Making sense

disappeared on both occasions after 3 weeks. Although the pathogenesis of EAC is unknown,’ EAC is considered to be a hypersensitivity reaction to bacterial, viral, mycobacterial, parasitic, or fungal infections; drugs (salicylates and antimalarials); or tumour proteins.4 Other processes reported include food ingestion (blue cheeses), thyroid diseases, and autoimmune disturbances. It may also be familial or follow the menstrual cycle.5 In this case, correlation between the development of the rash and the positive urine culture, as well as its resolution during antibiotic therapy on two occasions, suggests a causal association. Urinary infection with E coli should be

splenius capitais", he would probably have been horrified by the pronunciation, or contractions. However, I do not wish to condemn the Greek-Latin crasis. After all I have used it to mould my surname (Latro=thief [Latin], Nike=victory [Greek]) into a more palatable form (victory over the thieves) than might be inferred from its slanderous (for me) Latin stem!

considered in EAC.

2

Nicola Latronico Istituto di Anestesia

1 3

*J Borbujo, C de Miguel, A Lopez, R de Lucas, M Casado Dermatology Department, Hospital General de Mostoles, Mostoles, Madrid 9, Spain

4 5

1 2

3

4

Tyring SK. Reactive erythemas: erythema annulare centrifugum and erythema gyratum repens. Clin Dermatol 1993; 11: 135-39. Mahood JM. Erythema annulare centrifugum: a review of 24 cases with special reference to its association with underlying disease. Clin Exp Dermatol 1983; 8: 383-87. Furure M, Akasu R, Ohtake N, Tamaki K. Erythema annulare centrifugum induced by molluscum contagiosum. Br J Dermatol 1993; 128: 646-47. Betlloch I, Amador C, Chiner E, Varona C, Carbonell C, Vilar A. Erythema annulare centrifugum in Q fever. J Exp Clin Dermatol 1991; 30: 502.

5

Yaniv R, Spielberg O, Shapiro D, Feinstein A, Ben-Bassat I. Erythema annulare centrifugum as the presenting sign of Hodgkin’s disease. Int J Dermatol 1993; 32: 59-61.

Making

sense

SiR-To the arguments of Jeffcoate for proper use of words in medicine (Feb 17, p 451)’would add a few comments. The term "vasospasm", often used to describe the delayed in cerebral ischaemia patients with subarachnoid haemorrhage, is probably one of the best examples of a misleading medical word (complete Socrates’ syndrome). The Shorter Oxford English Dictionary defines vasospasm as a "sudden and violent muscular contraction", an event that does not take place at all in the pathophysiology of delayed cerebral ischaemia. The term also implies that drugs such as nimodipine are beneficial because they relax the vascular wall, whereas, once again, the real explanation, although incompletely understood, is certainly far from this.2 TRH (thyrotropin-releasing hormone) is a good example of nomenclature that can limit our understanding (incomplete Socrates’ syndrome). TRH is classically described as the hypothalamic hormone regulating the hypophyseal release of TSH, which in turn acts on the thyroid gland. However, the TRH tripeptide has been found throughout the central nervous system, as well as in other and placental, gastrointestinal, tissues-pancreatic, TRH several man. has reproductive-of species, including also been found in species lacking TSH, or the thyroid, and even in plants.3 Among the reported physiological effects of TRH are the ability to "reverse the effects of CNS depression whether due to physiological (hibernation), behavioural (learned immobility), or chemical (narcotic drugs and alcohol) means",4 and to cause hyperthermia, increased gastrointestinal contractility, changes in blood pressure,3 and maturation of premature lungs.5 When these findings are considered, we can no longer tolerate the simplistic designation thyrotropin-releasing hormone for a molecule with such an extraordinary array of physiological

properties. Finally, I agree with Jeffcoate that ancient languages face a crisis of neglect. Had Cicero heard (as I have) doctors referring to "the substantia naigra" and "the [muscle] 898

e

Rianimazione, Spedali Civili, 25125 Brescia, Italy

Jeffcoate W. Making sense. Lancet 1996; 347: 451-52. Van Gijn J. Subarachnoid haemorrhage. Lancet 1992; 339: 653-61. Jackson IMD. Thyrotropin-releasing hormone. N Engl J Med 1982; 306: 145-55. Metcalf G, Dettmar PW. Is thyrotropin releasing hormone an endogenous ergotropic substance in the brain? Lancet 1981; i: 586-89. Ballard RA, Ballard PL, Creasy RK, et al. Respiratory disease in verylow-birthweight infants after prenatal thyrotropin-releasing hormone and glucocorticoid. Lancet 1992; 339: 510-15.

SIR-Jeffcoate1 pleads for a name for the neurological test in which the patient is asked to hold his or her arms outstretched. The Netherlands has the opposite problemtoo many names. Some call it "Wartenberg’s test" while others prefer "Mingazzini I" or "Barre I" (the corresponding test for central weakness of the leg being "Mingazzini II" or "Barre II"). The more prosaic among us simply speak of "the test of the outstretched arms". In this confusion there is one positive aspect. The results of this useful test are almost always recorded in the notes. In answer to Jeffcoate’s plea, may I suggest the "manna-manoeuvre"? When patients stand in this fashion and with their eyes closed, it seems as if they are awaiting the biblical falling of manna from Heaven. The term is easily remembered because of the alliteration. The muddling of Greek and Latin in medical language, another topic in Jeffcoate’s essay, is not easily circumvented. Jeffcoate himself does it with "transient (Latin), benign (Latin), pleurisy (Greek)" and whether it is within one word (hyperreflexia) or two (dissecting aneurysm) it may not be so reprehensible. The number of other examples is probably

myriad (Greek), or legion (Latin). Why condemn? In Roman times Latin was much influenced by Greek and many Greek words were superficially latinised. As Horace puts it in his Epistles (II, i, 156) "Graecia capta ferum victorem cepit, et artes intulit agresti Latio" ("When Greece had been enslaved she made a slave of her rough conqueror, and introduced the arts into Latium, still rude", in Wickham’s translation). The Roman Empire, through which Europe’s classical heritage comes Graeco-Roman in culture and later centuries saw a further amalgamation of Greek and Latin in scientific terminology (eg, automobile and television). We can try to avoid words such as homolateral and quadriplegia because we have the correct forms ipsilateral and tetraplegia but it will prove to be impossible to purge medical language completely of Leek and Gratin terms. was

R F

Duyff

Department of Neurology, Lucas Andreas Ziekenhuis, 1061AE Amsterdam, Netherlands

1

Jeffcoate W. Making sense. Lancet 1996; 347: 451-52.

SiR Jeffcoate’ rightly decries the Editors

can

acronyms

thinking. Jeffcoate

help

lessen

current

"acronymous age".

this aspect of poor writingcomprehension and diminish critical correct

also pleads for the naming of a neurological test. But this is not possible: motor system analysis includes looking for wasting and involuntary movements, testing for

tone, posture, power,

coordination, and then reflexes.

sensory deficit, (superior peduncle thyrotoxicosis). Sometimes we tap the dorsum

nervousness

or

J N Blau Neurology

and

Neurosurgery,

London WC1N 3BG, UK

1 Jeffcoate W. Making sense. Lancet 1996; 347: 451-52.

SIR-Jeffcoate1 asks for names for the arms-outstretched, eyes-open-or-closed test in neurological examination. "Sleepwalker’s drift negative" or if positive "Sleepwalker’s left" or "sleepwalker’s right" would probably fix readily in the medical student’s mind. The more literary-minded physicians (who, incidentally, would have rejoiced with me in the Feb 17 Lancet) may welcome a nod in the direction of a notable somnambulist: "the patient displayed a positive Lady McBeth sign". John Rawlinson Medical Centre, Kimbolton,

Huntingdon, Cambs PE18 0JF, UK

1 Jeffcoate W. Making sense.

Lancet 1996; 347: 451-52.

HIV quantification: useful for vertical transmission?

prediction of

SIR-Volberding, discussing clinical applications of quantitative HIV-RNA methods (Jan 13, p 71),’ mentions that the concentration of HIV copies in pregnant women correlates with the risk of vertical transmission of HIV. We have observed, however, that mothers with low copy numbers (,;S 10 OOO/mL) also transmitted HIV to their

offspring. We investigated the plasma of 22 HIV-positive mothers by quantitative nucleic acid sequence based amplification (Organon Teknika, Eppelheim, Germany), qualitative PCR, p24-antigen, and virus culture at the time of delivery. We found that five mothers transmitted HIV vertically, three of them presenting with high copy numbers in the range 110000-170000/mL (2/3 positive for p24-antigen, 0/3 positive in virus culture). 19 mothers showed copy numbers lower than 70 000/mL of which two transmitted HIV. Their copy numbers were only 10 000/mL and less than 2000/mL, respectively. Both mothers were negative for p24-antigen and virus culture, but positive in qualitative PCR. Our data show that not only mothers with high copy numbers transmit HIV vertically but also mothers with low copy

numbers, although

other factors

contributing

at a- lower to vertical

*Bernhard Zöllner, Heinz-Hubert Feucht, Gertrud Matthias Schröter, Rainer Laufs

frequency. Therefore, transmission, such as

Helling-Giese,

*Institute of Medical Microbiology and Immunology, University Hospital Eppendorf, 20246 Hamburg, Germany; and Hospital for Obstetrics and Gynaecology, Hamburg

1

or

of the hands or displace the arms laterally to detect postural imbalance. Clearly there can be no name for all these tests and responses. A neurologist must first be a general physician. It is not widely appreciated that pain can alter many of these responses. Frozen shoulder, a common complication of a stroke or parkinsonism, needs bearing in mind and seeking. Hence the importance of Britain’s broad medical trainingwhich, I fear, will diminish if the Department of Health’s proposed cuts in specialist training are adopted. National Hospital for

mother’s clinical and immunological status during pregnancy,’’ should also be considered when assessing HIV copy numbers in pregnant women. the

look at the upper limbs at When examining posture, rest, when walking, and then ask the patient to hold the arms in an outstretched position (most efficiently by example). We note the speed with which the arms are elevated (slower muscle weakness, pyramidal and with proximal the of coming to lesions), compare rapidity extrapyramidal cerebellar and and in sensory disturbances), rest (impaired in deficit or downwards with drift (upwards sensory weakness or pyramidal disease), tremor of arms or fingers we

2

HIV quantification: clinical applications. Lancet 347: 71-73. European Collaborative Study. Risk factors for mother-to-child transmission of HIV-1. Lancet 1992; 339: 1007-12.

Volberding PA.

1996;

maternal vitamin A intake and risk of anomalies of structures with a cranial neural crest cell contribution

High

SIR-High-dose vitamin A (retinol or retinyl esters) is teratogenic in laboratory animals, and isotretinoin has been linked to congenital anomalies in man.’ Rothman and colleagues’ recently reported that women who consumed more than 10 000 IU of vitamin A per day were at increased risk of delivering infants with congenital anomalies of structures with a neural crest cell contribution. Cleft lip or cleft palate and conotruncal heart defects (eg, tetralogy of Fallot, or transposition of the major arteries) represent two thirds of the major malformations within such a grouping. 1

We have noted a 25-50% reduction in risk for both of these defect groups associated with maternal intake of a multivitamin supplement containing folic acid in the periconceptional period.2,3 Most of these supplements also contained vitamin A. During our case-control studies2,3 we had specifically asked about other vitamin supplements the women had used, one of which was single supplement vitamin A. The cleft study,and the conotruncal study3 pertained to California pregnancies in 1986-89, and it is reasonable to assume that all types of vitamin A supplementation will have been retinol or retinyl esters and not (3-carotene, which is not suspected of being teratogenic. The replacement of retinol with (3-carotene in US supplements was uncommon before 1991. Also the single vitamin A supplements will have contained at least 10 000 IU retinol. We assumed that women who took single vitamin A supplements and who also took a multivitamin supplement would be comparable with the over 10 000 IU/day group in Rothman’s study. We estimated risk among these women, relative to women who did not use any supplement containing vitamin A. For orofacial clefts, seven of 731 cases and nine of 734 control mothers used single supplements of vitamin A during the period 1 month before to 3 months after conception. The odds ratio (OR) was 0-55 (95% CI 0’21-1-5), indicating no increased risk associated with vitamin A use relative to 194 case and 137 control mothers who used no vitamins containing vitamin A or synthetic retinoids (one case mother). The seven exposed cases did not reveal an abundance of a single phenotype. For conotruncal heart defects, none of 207 case mothers and seven of 481 control mothers used single vitamin A supplements. The OR was 0 (95% CI 0-2-2) relative to 47 case and 86 control mothers who did not use vitamins containing vitamin A. All single supplement vitamin A users except one control took a prenatal or multivitamin as well. Thus for the women in our study who very probably consumed levels of vitamin A exceeding 10 000 IU per day we observed risks substantially less than the 4-8-fold increase for "cranial neural crest" anomalies reported by Rothman et

supplement

899