NITROGLYCERINE OINTMENT FOR DOPAMINE INDUCED PERIPHERAL DIGITAL ISCHAEMIA

290 sections were cut and stained with uranyl acetate and lead citrate and examined. Intracellular multiplication produced "microcolonies" of bacteria which were confirmed as L pneumophila serogroup 1 by fluorescent microscopy with a monoclonal antibody to that serotype (kindly supplied by Mr Ian Watkins, department of pathology, Oxford University). In the sections prepared from the 96 h sample many acanthamoeba cysts were seen and amongst these some (figure) contained clusters of healthy L pneumophila. Although the trophozoite forms of acanthamoebae are susceptible to the action of chlorine, the cysts are not5 and survive the water treatment procedures used in Britain. If L pneumophila infect acanthamoebae under natural conditions in the same way as they do experimentally to produce "microcolonies" of bacteria protected by a cyst wall, this would provide at least one means by which domestic water supplies become seeded with this bacterium.

epoxyresin;

Department of Electron Microscopy, John Radcliffe Hospital, Oxford

A. R. SKINNER

Provincial Laboratory of Public Health, Calgary, Canada

C. M. ANAND

Department of Virology, John Radcliffe Hospital,

A. MALIC J. B. KURTZ

Oxford OX3 9DU

NITROGLYCERINE OINTMENT FOR DOPAMINE INDUCED PERIPHERAL DIGITAL ISCHAEMIA

SIR,-The local vasodilatory properties of nitroglycerine ointment has been used to improve capillary blood flow in Raynaud’s diseaseand as an aid to venepuncture.We have tried topical nitroglycerine in two patients with peripheral digital ischaemia due to dopamine infusion. A 54-year-old woman with fulminating Pneumocystis carinii pneumonia while on treatment for Hodgkin’s disease required artificial ventilation with positive end-expiration pressure and cardiovascular support with dopamine (up to 20 pg/kg/min). Within 48 h her toes became cyanosed and cold and exhibited poor capillary return. The digital ischaemia worsened over the next 48 h, although all pedal pulses remained present. Withdrawal of the inotropic support was not possible because of the persistence of serious hypotension. A thin film of 2% nitroglycerine ointment (’Nitro-bid’; Protea) was applied evenly over her toes, the total dose being 15 mg glyceryl trinitrate. Within 30 min her toes were warm and pink and exhibited excellent capillary return. The improvement lasted 6 h and no adverse effects were encountered. A 68-year-old man who had had a myocardial infarction after repair of an abdominal aortic aneurysm was given dopamine by infusion for several days during which ischaemic changes in several toes developed. The local application of nitroglycerine ointment resulted in a sustained improvement in his digital perfusion. Peripheral digital ischaemia is a complication of therapy with dopamine,8ergotamine,and 0-blockers.10- It may also occur following inadvertent intra-arterial injection of vasoconstrictors or highly membrane soluble drugs.lTreatment with an a-adrenergic blocking agent may be effective but is not always practical. The local application of nitroglycerine ointment may provide a safe and 5. de Jonckheere J, van de Voorde H. Differences in destruction of

non-pathogenic Naegleria

and Acanthamoeba

by

cysts of pathogenic and App Envir Microbiol

chlorine.

1976; 31: 294-97. 6. Franks AG. Topical glyceryl trinitrate as adjunctive treatment in Raynaud’s disease. Lancet 1982; i: 76-77. 7. Herker JF, Lewis GBH, Stanley H. Nitroglycerine ointment as an aid to venepuncture. Lancet 1983, i: 332-33. 8. Alexander CS, Sako Y, Mikulie E Pedal gangrene with the use of dopamine. N Engl J Med 1975; 293: 591. 9. Cameron EA, French EB. St Anthony’s fire rekindled Gangrene due to therapeutic dose of ergotamine. Br Med J 1960; ii: 28-30. 10. Editorial. Long-term safety of receptor-blocking drugs Lancet 1978; i: 1242. 11. Knill RL, Evans D Gangrene following intra-arteriolar drugs. Can Anaesth Soc J 1975; 22: 637-42.

simple method of improving capillary blood flow not only iri Raynaud’s disease but also in some cases of iatrogenic peripheral digital ischaemia. Department of Anaesthesia and Intensive Care, Sir Charles Gairdner Hospital, Queen Elizabeth II Medical Centre, Nedlands, Western Australia 6009

N. M. GIBBS T. E. OH

BENZODIAZEPINE WITHDRAWAL

SIR,-Investigations on benzodiazepine withdrawal, such as the by Dr Tyler and colleagues (June 25, p 1402) are very important. As a result of publicity in the media, self-help groups to deal with this problem have been formed throughout the UK. I was involved in the formation of one and concluded that, if not properly run, these groups might cause a "withdrawal neurosis" by emphasising the one

horrors of withdrawal symptoms rather than the benefits of stopping these drugs. This is not to say that withdrawal should be sudden: the patient should be encouraged to decide on a time to stop. This will vary from 4 weeks to 3 months, depending on the duration of medication. Prolonged administration makes it more difficult for some people to stop taking these drugs. An unnecessarily long course of more than 3 months may follow from the practice of repeat prescriptions and the original purpose of giving the drug may be forgotten. To avoid drug dependency there should be a continual review of the need for the drug and it should be discontinued as soon as therapeutically possible. 16 Lytton Road, Pinner HA5 4RH

J. VAHRMAN

Commentary from Westminster Differing Views on Commitment to the NHS "The Government’s policies are a practical expression of commitment to a better National Health Service," the Health Minister, Mr Kenneth Clarke, told the annual meeting ofthe Association of Community Health Councils. This was a bold presentational approach, in view of the Government’s latest "non-cuts" that have lopped 100 million from expected NHS expenditure for this year, and which will have consequences in the longer term. Mr Clarke’s words were also something of a hostage to fortune, since it seems that the current Government review of future spending plans is certain to bear more heavily on the DHSS than on any other Government department, since the DHSS now accounts for about 40% of state spending. Mr Clarke’s audience may have wondered

even more about his "commitment" when, only it became clear that the lower manpower targets later, days

decreed for the NHS in the search for the year’s 100 millioc savings will involve reducing the numbers of doctors and nurses in the service. The numbers lost will be very small, bu: this is the first time medical de-manning of the NHS has been contemplated for many years.

Between 6000 and 8000 jobs are to be shed from the NHS’s workforce of 1 million by next April. The choice of which jobs should go is to be left to health authorities, although the DHSS is expected to offer some guidelines soon. Although officially the Department says it wants to protect the number’ of staff engaged in direct patient care, planners at the Elephant and Castle expect that reductions could well be made in some allegedly overprovided medical specialties One source in the Department suggests that a health