- Email: [email protected]
Minimum pesticide list for the developing world
CORRESPONDENCE
research restricted us to defining a categorical variable. This limitation inevitably leads to underestimates of burden, particularly when compared with risk factors assessed as a continuous measure. Without adequate data across the whole distribution, estimation of exposure becomes an exercise in extrapolation, requiring many assumptions and generalisations. We declined to make “best guesses” of exposure at levels beyond that which we could substantiate. The choice to work on more solid ground is conservative, but good science. Although this level of physical activity might seem modest, available data suggest that, for most adults, it is still too demanding. Less than half of the adult population in many countries undertake the equivalent of 30 min of brisk walking per day. WHO’s leadership in calculating attributable burden is work in progress,1,4 and for physical inactivity there is much work to be done. For this report we provide a new method for assessing physical inactivity that included multiple domains (leisure, transport, and work), and new metaanalyses estimating the magnitude of risk. But our efforts highlight gaping holes in information on levels of participation in different domains from around the world and the need for better quantification of the levels of activity associated with specific health benefits. Our results helped WHO to estimate the burden at a regional and global level and the methods (and limitations) are described in detail in the forthcoming technical report.5 Fiona Bull, on behalf of the CRA Physical Activity Work Group Division of Nutrition and Physical Activity, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA (e-mail: [email protected]) 1
2
3
4
5
Powles J, Day N. Interpreting the global burden of disease. Lancet 2002; 360: 1342–43. Kesaniemi YA, Danforth EJ, Jensen MD, et al. Dose-response issues concerning physical activity and health: an evidence-based symposium. Med Sci Sports Exercise 2001; 33: S351–58. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. J Am Med Assoc 1995; 273: 402–07. Ezzati M, Lopez AD, Rodgers A, et al. Selected major risk factors and global and regional burden of disease. Lancet 2002; 360: 1347–60. Bull FC, Armstrong T, Dixon T, et al. Physical inactivity. In: Ezzati M, Lopez A, Rodgers A, Murray C, eds. Comparative quantification of health risks: global and regional burden of disease due to selected major risk factors. Geneva: WHO (in press).
Minimum pesticide list for the developing world
2
3
Sir—We congratulate M Eddleston and colleagues (Oct 12, p 1163)1 on their innovative suggestion of a model minimum pesticide list. The assumption is that provision of more information to governments would allow them to decide which pesticides suit their needs. We see other strategies that could add to the success of this approach. Rather than sparse information alone, a lack of political commitment and administrative inertia is also responsible for poor decision making in developing countries. For example, the Sri Lankan government had access to data on the increased use of pesticides in suicides for 20 years or more, and calls for restriction of the availability of dangerous pesticides went on for many years.2–4 However, enactment and implementation of effective legislation on distribution and sale of pesticides has lagged behind and, as a result, consumers are able to purchase almost any toxic pesticide they wish, and we continue to record unacceptable numbers of pesticide-related suicides.1 The success of the minimum list would depend in part on a farmer’s choice of which pesticide to purchase. If this choice is to be at all rational, we need to regulate unethical advertising of dangerous pesticides over the mass media, if necessary by a binding treaty. For example, in Sri Lanka, dangerous pesticides are advertised on the television and radio, especially during programmes in the local Sinhala language, which are attractive to villagers. If we are to extrapolate from our experiences with the pharmaceutical industry and the essential drugs list, the chances are that farmers’ decisions are swayed by the incentives being offered by the trade and by directto-consumer advertising.5 To promote rational use of pesticides, governments could use pricing policies and differential taxation—eg, higher taxes for potentially more harmful pesticides. SJ is an evaluator and member of the data monitoring and ethics committee for trial on poisoning in Sri Lanka by M Eddleston and others.
*Saroj Jayasinghe, Damani de Silva *Departments of Clinical Medicine (SJ) and Psychological Medicine (DdS), Faculty of Medicine, Kynsey Road, Colombo 8, Sri Lanka (e-mail: [email protected]) 1
Eddleston M, Karaliedda L, Buckley N, et al. Pesticide poisoning in the developing world: a minimum pesticide list. Lancet 2002; 360: 1163–67.
THE LANCET • Vol 361 • January 18, 2003 • www.thelancet.com
4
5
Dissanayake SAW, de Silva WP. Suicide and attempted suicide in Sri Lanka. Ceylon J Med Sci 1974; 23: 10–27. Jeyaratnam J, de Alwis Seneviratne RS, Copplestone LE. Survey of pesticide poisoning in Sri Lanka. Bull World Health Organ 1982; 60: 615–19. Van der Hoek W, Konradsen F, Athukorala K, Wanigadewa T. Pesticide poisoning: a major health problem in Sri Lanka. Soc Sci Med 1998; 46: 495–504. Hoffman JR, Wilkes MW. Direct to consumer advertising of prescription drugs: an idea whose time should not come. BMJ 1999; 318: 1301–02.
Sir—Many of us health-care professionals in Nepal and India would second the call on WHO and the Food and Agriculture Organization (FAO) to develop a model minimum pesticides list, as suggested by Eddleston and colleagues.1 Because no good data are available about how to treat patients with overwhelming poisoning by pesticides like organophosphate, and because ventilators in most district hospitals malfunction or are absent, many patients can succumb to a complication of organophosphate poisoning called the intermediate syndrome.2 Organophosphate is the most frequently used agent in Nepal for selfharm. Poisoning is so common that sometimes a whole hospital ward is designated as an organophosphate ward. Furthermore, aluminium phosphide, which is much more lethal than organophosphate, clearly needs to be banned in South Asia.3 The tragedy in this part of the world stands out much more than elsewhere because the local observation is that most people who attempt suicide here (perhaps by contrast with the developed world) do it one time only; repeated attempts are rare. Because numbers of self-harm deaths fell in India after barbiturates were switched to benzodiazepines as a sedative drug,4 banning use of certain pesticides and forming a minimum pesticide list could certainly go a long way in clearly reducing suicide deaths in this part of the world. WHO and FAO need to step in more firmly to help and motivate local governments. Buddha Basnyat Nepal International Clinic, PO Box 3596, Lal Dubar, Kathmandu, Nepal (e-mail: [email protected]) 1
2
3
Eddleston M, Karalliedde L, Buckley N, et al. Pesticide poisoning in the developing world: a minimum pesticides list. Lancet 2002; 360: 1163–67. Basnyat B. Organophosphate poisoning: the importance of the intermediate syndrome. J Inst Med (Nepal) 2000; 22: 248–50. Siwach SB, Gupta A. The profile of poisonings in Haryana-Rohtak study. J Assoc Phys India 1995; 43: 756–59.
259
For personal use. Only reproduce with permission from The Lancet Publishing Group.
CORRESPONDENCE
4
Singh S, Wig N, Chaudhary D, Sood NK, Sharma BK. Changing pattern of acute poisoning in adults: experience of a large North-West Indian hospital. J Assoc Phys India 1997; 45: 194–97.
3
4
Herpes encephalitis Sir—The magnetic resonance (MR) Clinical picture, published in the Oct 26 issue (p 1286),1 showed predominantly right temporal lobe involvement with herpes encephalitis in a patient with altered mental status and fever. However, the scan shown was not a T2-weighted image with gadolinium, as stated by the authors, but a fluid-attenuated inversionrecovery (FLAIR) image with gadolinium (also referred to as contrast-enhanced FLAIR image). On FLAIR images, as seen in this case, the signal from cerebrospinal fluid is suppressed and becomes dark, by contrast with a very bright appearance on T2-weighted images. FLAIR MR sequences have become essential in assessment of brain lesions, because of their high sensitivity, which generally surpasses T2-weighted images, especially in areas adjacent to cerebrospinal fluid-containing spaces.2 The high signal seen in the apex of the fourth ventricle in the presented case is a flow-related artifact, typically seen on FLAIR images. Furthermore, T2-weighted sequences are generally not used with gadolinium, since they do not provide contrast enhancement; perfusion MRI uses specially designed dynamic postcontrast T2-weighted sequences, on which, by contrast, a loss of signal is seen with accumulation of gadolinium.3 For a time, contrast-enhanced FLAIR images were increasingly popular, and early reports suggested they could even replace contrastenhanced T1-weighted images. However, results of a recent study4 showed that FLAIR images with gadolinium have lower sensitivity and specificity than standard contrastenhanced T1-weighted images. Evidence is accumulating that diffusion-weighted images, known for their reliability in acute stroke assessment, seem to be more sensitive than FLAIR images for detection of herpes encephalitis.5 Zoran Rumboldt Department of Radiology, University Hospital “Sisters of Mercy”, Vinogradska 29, Zagreb, HR 10000, Croatia (e-mail: [email protected]) 1 2
Martin K, Franco-Paredes C. Herpes encephalitis. Lancet 2002; 360: 1286 Okuda T, Korogi Y, Shigematsu Y, et al. Brain lesions: when should fluid-attenuated
260
5
inversion-recovery sequences be used in brain evaluation? Radiology 1999; 212: 793–98. Lev M, Rosen B. Clinical applications of intracranial perfusion MR imaging. Neuroimaging Clin N Am 1999; 9: 309–31. Singh SK, Leeds NE, Ginsberg LE. MR imaging of leptomeningeal metastases: comparison of three sequences. AmJ Neuroradiol 2002; 23: 817–21. Teixeira J, Zimmerman RA, Haselgrove JC, Bilaniuk LT, Hunter JV. Diffusion imaging in pediatric central nervous system infections. Neuroradiology 2001; 43: 1031–39.
event”, or that “an individual’s sociological milieu is responsible for his or her cancer”. Ultimately, Shuter’s criticisms of Thabet and colleagues do not convince, because he chooses to undermine sound scientific evidence to further his own agenda. Martin Sidis Adan Hospital, Ministry of Health, Kuwait (e-mail: [email protected]) 1
2
Emotional problems of Palestinian children living in a war zone Sir—Jonathan Shuter (Oct 5, p 1098)1 commits a serious error in his use of junk science (faulty scientific analysis to further a special agenda). He criticises Abdel Aziz Mousa Thabet and colleagues2 for inferring causality from a cross-sectional analysis in their study of Palestinian children living in war zones. He also disputes the investigators’ findings that children’s emotional responses to exposure to political violence are acute and severe. Shuter argues that this finding is not justified because it is similar to “the conclusion that low-calorie drinks cause obesity, since many obese people drink these beverages”. Shuter’s objections prompt me to ask, are we making the same sort of mistake in cross-sectional studies of smoking and lung cancer, when we say that smoking causes lung cancer, because many patients with lung cancer are smokers? Next, Shuter suggests that Palestinian children’s emotional problems are caused by “the educational, political, religious, and social environment in which are raised”. To use the same analogy, if I said that “the educational, political, religious, and social environment in which human beings are raised causes emotional problems and this leads to lung cancer, but not the smoking” would The Lancet publish my letter? Shuter goes on to reject Thabet and colleagues’ comparison of children exposed to home bombardment and demolition with a control group. Shuter maintains that such demolition “is not a random event” since many of the homes that were destroyed “were bomb factories or munitions depots”. Again, Shuter’s contention is exactly as absurd as saying that “those exposed to smoking who developed lung cancer were already harbouring cancer, and this was not a random
Shuter J. Emotional problems in Palestinian children living in a war zone. Lancet 2002; 360: 1098. Thabet AAM, Abed Y, Vostanis P. Emotional problems in Palestinian children living in a war zone: a crosssectional study. Lancet 2002; 359: 1801–04.
Ocular tuberculosis Sir—Volker Grosse and colleagues (Sept 21, p 922)1 describe a 30-year-old Gambian man who presented with a constellation of symptoms and signs that suggested a differential diagnosis of systemic tuberculosis in addition to metastatic carcinoma and lymphoma. Obtaining ocular tissue for definitive diagnostic purpose is associated with a significant ocular morbidity. Therefore, a high degree of clinical suspicion is the key to early diagnosis. Instead of enucleating a vital sense organ like the eye, I feel that the authors should have done a biopsy of an easily accessible site such as the cervical lymph node to demonstrate the characteristic findings of caseating granuloma and Mycobacterium tuberculosis. The effectiveness of antituberculosis treatment has obviated the need for operative intervention in tuberculomas and tuberculous abscesses, except when decompression is required to prevent permanent neurological deficits. Furthermore, unlike other bacterial abscesses, tuberculous abscesses do not necessarily require drainage.2 When patients with tuberculosis elsewhere in the body develop clinical features of ocular involvement, the treatment of ocular tuberculosis is along the same lines as treatment of pulmonary tuberculosis.3 Therefore, instead of a hurried enucleation, the patient described by Grosse and colleagues could have been given a chance to preserve the right eye pending followup assessment after antituberculosis treatment. Another important point is that retobulbar optic neuritis and the resultant amblyopia are the most frequent and serious adverse effects of ethambutol treatment.4 Symptoms include blurred vision, central
THE LANCET • Vol 361 • January 18, 2003 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
research restricted us to defining a categorical variable. This limitation inevitably leads to underestimates of burden, particularly when compared with risk factors assessed as a continuous measure. Without adequate data across the whole distribution, estimation of exposure becomes an exercise in extrapolation, requiring many assumptions and generalisations. We declined to make “best guesses” of exposure at levels beyond that which we could substantiate. The choice to work on more solid ground is conservative, but good science. Although this level of physical activity might seem modest, available data suggest that, for most adults, it is still too demanding. Less than half of the adult population in many countries undertake the equivalent of 30 min of brisk walking per day. WHO’s leadership in calculating attributable burden is work in progress,1,4 and for physical inactivity there is much work to be done. For this report we provide a new method for assessing physical inactivity that included multiple domains (leisure, transport, and work), and new metaanalyses estimating the magnitude of risk. But our efforts highlight gaping holes in information on levels of participation in different domains from around the world and the need for better quantification of the levels of activity associated with specific health benefits. Our results helped WHO to estimate the burden at a regional and global level and the methods (and limitations) are described in detail in the forthcoming technical report.5 Fiona Bull, on behalf of the CRA Physical Activity Work Group Division of Nutrition and Physical Activity, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA (e-mail: [email protected]) 1
2
3
4
5
Powles J, Day N. Interpreting the global burden of disease. Lancet 2002; 360: 1342–43. Kesaniemi YA, Danforth EJ, Jensen MD, et al. Dose-response issues concerning physical activity and health: an evidence-based symposium. Med Sci Sports Exercise 2001; 33: S351–58. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. J Am Med Assoc 1995; 273: 402–07. Ezzati M, Lopez AD, Rodgers A, et al. Selected major risk factors and global and regional burden of disease. Lancet 2002; 360: 1347–60. Bull FC, Armstrong T, Dixon T, et al. Physical inactivity. In: Ezzati M, Lopez A, Rodgers A, Murray C, eds. Comparative quantification of health risks: global and regional burden of disease due to selected major risk factors. Geneva: WHO (in press).
Minimum pesticide list for the developing world
2
3
Sir—We congratulate M Eddleston and colleagues (Oct 12, p 1163)1 on their innovative suggestion of a model minimum pesticide list. The assumption is that provision of more information to governments would allow them to decide which pesticides suit their needs. We see other strategies that could add to the success of this approach. Rather than sparse information alone, a lack of political commitment and administrative inertia is also responsible for poor decision making in developing countries. For example, the Sri Lankan government had access to data on the increased use of pesticides in suicides for 20 years or more, and calls for restriction of the availability of dangerous pesticides went on for many years.2–4 However, enactment and implementation of effective legislation on distribution and sale of pesticides has lagged behind and, as a result, consumers are able to purchase almost any toxic pesticide they wish, and we continue to record unacceptable numbers of pesticide-related suicides.1 The success of the minimum list would depend in part on a farmer’s choice of which pesticide to purchase. If this choice is to be at all rational, we need to regulate unethical advertising of dangerous pesticides over the mass media, if necessary by a binding treaty. For example, in Sri Lanka, dangerous pesticides are advertised on the television and radio, especially during programmes in the local Sinhala language, which are attractive to villagers. If we are to extrapolate from our experiences with the pharmaceutical industry and the essential drugs list, the chances are that farmers’ decisions are swayed by the incentives being offered by the trade and by directto-consumer advertising.5 To promote rational use of pesticides, governments could use pricing policies and differential taxation—eg, higher taxes for potentially more harmful pesticides. SJ is an evaluator and member of the data monitoring and ethics committee for trial on poisoning in Sri Lanka by M Eddleston and others.
*Saroj Jayasinghe, Damani de Silva *Departments of Clinical Medicine (SJ) and Psychological Medicine (DdS), Faculty of Medicine, Kynsey Road, Colombo 8, Sri Lanka (e-mail: [email protected]) 1
Eddleston M, Karaliedda L, Buckley N, et al. Pesticide poisoning in the developing world: a minimum pesticide list. Lancet 2002; 360: 1163–67.
THE LANCET • Vol 361 • January 18, 2003 • www.thelancet.com
4
5
Dissanayake SAW, de Silva WP. Suicide and attempted suicide in Sri Lanka. Ceylon J Med Sci 1974; 23: 10–27. Jeyaratnam J, de Alwis Seneviratne RS, Copplestone LE. Survey of pesticide poisoning in Sri Lanka. Bull World Health Organ 1982; 60: 615–19. Van der Hoek W, Konradsen F, Athukorala K, Wanigadewa T. Pesticide poisoning: a major health problem in Sri Lanka. Soc Sci Med 1998; 46: 495–504. Hoffman JR, Wilkes MW. Direct to consumer advertising of prescription drugs: an idea whose time should not come. BMJ 1999; 318: 1301–02.
Sir—Many of us health-care professionals in Nepal and India would second the call on WHO and the Food and Agriculture Organization (FAO) to develop a model minimum pesticides list, as suggested by Eddleston and colleagues.1 Because no good data are available about how to treat patients with overwhelming poisoning by pesticides like organophosphate, and because ventilators in most district hospitals malfunction or are absent, many patients can succumb to a complication of organophosphate poisoning called the intermediate syndrome.2 Organophosphate is the most frequently used agent in Nepal for selfharm. Poisoning is so common that sometimes a whole hospital ward is designated as an organophosphate ward. Furthermore, aluminium phosphide, which is much more lethal than organophosphate, clearly needs to be banned in South Asia.3 The tragedy in this part of the world stands out much more than elsewhere because the local observation is that most people who attempt suicide here (perhaps by contrast with the developed world) do it one time only; repeated attempts are rare. Because numbers of self-harm deaths fell in India after barbiturates were switched to benzodiazepines as a sedative drug,4 banning use of certain pesticides and forming a minimum pesticide list could certainly go a long way in clearly reducing suicide deaths in this part of the world. WHO and FAO need to step in more firmly to help and motivate local governments. Buddha Basnyat Nepal International Clinic, PO Box 3596, Lal Dubar, Kathmandu, Nepal (e-mail: [email protected]) 1
2
3
Eddleston M, Karalliedde L, Buckley N, et al. Pesticide poisoning in the developing world: a minimum pesticides list. Lancet 2002; 360: 1163–67. Basnyat B. Organophosphate poisoning: the importance of the intermediate syndrome. J Inst Med (Nepal) 2000; 22: 248–50. Siwach SB, Gupta A. The profile of poisonings in Haryana-Rohtak study. J Assoc Phys India 1995; 43: 756–59.
259
For personal use. Only reproduce with permission from The Lancet Publishing Group.
CORRESPONDENCE
4
Singh S, Wig N, Chaudhary D, Sood NK, Sharma BK. Changing pattern of acute poisoning in adults: experience of a large North-West Indian hospital. J Assoc Phys India 1997; 45: 194–97.
3
4
Herpes encephalitis Sir—The magnetic resonance (MR) Clinical picture, published in the Oct 26 issue (p 1286),1 showed predominantly right temporal lobe involvement with herpes encephalitis in a patient with altered mental status and fever. However, the scan shown was not a T2-weighted image with gadolinium, as stated by the authors, but a fluid-attenuated inversionrecovery (FLAIR) image with gadolinium (also referred to as contrast-enhanced FLAIR image). On FLAIR images, as seen in this case, the signal from cerebrospinal fluid is suppressed and becomes dark, by contrast with a very bright appearance on T2-weighted images. FLAIR MR sequences have become essential in assessment of brain lesions, because of their high sensitivity, which generally surpasses T2-weighted images, especially in areas adjacent to cerebrospinal fluid-containing spaces.2 The high signal seen in the apex of the fourth ventricle in the presented case is a flow-related artifact, typically seen on FLAIR images. Furthermore, T2-weighted sequences are generally not used with gadolinium, since they do not provide contrast enhancement; perfusion MRI uses specially designed dynamic postcontrast T2-weighted sequences, on which, by contrast, a loss of signal is seen with accumulation of gadolinium.3 For a time, contrast-enhanced FLAIR images were increasingly popular, and early reports suggested they could even replace contrastenhanced T1-weighted images. However, results of a recent study4 showed that FLAIR images with gadolinium have lower sensitivity and specificity than standard contrastenhanced T1-weighted images. Evidence is accumulating that diffusion-weighted images, known for their reliability in acute stroke assessment, seem to be more sensitive than FLAIR images for detection of herpes encephalitis.5 Zoran Rumboldt Department of Radiology, University Hospital “Sisters of Mercy”, Vinogradska 29, Zagreb, HR 10000, Croatia (e-mail: [email protected]) 1 2
Martin K, Franco-Paredes C. Herpes encephalitis. Lancet 2002; 360: 1286 Okuda T, Korogi Y, Shigematsu Y, et al. Brain lesions: when should fluid-attenuated
260
5
inversion-recovery sequences be used in brain evaluation? Radiology 1999; 212: 793–98. Lev M, Rosen B. Clinical applications of intracranial perfusion MR imaging. Neuroimaging Clin N Am 1999; 9: 309–31. Singh SK, Leeds NE, Ginsberg LE. MR imaging of leptomeningeal metastases: comparison of three sequences. AmJ Neuroradiol 2002; 23: 817–21. Teixeira J, Zimmerman RA, Haselgrove JC, Bilaniuk LT, Hunter JV. Diffusion imaging in pediatric central nervous system infections. Neuroradiology 2001; 43: 1031–39.
event”, or that “an individual’s sociological milieu is responsible for his or her cancer”. Ultimately, Shuter’s criticisms of Thabet and colleagues do not convince, because he chooses to undermine sound scientific evidence to further his own agenda. Martin Sidis Adan Hospital, Ministry of Health, Kuwait (e-mail: [email protected]) 1
2
Emotional problems of Palestinian children living in a war zone Sir—Jonathan Shuter (Oct 5, p 1098)1 commits a serious error in his use of junk science (faulty scientific analysis to further a special agenda). He criticises Abdel Aziz Mousa Thabet and colleagues2 for inferring causality from a cross-sectional analysis in their study of Palestinian children living in war zones. He also disputes the investigators’ findings that children’s emotional responses to exposure to political violence are acute and severe. Shuter argues that this finding is not justified because it is similar to “the conclusion that low-calorie drinks cause obesity, since many obese people drink these beverages”. Shuter’s objections prompt me to ask, are we making the same sort of mistake in cross-sectional studies of smoking and lung cancer, when we say that smoking causes lung cancer, because many patients with lung cancer are smokers? Next, Shuter suggests that Palestinian children’s emotional problems are caused by “the educational, political, religious, and social environment in which are raised”. To use the same analogy, if I said that “the educational, political, religious, and social environment in which human beings are raised causes emotional problems and this leads to lung cancer, but not the smoking” would The Lancet publish my letter? Shuter goes on to reject Thabet and colleagues’ comparison of children exposed to home bombardment and demolition with a control group. Shuter maintains that such demolition “is not a random event” since many of the homes that were destroyed “were bomb factories or munitions depots”. Again, Shuter’s contention is exactly as absurd as saying that “those exposed to smoking who developed lung cancer were already harbouring cancer, and this was not a random
Shuter J. Emotional problems in Palestinian children living in a war zone. Lancet 2002; 360: 1098. Thabet AAM, Abed Y, Vostanis P. Emotional problems in Palestinian children living in a war zone: a crosssectional study. Lancet 2002; 359: 1801–04.
Ocular tuberculosis Sir—Volker Grosse and colleagues (Sept 21, p 922)1 describe a 30-year-old Gambian man who presented with a constellation of symptoms and signs that suggested a differential diagnosis of systemic tuberculosis in addition to metastatic carcinoma and lymphoma. Obtaining ocular tissue for definitive diagnostic purpose is associated with a significant ocular morbidity. Therefore, a high degree of clinical suspicion is the key to early diagnosis. Instead of enucleating a vital sense organ like the eye, I feel that the authors should have done a biopsy of an easily accessible site such as the cervical lymph node to demonstrate the characteristic findings of caseating granuloma and Mycobacterium tuberculosis. The effectiveness of antituberculosis treatment has obviated the need for operative intervention in tuberculomas and tuberculous abscesses, except when decompression is required to prevent permanent neurological deficits. Furthermore, unlike other bacterial abscesses, tuberculous abscesses do not necessarily require drainage.2 When patients with tuberculosis elsewhere in the body develop clinical features of ocular involvement, the treatment of ocular tuberculosis is along the same lines as treatment of pulmonary tuberculosis.3 Therefore, instead of a hurried enucleation, the patient described by Grosse and colleagues could have been given a chance to preserve the right eye pending followup assessment after antituberculosis treatment. Another important point is that retobulbar optic neuritis and the resultant amblyopia are the most frequent and serious adverse effects of ethambutol treatment.4 Symptoms include blurred vision, central
THE LANCET • Vol 361 • January 18, 2003 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.