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ORAL CONTRACEPTIVES AND MYOCARDIAL INFARCTION
411 AGE AND SKIN REACTIVITY SIR,-The relation between age and skin reactivity has been studied in the past, and lately also with reference to delayed
hypersensitivity.’ -5 We describe here some of the results of our investigations of differences of skin reactivity at various ages. We performed skin tests using: (a) 100 Christensen units of streptokinase (S.T.K.) (’ Streptase’, Behringwerke), which brings about the blastic transformation of lymphocytes in culture, and skin infiltration characterised by perivascular infiltration of mononuclear cells; (b) 0-0001 mg. of the lipopolysaccharide of Salmonella typhi, type 2 (L.S.T.), which does not provoke blas-c transformation in vitro and causes a skin reaction with infiltration of granulocytes 6 ; (c) 0.01 mg. of phytohsemagglutinin (P.H.A.) (’ Phytohaemagglutinin’, Wellcome), which is known to provoke blastic transformation in vitro of lymphocytes and to give a skin reaction of delayedhypersensitivity type. 6These substances had been previously used for skin tests in man by other workers. 7-9 1. Straus, H. W.J. Allergy, 1931, 2, 137. 2. Uhr, J. W., Dancis, J., Grantz Neumann, C. Nature, Lond. 1960,187,1130. 3. Johnston, R. N., Ritchie, R. T., Murray, I. H. F. Br. med. J. 1963, ii, 720. 4. Burgio, G. R. ibid. 1964, i, 1111. 5. Burgio, G. R., Vaccaro, R., Frattegiani, A. Helv. Pœdiat. Acta, 1964, 19, 355. 6. Burgio, G. R., Astaldi, G., Genova, R., Curtoni, E. XIIth International Congress of Cell Biology, Brussels, 1968. 7. Airò, R., Mihailescu, E., Astaldi, G., Meardi, G. Lancet, 1967, i, 899. 8. Kwapinski, J. B., Snyder, M. L. The Immunology of Rheumatism, p. 183. New York, 1962. 9. Gerbasi, M., Burgio, G. R. Boll. Soc. ital. Biol. sper. 1945, 20, 561.
584 skin tests were performed with S.T.K., 628 with P.H.A., and 545 with L.S.T.; we avoided testing subjects with streptococcal infections (either at the time of the investigation or in the recent past), those whose skin reactivity could be altered, and those living in closed communities. The injections were given into the skin of the medial aspect of the forearm. For evaluation of the reactions both indurated and erythematous areas were considered. The study was carried out between March 1, 1966, and Feb. 29, 1968; almost the same number of skin tests were performed in each month. Almost all subjects reacted to L.S.T. and P.H.A., but many subjects in various age-groups, especially young infants, did not react to s.T.K. The mean diameters of the skin reactions obtained in the various age-groups, measured 24 hours after inoculation, and the standard errors, are shown in the accompanying figure. The theoretical curves are also shown: the shape of the curves does not change significantly, either when they include negative reactions, or when they are obtained from the maximal reactions, often observed after 24 hours. It is evident that, for all three substances used, the size of the skin reaction largely depends upon the age. This is quantitatively expressed by the mathematical formulas shown in the figure, by means of which the extrapolated curves were obtained. The Blood Research Foundation Centre is supported by the Blood Research Foundation, Washington, D.C., U.S.A. G. R. BURGIO Pædiatric Clinic, G. RIZZONI. University of Pavia. Blood Research Foundation Centre, Tortona.
E. MARNI.
MENAPHTHONE IN MULTIPLE SCLEROSIS SIR,-Henzi and Uehlinger have reportedsome benefit from the oral use of menaphthone in 14 patients with multiple sclerosis. This treatment was based on my observations.2 Because their results are not so definite as mine I wish to state that in my experience only menaphthone sodium bisulphite given intramuscularly produces the results reported in 1965 and which I have since confirmed. Sanatorium for Nervous Diseases, Koscian,
near
Poznan,
Poland.
JAN. A. TOMASZKIEWICZ.
ORAL CONTRACEPTIVES AND MYOCARDIAL INFARCTION the best of our knowledge no firm evidence has SiR.ņTo been presented so far connecting the taking of oral contraceptives with thromboembolic disorders.3 The following casereport suggests such a relation. A thirty-nine-year-old Hungarian woman was admitted to hospital because of severe precordial pains lasting some hours before admission. The patient, who immigrated to Israel in 1958, had been completely healthy before this admission. She is married, and has two healthy children. Her menstruation is regular and normal. Six months previously she had begun taking regularlyEnovid ’ (norethynodrel 5 mg., mestranol 0-075 mg.). There was no family history of cardiovascular diseases, diabetes, or hypertension. On admission, physical examination showed no abnormal findings, but the electrocardiogram (E.c.G.) showed a fresh anterolateral infarction. All routine laboratory tests, including estimations of glucose-tolerance, total lipids, and cholesterol were within normal limits. The hospital course was uneventful and the patient was discharged after three weeks. During the past five years, 417 women have been admitted to this hospital because of myocardial infarction, but only 7 of them (1-6%) have been under forty years old.4 5 of these had a Mean diameters (mm.) of skin reactions (ordinate) at various ages, with standard errors and theoretical curves.
1. Henzi, H., Uehlinger, A. Schweiz med. Wschr. 1968, 98, 688. 2. Tomaszkiewicz, J. A. Lancet, 1965, ii, 190. 3. New Eng. J. Med. 1968, 278, 452. 4. Amikam, S., Valero, A. M.D. thesis, Jerusalem, 1966.
412
precipitating factor: hypertension (2 patients), diabetes mellitus (1), systemic lupus erythematosus (1), and myxredema (1). The 6th patient has a diaphragmatic hernia; an E.C.G. during her stay in hospital showed only T-wave changes, which subsided after a few days, so that it is not clear whether they due to coronary heart-disease. No data are available about the 7th patient. These findings show that myocardial infarction without a precipitating factor is uncommon in women during their productive period. J. SCHARF A. M. NAHIR Department of Internal Medicine A, B. PELED Rambam Government Hospital. A. ASAD. Haifa, Israel.
were
A MAMMO-RENAL SYNDROME ? SIR,-One of my female patients was operated on for bilateral Routine pyelography showed breasts. supernumerary bilateral supernumerary kidneys, with ureters entering independently into the bladder.Another female patient had a unilateral supernumerary breast. Pyelography showed a supernumerary kidney on the same side, ending in a common ureter. Anomalies associated with supernumerary breasts have not been reported. In females, prevalence of supenumerary breasts is about 1 % and the prevalence of kidney reduplication is equally about 1 %. The chance occurrence of the two anomalies in the same patient is 1 in 10,000. I wonder whether aplasia of one breast is not associated -with unilateral renal hypoplasia in some rare instances. Ter Weeden-Zulte, LUC GOEMINNE. Belgium.
ENHANCEMENT OF ANTITUBERCULOSIS-DRUG ACTION BY ACRIDINES
SiR,-Sevag et al.23 have shown that mepacrine (’ Atabrine ’) and other acridines inhibit the development of drug resistance by Staphylococcus spp. and Escherichia coli during continuous incubation in a liquid medium. Lately Warren et al.4 have reported that mepacrine also inhibits development of drug resistance by Mycobacterium tuberculosis. Several acridines have been studied in our laboratory, and several compounds have shown much higher activity than mepacrine. They also inhibit the development of resistance to streptomycin in M. phlei and M. avium. We report here preliminary findings on the influence of acridines on the activity of antituberculosis
drugs. M. tuberculosis, strain H37Rv, was suspended in Sauton medium enriched with bovine serum andTween 80’. Non-bacteriostatic concentrations of acridines were established in preliminary experiments. The activity of antituberculosis drugs was tested by serial dilution in the same medium. The viable count of mycobacteria in each tube was about 2 x 108. Such a large population must have contained resistant mutants, thus increasing the minimal inhibiting concentration (M.l.C.) of the drug. The M.i.c. of each drug (in g. per ml.) greatly diminished when one of the acridines in sub-bacteriostatic concentrations was added, as follows:
The coefficients of activation
were
1250
to
20 for
isoniazid,
(editor) Handbook of Congenital Malformations; p. 17. Rubin, Philadelphia. 1967 2. Sevag, M. G., Ashton, B. Nature, Lond. 1964, 203, 1323-1326. 3. Heller, C. S., Sevag, M. G. Appl. Microbiol. 1966, 14, 879. 4. Warren, G., Gregory, F., Healy, E., Flint, S. Nature, Lond. 1967, 1.
A.
215,
526.
10 to 4 for
streptomycin,
30 to 4 for
kanamycin, and
17 to 4 for
cycloserine. solid medium were also done. Acridines, especially proflavine, increased the bactericidal activity of antituberculosis drugs. Thus after 30 days’ incubation at 37°C, isoniazid was bactericidal in concentrations of not less than 25 g. per ml., and in concentrations of 0-75 {jLg. per ml. when proflavine was added. The corresponding concentrations for streptomycin were 2 and 0-25 g. per ml., and for cycloserine more than 50 and 12-5 g. per ml. Viable
The
counts on
enhancing
effect of acridines may be of
importance in
treating tuberculous foci containing large numbers of M. tuberculosis. Department of Chemotherapy, Institute of Pharmacology and Chemotherapy, Academy of Medical Science of the U.S.S.R.
V. N. SOLOVIEV V. S. ZUEVA.
PLATELET-FACTOR-3 AVAILABILITY IN A PATIENT WITH GLANZMANN’S DISEASE SIR,-In some patients with Glanzmann’s disease (thrombocytasthenia), the prothrombin is not sufficiently consumed,12z when the platelet-rich plasma (P.R.P.) is incubated with kaolin, platelet factor 3 (P.F.3) activity is abnormal,1-4 On the other hand, when washed platelets are later assayed by the thrombo-
plastin-generation test (T.G.T.), normal platelet clotting activity is observed.23 Hardisty et al.l reported that the platelets of one of their patients were less active than normal ones when assayed by the T.G.T. Weiss and Kochwa 4 recorded that when this method was used on 1 % suspensions of the platelets of three of their patients the activity was normal, and that it was only when more diluted suspensions were used that the activity was lower than that observed in normal subjects. We have recently conducted a number of tests on the platelets of a patient with Glanzmann’s disease for the purpose of determining P.F.3 activity. The P.R.P. of the patient and of the controls were so adjusted with their own platelet-poor plasmas (P.P.P.) as to contain 200,000 platelets per c.mm. The P.R.P. was centrifuged at 4500 r.p.m. for 30 minutes at 5°C. The supernatant was discarded; the platelet pellets were resuspended successively in substrate P.P.P., in isotonic saline solution, and in distilled water, retaining the original volume. The platelet suspensions made in saline and in distilled water were mixed with an equal volume of substrate P.P.P. The’Stypven’time for the P.P.P. treated in this way was then recorded. One of the tests was carried out after the platelets had been washed in a saline solution three times. The results were as follows (stypven-time in seconds):
These findings clearly show that in this patient the amount of P.P.3 activity made available was less than in normal subjects. The more the platelets were manipulated, the more active they became. When incubated in distilled water the coagulant activity became normal. This indicates that, as in thrombopathia (Willebrand-Jurgens type), the platelets contain this factor but it does not easily become available. In the T.G.T. assay, a 200,000 per c.mm. platelet suspension showed that the minimum substrate clotting time was 3 seconds longer with the patient’s platelets than with those of normal subjects. Kaolin did not have any effect on the patient’s P.R.P. stypventime. Department of Hæmatology, ŞEREF INCEMAN 1st Internal Clinic of Istanbul Medical School, YÜCEL TANGÜN. Istanbul, Turkey. R. M., Dormandy, K. M., Hutton, R. A. Br. J. Hœmat. 1964, 10, 371. 2. Zucker, M. B., Pert, J., Hilgartner, M. W. Blood, 1966, 28, 524. 3. Caen, J. P., Castaldi, P. A., Leclerc, J. C., Inceman, Ş., Larrieu, M. J. Probst, M., Bernard, J. Am. J. Med. 1966, 41, 4. 4. Weiss, H. J., Kochwa, S. J. Lab. clin. med. 1968, 71, 163. 1.
Hardisty,
hypersensitivity.’ -5 We describe here some of the results of our investigations of differences of skin reactivity at various ages. We performed skin tests using: (a) 100 Christensen units of streptokinase (S.T.K.) (’ Streptase’, Behringwerke), which brings about the blastic transformation of lymphocytes in culture, and skin infiltration characterised by perivascular infiltration of mononuclear cells; (b) 0-0001 mg. of the lipopolysaccharide of Salmonella typhi, type 2 (L.S.T.), which does not provoke blas-c transformation in vitro and causes a skin reaction with infiltration of granulocytes 6 ; (c) 0.01 mg. of phytohsemagglutinin (P.H.A.) (’ Phytohaemagglutinin’, Wellcome), which is known to provoke blastic transformation in vitro of lymphocytes and to give a skin reaction of delayedhypersensitivity type. 6These substances had been previously used for skin tests in man by other workers. 7-9 1. Straus, H. W.J. Allergy, 1931, 2, 137. 2. Uhr, J. W., Dancis, J., Grantz Neumann, C. Nature, Lond. 1960,187,1130. 3. Johnston, R. N., Ritchie, R. T., Murray, I. H. F. Br. med. J. 1963, ii, 720. 4. Burgio, G. R. ibid. 1964, i, 1111. 5. Burgio, G. R., Vaccaro, R., Frattegiani, A. Helv. Pœdiat. Acta, 1964, 19, 355. 6. Burgio, G. R., Astaldi, G., Genova, R., Curtoni, E. XIIth International Congress of Cell Biology, Brussels, 1968. 7. Airò, R., Mihailescu, E., Astaldi, G., Meardi, G. Lancet, 1967, i, 899. 8. Kwapinski, J. B., Snyder, M. L. The Immunology of Rheumatism, p. 183. New York, 1962. 9. Gerbasi, M., Burgio, G. R. Boll. Soc. ital. Biol. sper. 1945, 20, 561.
584 skin tests were performed with S.T.K., 628 with P.H.A., and 545 with L.S.T.; we avoided testing subjects with streptococcal infections (either at the time of the investigation or in the recent past), those whose skin reactivity could be altered, and those living in closed communities. The injections were given into the skin of the medial aspect of the forearm. For evaluation of the reactions both indurated and erythematous areas were considered. The study was carried out between March 1, 1966, and Feb. 29, 1968; almost the same number of skin tests were performed in each month. Almost all subjects reacted to L.S.T. and P.H.A., but many subjects in various age-groups, especially young infants, did not react to s.T.K. The mean diameters of the skin reactions obtained in the various age-groups, measured 24 hours after inoculation, and the standard errors, are shown in the accompanying figure. The theoretical curves are also shown: the shape of the curves does not change significantly, either when they include negative reactions, or when they are obtained from the maximal reactions, often observed after 24 hours. It is evident that, for all three substances used, the size of the skin reaction largely depends upon the age. This is quantitatively expressed by the mathematical formulas shown in the figure, by means of which the extrapolated curves were obtained. The Blood Research Foundation Centre is supported by the Blood Research Foundation, Washington, D.C., U.S.A. G. R. BURGIO Pædiatric Clinic, G. RIZZONI. University of Pavia. Blood Research Foundation Centre, Tortona.
E. MARNI.
MENAPHTHONE IN MULTIPLE SCLEROSIS SIR,-Henzi and Uehlinger have reportedsome benefit from the oral use of menaphthone in 14 patients with multiple sclerosis. This treatment was based on my observations.2 Because their results are not so definite as mine I wish to state that in my experience only menaphthone sodium bisulphite given intramuscularly produces the results reported in 1965 and which I have since confirmed. Sanatorium for Nervous Diseases, Koscian,
near
Poznan,
Poland.
JAN. A. TOMASZKIEWICZ.
ORAL CONTRACEPTIVES AND MYOCARDIAL INFARCTION the best of our knowledge no firm evidence has SiR.ņTo been presented so far connecting the taking of oral contraceptives with thromboembolic disorders.3 The following casereport suggests such a relation. A thirty-nine-year-old Hungarian woman was admitted to hospital because of severe precordial pains lasting some hours before admission. The patient, who immigrated to Israel in 1958, had been completely healthy before this admission. She is married, and has two healthy children. Her menstruation is regular and normal. Six months previously she had begun taking regularlyEnovid ’ (norethynodrel 5 mg., mestranol 0-075 mg.). There was no family history of cardiovascular diseases, diabetes, or hypertension. On admission, physical examination showed no abnormal findings, but the electrocardiogram (E.c.G.) showed a fresh anterolateral infarction. All routine laboratory tests, including estimations of glucose-tolerance, total lipids, and cholesterol were within normal limits. The hospital course was uneventful and the patient was discharged after three weeks. During the past five years, 417 women have been admitted to this hospital because of myocardial infarction, but only 7 of them (1-6%) have been under forty years old.4 5 of these had a Mean diameters (mm.) of skin reactions (ordinate) at various ages, with standard errors and theoretical curves.
1. Henzi, H., Uehlinger, A. Schweiz med. Wschr. 1968, 98, 688. 2. Tomaszkiewicz, J. A. Lancet, 1965, ii, 190. 3. New Eng. J. Med. 1968, 278, 452. 4. Amikam, S., Valero, A. M.D. thesis, Jerusalem, 1966.
412
precipitating factor: hypertension (2 patients), diabetes mellitus (1), systemic lupus erythematosus (1), and myxredema (1). The 6th patient has a diaphragmatic hernia; an E.C.G. during her stay in hospital showed only T-wave changes, which subsided after a few days, so that it is not clear whether they due to coronary heart-disease. No data are available about the 7th patient. These findings show that myocardial infarction without a precipitating factor is uncommon in women during their productive period. J. SCHARF A. M. NAHIR Department of Internal Medicine A, B. PELED Rambam Government Hospital. A. ASAD. Haifa, Israel.
were
A MAMMO-RENAL SYNDROME ? SIR,-One of my female patients was operated on for bilateral Routine pyelography showed breasts. supernumerary bilateral supernumerary kidneys, with ureters entering independently into the bladder.Another female patient had a unilateral supernumerary breast. Pyelography showed a supernumerary kidney on the same side, ending in a common ureter. Anomalies associated with supernumerary breasts have not been reported. In females, prevalence of supenumerary breasts is about 1 % and the prevalence of kidney reduplication is equally about 1 %. The chance occurrence of the two anomalies in the same patient is 1 in 10,000. I wonder whether aplasia of one breast is not associated -with unilateral renal hypoplasia in some rare instances. Ter Weeden-Zulte, LUC GOEMINNE. Belgium.
ENHANCEMENT OF ANTITUBERCULOSIS-DRUG ACTION BY ACRIDINES
SiR,-Sevag et al.23 have shown that mepacrine (’ Atabrine ’) and other acridines inhibit the development of drug resistance by Staphylococcus spp. and Escherichia coli during continuous incubation in a liquid medium. Lately Warren et al.4 have reported that mepacrine also inhibits development of drug resistance by Mycobacterium tuberculosis. Several acridines have been studied in our laboratory, and several compounds have shown much higher activity than mepacrine. They also inhibit the development of resistance to streptomycin in M. phlei and M. avium. We report here preliminary findings on the influence of acridines on the activity of antituberculosis
drugs. M. tuberculosis, strain H37Rv, was suspended in Sauton medium enriched with bovine serum andTween 80’. Non-bacteriostatic concentrations of acridines were established in preliminary experiments. The activity of antituberculosis drugs was tested by serial dilution in the same medium. The viable count of mycobacteria in each tube was about 2 x 108. Such a large population must have contained resistant mutants, thus increasing the minimal inhibiting concentration (M.l.C.) of the drug. The M.i.c. of each drug (in g. per ml.) greatly diminished when one of the acridines in sub-bacteriostatic concentrations was added, as follows:
The coefficients of activation
were
1250
to
20 for
isoniazid,
(editor) Handbook of Congenital Malformations; p. 17. Rubin, Philadelphia. 1967 2. Sevag, M. G., Ashton, B. Nature, Lond. 1964, 203, 1323-1326. 3. Heller, C. S., Sevag, M. G. Appl. Microbiol. 1966, 14, 879. 4. Warren, G., Gregory, F., Healy, E., Flint, S. Nature, Lond. 1967, 1.
A.
215,
526.
10 to 4 for
streptomycin,
30 to 4 for
kanamycin, and
17 to 4 for
cycloserine. solid medium were also done. Acridines, especially proflavine, increased the bactericidal activity of antituberculosis drugs. Thus after 30 days’ incubation at 37°C, isoniazid was bactericidal in concentrations of not less than 25 g. per ml., and in concentrations of 0-75 {jLg. per ml. when proflavine was added. The corresponding concentrations for streptomycin were 2 and 0-25 g. per ml., and for cycloserine more than 50 and 12-5 g. per ml. Viable
The
counts on
enhancing
effect of acridines may be of
importance in
treating tuberculous foci containing large numbers of M. tuberculosis. Department of Chemotherapy, Institute of Pharmacology and Chemotherapy, Academy of Medical Science of the U.S.S.R.
V. N. SOLOVIEV V. S. ZUEVA.
PLATELET-FACTOR-3 AVAILABILITY IN A PATIENT WITH GLANZMANN’S DISEASE SIR,-In some patients with Glanzmann’s disease (thrombocytasthenia), the prothrombin is not sufficiently consumed,12z when the platelet-rich plasma (P.R.P.) is incubated with kaolin, platelet factor 3 (P.F.3) activity is abnormal,1-4 On the other hand, when washed platelets are later assayed by the thrombo-
plastin-generation test (T.G.T.), normal platelet clotting activity is observed.23 Hardisty et al.l reported that the platelets of one of their patients were less active than normal ones when assayed by the T.G.T. Weiss and Kochwa 4 recorded that when this method was used on 1 % suspensions of the platelets of three of their patients the activity was normal, and that it was only when more diluted suspensions were used that the activity was lower than that observed in normal subjects. We have recently conducted a number of tests on the platelets of a patient with Glanzmann’s disease for the purpose of determining P.F.3 activity. The P.R.P. of the patient and of the controls were so adjusted with their own platelet-poor plasmas (P.P.P.) as to contain 200,000 platelets per c.mm. The P.R.P. was centrifuged at 4500 r.p.m. for 30 minutes at 5°C. The supernatant was discarded; the platelet pellets were resuspended successively in substrate P.P.P., in isotonic saline solution, and in distilled water, retaining the original volume. The platelet suspensions made in saline and in distilled water were mixed with an equal volume of substrate P.P.P. The’Stypven’time for the P.P.P. treated in this way was then recorded. One of the tests was carried out after the platelets had been washed in a saline solution three times. The results were as follows (stypven-time in seconds):
These findings clearly show that in this patient the amount of P.P.3 activity made available was less than in normal subjects. The more the platelets were manipulated, the more active they became. When incubated in distilled water the coagulant activity became normal. This indicates that, as in thrombopathia (Willebrand-Jurgens type), the platelets contain this factor but it does not easily become available. In the T.G.T. assay, a 200,000 per c.mm. platelet suspension showed that the minimum substrate clotting time was 3 seconds longer with the patient’s platelets than with those of normal subjects. Kaolin did not have any effect on the patient’s P.R.P. stypventime. Department of Hæmatology, ŞEREF INCEMAN 1st Internal Clinic of Istanbul Medical School, YÜCEL TANGÜN. Istanbul, Turkey. R. M., Dormandy, K. M., Hutton, R. A. Br. J. Hœmat. 1964, 10, 371. 2. Zucker, M. B., Pert, J., Hilgartner, M. W. Blood, 1966, 28, 524. 3. Caen, J. P., Castaldi, P. A., Leclerc, J. C., Inceman, Ş., Larrieu, M. J. Probst, M., Bernard, J. Am. J. Med. 1966, 41, 4. 4. Weiss, H. J., Kochwa, S. J. Lab. clin. med. 1968, 71, 163. 1.
Hardisty,