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Pelvic exenteration
No shock was advised or delivered in the other 12 passengers without VF in flight. All 9 with asystole or idioventricular rhythm died and resuscitation was discontinued in flight; all 3 with sinus rhythm initially survived, but 1 died within 24 h. Aircraft were diverted on seven occasions. 13 episodes of cardiac arrest occurred in terminals. VF was the cause in 11, and sinus rhythm was documented in 2. Defibrillation was initially successful in all, and 3 were subsequently discharged from hospital. 1 who had had sinus rhythm later died. Deaths on board Qantas aircraft correspond to 87 per million flight sectors (single journeys between take-off and landing) or 0-72 per million passengers. These figures are higher than previously reported4 and suggested 500-1000 deaths in International Air Transport Association aircraft per annum from cardiac arrest world wide. This death rate is far higher than from trauma.’ Successful management of VF in aircraft suggests that a defibrillation programme might usefully be incorporated into airline safety procedures throughout the industry.
hospital discharge.
*Michael O’Rourke, Eric Donaldson *University of New South Wales, St Vincent’s Hospital, Sydney NSW 2010, Australia; and Qantas Airways, Sydney (Kingsford Smith) Airport, Sydney 1
2 3 4
5
Weaver WD, Hill D, Fahrenbruch CE, et al. Use of the automatic external defibrillator in the management of out-of-hospital cardiac arrest. N Engl J Med 1988; 319: 661-66. O’Rourke MF, Hall J. Pre-hospital cardiac arrest in New South Wales during 1992. Aust NZ J Med 1994; 24: 619. O’Rourke MF, Donaldson E. An airline cardiac arrest program. Circulation 1994; 90: 1-287. Cumming RO, Chapman PJC, Chamberlain DA, Schjbach JA, Litwin PE. In-flight deaths during commercial air travel: how big is the
problem? JAMA 1988; 259: 1983-88. Friend T. Cardiac equipment on planes could USA Today 1994; Nov 17: 1.
save
hundreds.
Pelvic exenteration SiR-Saunders’ Jan 7 commentary serves as a timely reminder that there is a place for this ultra-radical surgical procedure in selected patients. Exenteration has to be done in centres having specialists with the expertise and experience not only to select appropriate cases but also to undertake the reconstructive and rehabilitative procedures that are now available and necessary with current surgical techniques. Not only are vaginal reconstructive procedures possible with either myocutaneous grafts or segments of non-irradiated gastro-intestinal tract, but also continent bladder diversions can be done with high-volume lowpressure "reservoirs" rather than the standard wet urostomy and ileal conduit. Low-stapling techniques mean that, despite radiotherapy, rectal continuity can sometimes be restored. Careful selection means that up to 40% of patients referred for consideration for the procedure are deemed suitable for exenteration after full assessment. Experience has shown that prognostic factors that adversely influence survival are age over 69 years, recurrence of tumours within 3 years, persistent recurrence, and positive resection 1
margins.
These comments apply to most patients in whom cure is still the aim. However, despite failed primary treatment, by surgery or radiotherapy (or usually both), there is also a small place for palliative exenteration. This treatment applies to patients with not only large and foul recurrence of vulvar cancer, but also other primaries, such as vagina, cervix, rectum, bladder, and prostate. Pain from perineal, clitoral, or anal involvement may be relieved by surgical wide excision. Foul discharge from fungating tumours can be cured similar after excision, often with suitable 516
grafting. Fistulae can be dealt with by appropriate diversion, and, if extirpation is possible, the coexisting bleeding and discharge is cleared. In selected cases, with a cross-disciplinary approach after failed previous treatment, there is a place for palliative radical surgery, even by exenteration. musculocutaneous
2
*John H
Shepherd, C R J Woodhouse
Depts of Gynaecological, Oncology and Urology, Royal Marsden NHS Trust, London SW3 6JJ, UK
Shepherd JH, Ngan HYS, Neven P, Fryatt I, Woodhouse CRJ, Hendry WF. Multivariate analysis of factors affecting survival in pelvic exenteration. Int J Gynecol Cancer 1994; 4: 361-70. Woodhouse CRJ, Plail RO, Schlesinger PE, Shepherd JH, Hendry WF, Breach NN. Exenteration as palliation for patients with advanced pelvic malignancy. Br J Urol (in press).
1
2
Clozapine
in Parkinson’s disease
SIR-Ihave recently reported the benefit of clozapine in a patient with advanced Parkinson’s disease who had nocturnal agitation, confusion, and relentless tremor.’ Others have described similar casesY Auzou and colleagues (Oct 1, p 955) suggest that clozapine in fact increases psychotic symptoms. From their description it is unclear whether clozapine was the cause of deterioration, especially since there was initial improvement. Further, not only was clozapine subsequently withdrawn, but haloperidol was introduced. The latter drug would cause an improvement in psychotic symptoms whatever the cause of the delirium. If the psychotic symptoms were precipitated by clozapine, even if the drug is continued, the problem might resolve.’ Variability of clinical response and side-effects when a drug is used is not uncommon. Published reports show that clozapine can be beneficial in some but cause important side-effects in others. In Australia clozapine is restricted to the treatment of schizophrenia. This restriction is unfortunate because it does not allow some patients with Parkinson’s disease to gain great benefit at a time when the condition is becoming difficult to manage for patients, carers, and medical attendants. Furthermore, monitoring for side-effects would be an easy task in this group of patients. All the case reports highlight the great need for further randomised control trials of clozapine in Parkinson’s disease. The relaxation of stringent control should be considered provided that sideeffects are closely monitored. Peter Gonski Sutherland Hospital, Miranda, NSW 2228, Australia
1
2 3
4
Gonski PN. The use of clozapine in Parkinson’s disease. Aust NZ J Med 994; 24: 585. Kahn N, Freeman A, James JL, et al. Clozapine is beneficial for psychosis in Parkinson’s disease. Neurology Oct 1991; 41: 1699-700. Factor SA, Brown D, Eroc S, et al. Clozapine: a 2 year open trial in Parkinson’s disease patients with psychosis. Neurology 1994; 44: 544-46. Greene P, Cote L, Fahn S. Treatment of drug induced psychosis in Parkinson’s disease with clozapine. Adv Neurol 1993; 60: 703-06.
Authors’
reply
SiR-Gonski raises two points: he has doubts about the causality of clozapine in the worsening of psychotic symptoms in our patient, and he regrets that clozapine is not available in Australia for the treatment of psychotic symptoms in Parkinson’s disease, presumably fearing that our report could cast doubts on its efficacy, and retard its authorisation.
hospital discharge.
*Michael O’Rourke, Eric Donaldson *University of New South Wales, St Vincent’s Hospital, Sydney NSW 2010, Australia; and Qantas Airways, Sydney (Kingsford Smith) Airport, Sydney 1
2 3 4
5
Weaver WD, Hill D, Fahrenbruch CE, et al. Use of the automatic external defibrillator in the management of out-of-hospital cardiac arrest. N Engl J Med 1988; 319: 661-66. O’Rourke MF, Hall J. Pre-hospital cardiac arrest in New South Wales during 1992. Aust NZ J Med 1994; 24: 619. O’Rourke MF, Donaldson E. An airline cardiac arrest program. Circulation 1994; 90: 1-287. Cumming RO, Chapman PJC, Chamberlain DA, Schjbach JA, Litwin PE. In-flight deaths during commercial air travel: how big is the
problem? JAMA 1988; 259: 1983-88. Friend T. Cardiac equipment on planes could USA Today 1994; Nov 17: 1.
save
hundreds.
Pelvic exenteration SiR-Saunders’ Jan 7 commentary serves as a timely reminder that there is a place for this ultra-radical surgical procedure in selected patients. Exenteration has to be done in centres having specialists with the expertise and experience not only to select appropriate cases but also to undertake the reconstructive and rehabilitative procedures that are now available and necessary with current surgical techniques. Not only are vaginal reconstructive procedures possible with either myocutaneous grafts or segments of non-irradiated gastro-intestinal tract, but also continent bladder diversions can be done with high-volume lowpressure "reservoirs" rather than the standard wet urostomy and ileal conduit. Low-stapling techniques mean that, despite radiotherapy, rectal continuity can sometimes be restored. Careful selection means that up to 40% of patients referred for consideration for the procedure are deemed suitable for exenteration after full assessment. Experience has shown that prognostic factors that adversely influence survival are age over 69 years, recurrence of tumours within 3 years, persistent recurrence, and positive resection 1
margins.
These comments apply to most patients in whom cure is still the aim. However, despite failed primary treatment, by surgery or radiotherapy (or usually both), there is also a small place for palliative exenteration. This treatment applies to patients with not only large and foul recurrence of vulvar cancer, but also other primaries, such as vagina, cervix, rectum, bladder, and prostate. Pain from perineal, clitoral, or anal involvement may be relieved by surgical wide excision. Foul discharge from fungating tumours can be cured similar after excision, often with suitable 516
grafting. Fistulae can be dealt with by appropriate diversion, and, if extirpation is possible, the coexisting bleeding and discharge is cleared. In selected cases, with a cross-disciplinary approach after failed previous treatment, there is a place for palliative radical surgery, even by exenteration. musculocutaneous
2
*John H
Shepherd, C R J Woodhouse
Depts of Gynaecological, Oncology and Urology, Royal Marsden NHS Trust, London SW3 6JJ, UK
Shepherd JH, Ngan HYS, Neven P, Fryatt I, Woodhouse CRJ, Hendry WF. Multivariate analysis of factors affecting survival in pelvic exenteration. Int J Gynecol Cancer 1994; 4: 361-70. Woodhouse CRJ, Plail RO, Schlesinger PE, Shepherd JH, Hendry WF, Breach NN. Exenteration as palliation for patients with advanced pelvic malignancy. Br J Urol (in press).
1
2
Clozapine
in Parkinson’s disease
SIR-Ihave recently reported the benefit of clozapine in a patient with advanced Parkinson’s disease who had nocturnal agitation, confusion, and relentless tremor.’ Others have described similar casesY Auzou and colleagues (Oct 1, p 955) suggest that clozapine in fact increases psychotic symptoms. From their description it is unclear whether clozapine was the cause of deterioration, especially since there was initial improvement. Further, not only was clozapine subsequently withdrawn, but haloperidol was introduced. The latter drug would cause an improvement in psychotic symptoms whatever the cause of the delirium. If the psychotic symptoms were precipitated by clozapine, even if the drug is continued, the problem might resolve.’ Variability of clinical response and side-effects when a drug is used is not uncommon. Published reports show that clozapine can be beneficial in some but cause important side-effects in others. In Australia clozapine is restricted to the treatment of schizophrenia. This restriction is unfortunate because it does not allow some patients with Parkinson’s disease to gain great benefit at a time when the condition is becoming difficult to manage for patients, carers, and medical attendants. Furthermore, monitoring for side-effects would be an easy task in this group of patients. All the case reports highlight the great need for further randomised control trials of clozapine in Parkinson’s disease. The relaxation of stringent control should be considered provided that sideeffects are closely monitored. Peter Gonski Sutherland Hospital, Miranda, NSW 2228, Australia
1
2 3
4
Gonski PN. The use of clozapine in Parkinson’s disease. Aust NZ J Med 994; 24: 585. Kahn N, Freeman A, James JL, et al. Clozapine is beneficial for psychosis in Parkinson’s disease. Neurology Oct 1991; 41: 1699-700. Factor SA, Brown D, Eroc S, et al. Clozapine: a 2 year open trial in Parkinson’s disease patients with psychosis. Neurology 1994; 44: 544-46. Greene P, Cote L, Fahn S. Treatment of drug induced psychosis in Parkinson’s disease with clozapine. Adv Neurol 1993; 60: 703-06.
Authors’
reply
SiR-Gonski raises two points: he has doubts about the causality of clozapine in the worsening of psychotic symptoms in our patient, and he regrets that clozapine is not available in Australia for the treatment of psychotic symptoms in Parkinson’s disease, presumably fearing that our report could cast doubts on its efficacy, and retard its authorisation.