLANTATION IN ACUTE LYMPHOBLASTIC LEUKAEMIA
SIR,-A 1986 Lancet article by Chessells et all generated lively correspondence. We wish to emphasise the curative intent of bone-marrow transplantation (BMT) and the need to report data after a follow-up of 5 or more years. We have reported on 21 children with acute lymphoblastic leukaemia (ALL) who relapsed, achieved second remission, and were treated with chemotherapy and a concurrent group of 24 patients who had a donor and were treated with BMT while in a second or subsequent marrow remission.2 Initial induction therapy was given in several institutions but, after first relapse, all patients were treated in a single centre by the same team of physicians. In a follow-up, all children treated with chemotherapy had relapsed and
573-80.
DECREASE IN ACUTE HEPATITIS B INCIDENCE IN ENGLAND AND WALES IN 1985-86
SIR,—The annual total of laboratory reports of acute clinical hepatitis B to the Public Health Laboratory Service, which ranged from about 1000 to 1200 during the years 1975-83, rose sharply to almost 2000 in 1984. Thereafter, however, there has been a sharp fall to about 1300 in 1986. Drug abusers have consistently constituted the largest single group, and fluctuations in the annual totals of acute hepatitis B have been due mainly to changes in numbers of addicts. The number of cases with a history of drug abuse increased from less than 300 in 1983 to about 600 in 1984 and then fell to about 300 in 1986 (figure). Male homosexuals have constituted a smaller portion of the total but their numbers also fell from a peak of 150 in 1984 to less than 100 in 1986, the smallest annual total for this group since 1981. The observed decline in drug abuse associated cases must have been due to one or more of the
YEARS
Kaplan-Meier product limit estimates of disease-free survival for 14 children given BMT for ALL in second remission. . = long-term survivor.
381 died by 3 years while 8 of the marrow-grafted patients continued in untreated remission3 and these 8 are in remission to this day. 14 of the 24 were transplanted in second remission. The figure shows actuarial survival with 4 of the 14 in event-free survival after 7-10 years. In addition to the marrow relapse, 1 of these 4 had a central nervous system (CNS) relapse, and 1 a CNS and ovarian relapse. All 4 surviving patients lead normal lives and attend high school or college. Late effects of transplantation include cataracts in 3 and primary ovarian failure in 1. All had normal growth and the 3 who were prepubertal at transplantation developed normally through puberty. As several of your correspondents say, the results of chemotherapy are improving and the same is true for BMT. However, the optimum age, type and stage of leukaemia, and appropriate prognostic indicators for BMT are controversial.3 The answers will come from prospective studies but "rapid advances in chemotherapy regimens and in marrow grafting regimens are likely to invalidate the results of a prospective study by the time it is completed".4
report here our experience with it during the pilgrimage season of 1406 AH in the muslim calendar (August, 1986). A patient trolley (75 x 180 cm) was constructed (figure) with a stainless steel tray to limit water spillage and to wash away excreta. Two fans with 35 cm diameter blades direct room air over the patient and Extech thermocouples are used to measure core and body surface temperatures. The patient is undressed and covered with a fine gauze sheet soaked in water at 20°C. The maximum speed of airflow, 50 cm below the centre of the fan at the top of the bed, is 2-6 m/s. The skin temperature was kept at 30-32°C, if it fell below 30°C the speed of the fans was reduced. We treated 25 consecutive patients (17 males, 8 females) with heatstroke; cooling was started immediately, using the cooling bed. Other medical problems, such as convulsions, were treated by standard medications.1,6 SUMMARY OF RESULTS
’
Department of Pediatric
Hematology/Oncology, University of Chicago
F. LEONARD
Fred Hutchinson Cancer Research Center and University of Washington, School of Medicine, Seattle, WA 98104, USA
JEAN SANDERS
JOHNSON
E. DONNALL THOMAS
1. Chessells
JM, Rogers DW, Leiper AD, et al. Bone-marrow transplantation has a limited role in prolonging second marrow remission in childhood lymphoblastic leukaemia. Lancet 1986; i: 1239-41. 2. Johnson FL, Thomas ED, Clark BS, Chard RL, Hartmann JR, Storb R. A comparison of marrow transplantation with chemotherapy for children with acute lymphoblastic leukemia in second or subsequent remission. N Engl J Med 1981; 305: 846-51. 3. Johnson FL, Thomas ED. Treatment of relapsed acute lymphoblastic leukemia in childhood. N Enel J Med 1984; 310: 263. 4. Thomas ED. Long-term results of marrow transplantation for leukemia. Bone Marrow Transplantation 1986; 1 (suppl 1): 175-76.
The rectal temperature was reduced to 39°C in 40 min on average, at a rate ofO’087OCjmin, at which point unassisted cooling was resorted to. 19 patients recovered completely within 24 h. The other 6 also recovered, but aspiration pneumonia developed in 3, intubation was required in 2, and 1 patient had low platelet count but no evidence of disseminated vascular coagulopathy or bleeding.
The
cooling
rate
achieved with
our
bed is about twice that
reported for the cooling unit introduced by Weiner and Khogali. 6,7 Another advantage is the cheapness, portability, and simplicity of the unit, so that it can be used at any health centre near the pilgrimage camps and gatherings.
Supported by College of Medicine Research Centre grant 117. We thank Jamjoom and the Ministry of Health for their help.
Dr Adnan
SIMPLIFIED COOLING BED FOR HEATSTROKE
SIR,-Heatstroke is a major hazard of the annual pilgrimage to Mekkah, the Haj, in which some 2 million muslims take part.l,2 For the next fifteen years this pilgrimage will be in the summer months, as high as 48°C in the shade. Rapid cooling has proved helpful in heatstroke,3though immersion of the patient in a tub of iced water has many disadvantages.4 Evaporative cooling has been more effective,2,s,6 and a specially designed body cooling unit was introduced for this purpose? Though effective its practical application on a wide scale has been questioned.2,8The unit is expensive, needs trained personnel, takes up a lot of space, and has to be installed in a special treatment centre. To overcome these difficulties we designed a simple cooling bed, the King Saud University cooling bed, and
Members of the Haj research team are: M. 0. Mekki, R. A. Sulimani, M. S. Noah, S. Kinnani, A. Channa, H. Al-Arfaj, A. Al-Anazi, A. Al-Dalaan, and Ali Saad.
A. K. AL-ASKA H. ABU-AISHA B. YAQUB S. S. AL-HARTHI A. SALLAM,
when the temperature may be
College of Medicine, King Saud University, Riyadh 11461, Saudia Arabia
1.
Project leaders,
King Saud University Haj Research Team: 1406 (1986)
Yaqub B, Al-Harthi S, Al-Orainey I, Laajam M, Obeid M. Heat stroke at the Mekkah pilgrimage: Clinical characteristic and course of 30 patients. Quart Med 1986; 59: J 523-30.
2.
Al-Aska A, Yaqub B, Al-Harthi S, Al-Dalaan A. Rapid cooling in management of heat stroke: Clinical methods and practical implication. Ann Saudi Med (in press). 3. Clowes GMA, Jr, O’Donnel TF, Jr. Heat stroke. N Engl J Med 1974; 291: 564-74. 4. Ferris EB, Jr, Blankenhorn MA, Robmson HW, et al. Heat stroke: clinical and chemical observation on 44 cases. J Clin Invest 1938; 17: 249-64. 5. Wyndham CH, Stryden NB, Cooke MM, et al. Methods of cooling subjects with hyperpyrexia. J Appl Physiol 1959; 771-76. 6. Khogali M, Weiner JS. Heat stroke: Report of 18 cases. Lancet 1980; ii: 276-78. 7. Weiner J, Khogali M. A physiological body-cooling unit for treatment of heat stroke. Lancet 1980; i: 507-09. 8. Al-Harthi S, Yaqub B, Al-Nozha M, Al-Aska A, Seraj M. Management of heat stroke patients by rapid cooling at Mekkah pilgrimage (Haj 1404): Comparing a conventional method with a body cooling unit. Saudi Med J 1986; 7: 369-72.
CONSERVATIVE TREATMENT OF ÉCTOPIC PREGNANCY BY TRANSVAGINAL ASPIRATION UNDER SONOGRAPHIC CONTROL AND METHOTREXATE INJECTION
King Saud University cooling bed. (A) stainless steel pan; (B) drain pipe; (C) rubber strips fixed on steel stretcher; (D and E) electric fans adjustable in three dimensions; (F) panel for temperature probes, and single electricity outlet for whole unit.
SIR,-Methotrexate has been proposed for the treatment of ectopic pregnancy after salpingotomyl or for systemic conservative treatment alone.2 We report a case of local application of methotrexate for tubal pregnancy with a transvaginal puncturing technique originally developed for follicle aspiration.3 For local