- Email: [email protected]
POST-TRAUMATIC ATLANTO-OCCIPITAL DISLOCATION REVEALED BY SUDDEN CARDIORESPIRATORY ARREST
447 involved in the aetiology of both primary HMR and HMR which arises in an already compromised host. M. F. MARTELLI A. TABILIO F. AVERSA B. FALINI
Clinica Medica 1°,
University of Perugia Medical School, 06100, Perugia, Italy Clinica Medica 3°,
University of Rome,
spongiform encephalopathy) or when mechanical saws are being used. We recommend a reappraisal of the Howie code of practice in the light of these and other criticisms. 8. 10 The impact of the code on education and training in many hospitals will be harmful. Insufficient emphasis has been placed on the importance of general technique of the operator. In particular, the requirements for ventilation in post-mortem rooms are expensive and of doubtful and
benefit.
00161 Rome,
G. ROCCHI
Italy
Newsham General Liverpool L6 4AF
WILFRED FINE E. J. BURGESS
Hospital,
SAFETY IN THE POST-MORTEM ROOM
SIR,-The educational value to clinicians of post-mortem examination of selected cases is widely acknowledged and has been demonstrated by retrospective study.’ Implementation of the socalled Howie code ofpracticehas, in the Liverpool area, resulted in the recent closure of five post-mortem rooms; facilities remain at two hospitals only. In one fell swoop much of the education and interest for junior doctors has been removed. Few juniors will have the time to travel to the nearest hospital with an approved postmortem room, and the change will almost certainly drastically reduce the number of necropsies done in the area. Indiscriminate pressure for reform was generated by the outbreak of smallpox at -Birmingham University Medical School in 1978. The resulting inquiry3considered the safety arrangements for the few laboratories handling very hazardous (category A) pathogens. This was followed closely by publication of the Howie code,2which was concerned with pathogens of lesser hazard. What justifies the radical changes necessitated by the code? The risk of infection of necropsy work in Britain has received little study. There is an excess of tuberculosis among workers in medical laboratories, 4,5 necropsy technicians being most at risk5 the slight excess in mortality from tuberculosis noted earlier appears no longer to be present.Attack rates for hepatitis among laboratory staff fell dramatically after 1974 and remained low (1975-78) compared with previous years (1970-74).
although
Exceptional
was
an
unchanged
rate
among
biochemistry
technicians. No case of hepatitis has been recorded among necropsy staff since 1974.Thus, there seems to be no indication of need for additional catch-all safety precautions. The Howie code2lists specific precautions to be taken with necropsies on known or suspected cases of tuberculosis. There are some important anomalies in the requirements of the Howie code for post-mortem examinations. The code makes a firm rule that post-mortem rooms should have air extraction in the order of ten changes of air per hour and that there should be a downward draught of air away from the operator’s face. This requirement could be met by the installation of large ventilation fans (costing about L12 000) low down in the post-mortem room. However, generation of air movement at a high rate will not by itself protect an operator: increased turbulence may indeed promote the spread of pathogens. A properly engineered system providing laminar flow of air would be required, at very great expense: this is not considered in
POST-TRAUMATIC ATLANTO-OCCIPITAL DISLOCATION REVEALED BY SUDDEN CARDIORESPIRATORY ARREST
SIR,-Spinal injuries with osteodiscal and ligament lesions accompanied by neurological signs are seen less frequently in children than in adolescents or adults. This is especially true of cervical spine lesions, the muscles and ligaments being supple in
children. On April 15, 1982, a 4-year-old boy was hit by a car. He was rushed to the hospital, and admitted in shock. Peritoneal aspiration confirmed intra-abdominal bleeding. A laparotomy was done, leading to a splenectomy, and several hepatic sutures were inserted. Recovery from general anaesthesia was uneventful, and, in the absence of any other signs of trauma or neurological disorder, the endotracheal tube was removed. 4 h after extubation, he suddenly stopped breathing and efforts at resuscitation failed. A small subcutaneous cervical haematoma justified post-mortem radiological examination of the cervical spine, which revealed an occipital Cl dislocation (see figure). Safety in laboratories. Br Med J 1978; 1: 871-72. Safety in microbiology laboratories Lancet 1979; ii: 1308. 10. Bakhshi SS. Preventing infection in clinical laboratories. Br Med J 1980; 280: 1452. 1. Andrews LG, Jung KS. Spinal cord injuries in children in British Columbia. Paraplegia 8. Editorial.
9. Simmons NA.
1979; 17: 442-51. 2. Audic
B, Maury M. Secondary Paraplegia 1969; 7: 10-16.
vertebral deformities
in
childhood and adolescence.
-
the Howie code. Also, it seems inconsistent that complementary protection of the facial region from splashing or other.airborne contamination, by routine use of visors during post-mortem work, is not a requirement. The code directs only that visors be worn for cases of special risk (i.e., viral hepatitis, brucellosis, leptospirosis 1. Holler JW, De Morgan NP. A
retrospective study of 200 post-mortem examinations.J Med Educ 1970; 45: 168-70. 2. D.H.S.S. Working Party (chairman J. W. Howie). Code of practice for the prevention of infection m clinical laboratories and post-mortem rooms. London: H.M.S.O., 1978. 3. Shooter RA (chairman). Report of the investigation into the cause of the 1978 Birmingham smallpox occurrence. London: H.M.S.O., 1980 4. Reid DD. Incidence of tuberculosis among workers in medical laboratories Br Med J 1957; ii: 10-14. 5. Harrington JM, Shannon HS. Incidence of tuberculosis, hepatitis, brucellosis and shigellosis in British medical laboratory workers. Br MedJ 1976, i: 759-62. 6. Harrington JM, Shannon HS. Mortality study of pathologists and medical laboratory technicians Br Med J 1975; i: 329-32. 7. Grist NR. Hepatitis in clinical laboratories 1977-78. J Clin Pathol 1980; 33: 471-73.
Occipital
Cl dislocation in
4-year-old boy.
448 The stability of the atlanto-occipital articulation depends, in large part, on the alar and atlanto-occipital ligaments. This is an unstable articulation,3- especially in young children whose pliant ligaments permit a large degree of rotation.Accidents of this type usually result in immediate death from vertebral artery injury, but there may be severe neurological and respiratory disorders, with an 7 eventually fatal outcome. This case emphasises the need for X-rays of the cervical spine after all multiple injury accidents. If a thoracic or abdominal lesion requires immediate attention, endotracheal intubation should be done very carefully; in the case described, the time lapse between the injury and the respiratory arrest was probably due to spontaneous secondary mobilisation of the atlas. The fact that intubation provoked no neurological signs was probably due to contraction of the paravertebral muscles. The use of curare during anaesthesia probably relaxed these muscles enough to permit
apical
displacement. FRANCIS LESOIN MARYLINE BLONDEL PATRICK DHELLEMMES CHARLES E. THOMAS CHRISTIAN VIAUD MICHEL JOMIN
Neurosurgery Service B, Centre Hospitalier Régional, Lille 59037, France
ST DAVID’S
HOSPITAL, CARMARTHEN
SIR,-Your Parliamentary correspondent, writing (July 31, p. 282) about conditions at this hospital, states that this Health
Authority has been relieved temporarily of its responsibility in providing care for the mentally ill. This is not so. The Secretary of to accept one of the main recommendations of the Health Advisory Service report to establish a review group to monitor progress towards agreed objectives. The East Dyfed Health Authority remains responsible for the management of the services at the hospital.
State for Wales has decided
East Dyfed Health Authority, Starling Park House,
Carmarthen SA31 3HL
J. E. TAYLOR
EPIDEMIOLOGY OF DIABETES AMONG BANTUS
SIR,-Your editorial of June 26 was very valuable in showing the importance of epidemiology for the understanding of diseases in the tropics. Indeed, epidemiology forms the base for health service planning. The readiness of clinicians in helping to conduct epidemiological studies is important. However, because of the heavy workload in the tropics, especially in rural areas, many important studies will never be started. The solution might be cooperation between areas. I am trying to study the epidemiology of diabetes in Bantu populations. Apart from the information given in the studies summarised by Jackson,very little is known about this subject. A preliminary survey shows a prevalence of 1’56% among a hospital population of Wahayas, a Bantu people, whereas the prevalence among a Bantu population in South Africa is 0 -053%.2 I would appreciate more information from clinicians working in Bantu
MOSAICISM 48,XX, + 8, + 21/47,XX, + 21 IN DOWN SYNDROME AND RAPID PROGRESSION FROM PRELEUKAEMIA TO ACUTE LEUKAEMIA SIR,-Reports of patients with Down Syndrome who rapidly go into the acute phase of leukaemia after a long preleukemic phasel,2 or after a period of spontaneous remission3,4 raise the question of what factors may be related to such an unexpected course of the disease. Certain chromosome abnormalities may affect leukaemogenicity, and we report here bone-marrow and peripheralblood cell mosaicism 48,XX,+8, + 21/47,XX, + 21 in a patient in whom acute undifferentiated leukaemia developed after nearly 6 months of stable preleukaemia. She was first seen at 21 months of age with widespread purpura. Typical features of Down syndrome had been present from birth. No other clinical abnormalities were found. Repeated investigations during a 2-month observation in hospital showed a persistently low platelet count; absence of megakaryocytes, hypoplastic erythropoiesis and gradually diminishing granulopoiesis in the bone marrow; and a progressive increase in proportion of blast cells to 33% in the peripheral blood and to 3-5—32-5% in the bone marrow. Morphological and cytochemical examination of the blast cells suggested an undifferentiated cell proliferation. Follow-up over the next four months, without the patient being on specific therapy, showed stable blood and bone marrow blast numbers. A month later the patient died shortly after admission to the hospital with symptoms suggesting central nervous system haemorrhage. There was
hepatosplenomegaly, anaemia, thrombocytopenia, leukocytosis (25 400 white celFs/1), and up to 55% blast cells in the peripheral blood. Chromosome
analysis of bone-marrow cells cultured without phytohaemagglutinin (PHA) for 24 h revealed trisomy 8 and 21 in each of the analysed cells (12 metaphase cells) at the start of the observation
and mosaicism 48,XX,+8,+21/47,XX,+21 (6/4 metaphase cells) five months later. Peripheral blood cells cultured
for 72 h with PHA first showed trisomy 8 in only 4
out
of 70
analysed cells; however, at the second examination trisomy 8 noticed in 37 out of 64 analysed metaphases (figure).
was
Y, Rowley JD, Variakojis D, Chilcote RR, Moohr JW, Patel D. Chromosome abnormalities in Down’s syndrome patients with acute leukemia. Blood 1981; 58: 459. 2. Sikand GS, Taysi K, Strandjord SE, Griffith R, Viotti TJ. Trisomy 21 in bone marrow cells of patient with a prolonged preleukemic phase. Med Ped Oncol 1980, 8: 237 3. Honda F, Punnett HH, Charney E, Miller G, Thiede HA. Serial cytogenetic and hematologic studies on a mongol with trisomy 21 and acute congenital leukemia J Pediatr 1964, 65: 880. 4. Rosner F, Lee SL. Down’s syndrome and acute leukemia: Myeloblastic or lymphoblastic? Report of forty-three cases and review of the literature. AmJ Med 1972, 53: 203. 5. Nowell PC. Preleukemias. Hum Pathol 1981; 12: 522 1. Kaneko
areas.
Ndolage Hospital, PO Box 34, Kamachumu, Tanzania
BO AHRÉN
Fielding JW, Burstein AA, Frankel VH. The nuchal ligament. Spine 1976; 1: 3-6. Jirout J. The dynamic dependence of the lower cervical vertebrae on the atlantooccipital joints. Neuroradiology 1974, 7: 249-51. 5 Johnson RM, Crelin ES, Withe A, Panjabi MM. Some new observations on the functional anatomy of the lower cervical spine. Clin Orthop 1975; 111: 192-95. 6. White AA, Panjabi MM, Brand RA. A system for defining position and motion of the human body parts Med Biol Eng 1975; 13: 261-68. 7. Evarts MC. Traumatic occipito atantol dislocation: Report of a case with survival. J Bone Joint Surg 1970; 52A: 1653-56. 1. Jackson WPU. Epidemiology of diabetes in South Africa. In: Levine R, Luft R, eds. Advances in metabolic disorders, vol. 9. New York: Academic Press, 1978: 111-46. 2. Cosnett JE. Illness among Natal Indians: A survey of hospital admissions. S Afr Med J 3. 4.
1957; 31: 1109-15.
Karyotype showing cell-line of 48,XX, + 8, + 21
banding).
from the blood
(RHG
Clinica Medica 1°,
University of Perugia Medical School, 06100, Perugia, Italy Clinica Medica 3°,
University of Rome,
spongiform encephalopathy) or when mechanical saws are being used. We recommend a reappraisal of the Howie code of practice in the light of these and other criticisms. 8. 10 The impact of the code on education and training in many hospitals will be harmful. Insufficient emphasis has been placed on the importance of general technique of the operator. In particular, the requirements for ventilation in post-mortem rooms are expensive and of doubtful and
benefit.
00161 Rome,
G. ROCCHI
Italy
Newsham General Liverpool L6 4AF
WILFRED FINE E. J. BURGESS
Hospital,
SAFETY IN THE POST-MORTEM ROOM
SIR,-The educational value to clinicians of post-mortem examination of selected cases is widely acknowledged and has been demonstrated by retrospective study.’ Implementation of the socalled Howie code ofpracticehas, in the Liverpool area, resulted in the recent closure of five post-mortem rooms; facilities remain at two hospitals only. In one fell swoop much of the education and interest for junior doctors has been removed. Few juniors will have the time to travel to the nearest hospital with an approved postmortem room, and the change will almost certainly drastically reduce the number of necropsies done in the area. Indiscriminate pressure for reform was generated by the outbreak of smallpox at -Birmingham University Medical School in 1978. The resulting inquiry3considered the safety arrangements for the few laboratories handling very hazardous (category A) pathogens. This was followed closely by publication of the Howie code,2which was concerned with pathogens of lesser hazard. What justifies the radical changes necessitated by the code? The risk of infection of necropsy work in Britain has received little study. There is an excess of tuberculosis among workers in medical laboratories, 4,5 necropsy technicians being most at risk5 the slight excess in mortality from tuberculosis noted earlier appears no longer to be present.Attack rates for hepatitis among laboratory staff fell dramatically after 1974 and remained low (1975-78) compared with previous years (1970-74).
although
Exceptional
was
an
unchanged
rate
among
biochemistry
technicians. No case of hepatitis has been recorded among necropsy staff since 1974.Thus, there seems to be no indication of need for additional catch-all safety precautions. The Howie code2lists specific precautions to be taken with necropsies on known or suspected cases of tuberculosis. There are some important anomalies in the requirements of the Howie code for post-mortem examinations. The code makes a firm rule that post-mortem rooms should have air extraction in the order of ten changes of air per hour and that there should be a downward draught of air away from the operator’s face. This requirement could be met by the installation of large ventilation fans (costing about L12 000) low down in the post-mortem room. However, generation of air movement at a high rate will not by itself protect an operator: increased turbulence may indeed promote the spread of pathogens. A properly engineered system providing laminar flow of air would be required, at very great expense: this is not considered in
POST-TRAUMATIC ATLANTO-OCCIPITAL DISLOCATION REVEALED BY SUDDEN CARDIORESPIRATORY ARREST
SIR,-Spinal injuries with osteodiscal and ligament lesions accompanied by neurological signs are seen less frequently in children than in adolescents or adults. This is especially true of cervical spine lesions, the muscles and ligaments being supple in
children. On April 15, 1982, a 4-year-old boy was hit by a car. He was rushed to the hospital, and admitted in shock. Peritoneal aspiration confirmed intra-abdominal bleeding. A laparotomy was done, leading to a splenectomy, and several hepatic sutures were inserted. Recovery from general anaesthesia was uneventful, and, in the absence of any other signs of trauma or neurological disorder, the endotracheal tube was removed. 4 h after extubation, he suddenly stopped breathing and efforts at resuscitation failed. A small subcutaneous cervical haematoma justified post-mortem radiological examination of the cervical spine, which revealed an occipital Cl dislocation (see figure). Safety in laboratories. Br Med J 1978; 1: 871-72. Safety in microbiology laboratories Lancet 1979; ii: 1308. 10. Bakhshi SS. Preventing infection in clinical laboratories. Br Med J 1980; 280: 1452. 1. Andrews LG, Jung KS. Spinal cord injuries in children in British Columbia. Paraplegia 8. Editorial.
9. Simmons NA.
1979; 17: 442-51. 2. Audic
B, Maury M. Secondary Paraplegia 1969; 7: 10-16.
vertebral deformities
in
childhood and adolescence.
-
the Howie code. Also, it seems inconsistent that complementary protection of the facial region from splashing or other.airborne contamination, by routine use of visors during post-mortem work, is not a requirement. The code directs only that visors be worn for cases of special risk (i.e., viral hepatitis, brucellosis, leptospirosis 1. Holler JW, De Morgan NP. A
retrospective study of 200 post-mortem examinations.J Med Educ 1970; 45: 168-70. 2. D.H.S.S. Working Party (chairman J. W. Howie). Code of practice for the prevention of infection m clinical laboratories and post-mortem rooms. London: H.M.S.O., 1978. 3. Shooter RA (chairman). Report of the investigation into the cause of the 1978 Birmingham smallpox occurrence. London: H.M.S.O., 1980 4. Reid DD. Incidence of tuberculosis among workers in medical laboratories Br Med J 1957; ii: 10-14. 5. Harrington JM, Shannon HS. Incidence of tuberculosis, hepatitis, brucellosis and shigellosis in British medical laboratory workers. Br MedJ 1976, i: 759-62. 6. Harrington JM, Shannon HS. Mortality study of pathologists and medical laboratory technicians Br Med J 1975; i: 329-32. 7. Grist NR. Hepatitis in clinical laboratories 1977-78. J Clin Pathol 1980; 33: 471-73.
Occipital
Cl dislocation in
4-year-old boy.
448 The stability of the atlanto-occipital articulation depends, in large part, on the alar and atlanto-occipital ligaments. This is an unstable articulation,3- especially in young children whose pliant ligaments permit a large degree of rotation.Accidents of this type usually result in immediate death from vertebral artery injury, but there may be severe neurological and respiratory disorders, with an 7 eventually fatal outcome. This case emphasises the need for X-rays of the cervical spine after all multiple injury accidents. If a thoracic or abdominal lesion requires immediate attention, endotracheal intubation should be done very carefully; in the case described, the time lapse between the injury and the respiratory arrest was probably due to spontaneous secondary mobilisation of the atlas. The fact that intubation provoked no neurological signs was probably due to contraction of the paravertebral muscles. The use of curare during anaesthesia probably relaxed these muscles enough to permit
apical
displacement. FRANCIS LESOIN MARYLINE BLONDEL PATRICK DHELLEMMES CHARLES E. THOMAS CHRISTIAN VIAUD MICHEL JOMIN
Neurosurgery Service B, Centre Hospitalier Régional, Lille 59037, France
ST DAVID’S
HOSPITAL, CARMARTHEN
SIR,-Your Parliamentary correspondent, writing (July 31, p. 282) about conditions at this hospital, states that this Health
Authority has been relieved temporarily of its responsibility in providing care for the mentally ill. This is not so. The Secretary of to accept one of the main recommendations of the Health Advisory Service report to establish a review group to monitor progress towards agreed objectives. The East Dyfed Health Authority remains responsible for the management of the services at the hospital.
State for Wales has decided
East Dyfed Health Authority, Starling Park House,
Carmarthen SA31 3HL
J. E. TAYLOR
EPIDEMIOLOGY OF DIABETES AMONG BANTUS
SIR,-Your editorial of June 26 was very valuable in showing the importance of epidemiology for the understanding of diseases in the tropics. Indeed, epidemiology forms the base for health service planning. The readiness of clinicians in helping to conduct epidemiological studies is important. However, because of the heavy workload in the tropics, especially in rural areas, many important studies will never be started. The solution might be cooperation between areas. I am trying to study the epidemiology of diabetes in Bantu populations. Apart from the information given in the studies summarised by Jackson,very little is known about this subject. A preliminary survey shows a prevalence of 1’56% among a hospital population of Wahayas, a Bantu people, whereas the prevalence among a Bantu population in South Africa is 0 -053%.2 I would appreciate more information from clinicians working in Bantu
MOSAICISM 48,XX, + 8, + 21/47,XX, + 21 IN DOWN SYNDROME AND RAPID PROGRESSION FROM PRELEUKAEMIA TO ACUTE LEUKAEMIA SIR,-Reports of patients with Down Syndrome who rapidly go into the acute phase of leukaemia after a long preleukemic phasel,2 or after a period of spontaneous remission3,4 raise the question of what factors may be related to such an unexpected course of the disease. Certain chromosome abnormalities may affect leukaemogenicity, and we report here bone-marrow and peripheralblood cell mosaicism 48,XX,+8, + 21/47,XX, + 21 in a patient in whom acute undifferentiated leukaemia developed after nearly 6 months of stable preleukaemia. She was first seen at 21 months of age with widespread purpura. Typical features of Down syndrome had been present from birth. No other clinical abnormalities were found. Repeated investigations during a 2-month observation in hospital showed a persistently low platelet count; absence of megakaryocytes, hypoplastic erythropoiesis and gradually diminishing granulopoiesis in the bone marrow; and a progressive increase in proportion of blast cells to 33% in the peripheral blood and to 3-5—32-5% in the bone marrow. Morphological and cytochemical examination of the blast cells suggested an undifferentiated cell proliferation. Follow-up over the next four months, without the patient being on specific therapy, showed stable blood and bone marrow blast numbers. A month later the patient died shortly after admission to the hospital with symptoms suggesting central nervous system haemorrhage. There was
hepatosplenomegaly, anaemia, thrombocytopenia, leukocytosis (25 400 white celFs/1), and up to 55% blast cells in the peripheral blood. Chromosome
analysis of bone-marrow cells cultured without phytohaemagglutinin (PHA) for 24 h revealed trisomy 8 and 21 in each of the analysed cells (12 metaphase cells) at the start of the observation
and mosaicism 48,XX,+8,+21/47,XX,+21 (6/4 metaphase cells) five months later. Peripheral blood cells cultured
for 72 h with PHA first showed trisomy 8 in only 4
out
of 70
analysed cells; however, at the second examination trisomy 8 noticed in 37 out of 64 analysed metaphases (figure).
was
Y, Rowley JD, Variakojis D, Chilcote RR, Moohr JW, Patel D. Chromosome abnormalities in Down’s syndrome patients with acute leukemia. Blood 1981; 58: 459. 2. Sikand GS, Taysi K, Strandjord SE, Griffith R, Viotti TJ. Trisomy 21 in bone marrow cells of patient with a prolonged preleukemic phase. Med Ped Oncol 1980, 8: 237 3. Honda F, Punnett HH, Charney E, Miller G, Thiede HA. Serial cytogenetic and hematologic studies on a mongol with trisomy 21 and acute congenital leukemia J Pediatr 1964, 65: 880. 4. Rosner F, Lee SL. Down’s syndrome and acute leukemia: Myeloblastic or lymphoblastic? Report of forty-three cases and review of the literature. AmJ Med 1972, 53: 203. 5. Nowell PC. Preleukemias. Hum Pathol 1981; 12: 522 1. Kaneko
areas.
Ndolage Hospital, PO Box 34, Kamachumu, Tanzania
BO AHRÉN
Fielding JW, Burstein AA, Frankel VH. The nuchal ligament. Spine 1976; 1: 3-6. Jirout J. The dynamic dependence of the lower cervical vertebrae on the atlantooccipital joints. Neuroradiology 1974, 7: 249-51. 5 Johnson RM, Crelin ES, Withe A, Panjabi MM. Some new observations on the functional anatomy of the lower cervical spine. Clin Orthop 1975; 111: 192-95. 6. White AA, Panjabi MM, Brand RA. A system for defining position and motion of the human body parts Med Biol Eng 1975; 13: 261-68. 7. Evarts MC. Traumatic occipito atantol dislocation: Report of a case with survival. J Bone Joint Surg 1970; 52A: 1653-56. 1. Jackson WPU. Epidemiology of diabetes in South Africa. In: Levine R, Luft R, eds. Advances in metabolic disorders, vol. 9. New York: Academic Press, 1978: 111-46. 2. Cosnett JE. Illness among Natal Indians: A survey of hospital admissions. S Afr Med J 3. 4.
1957; 31: 1109-15.
Karyotype showing cell-line of 48,XX, + 8, + 21
banding).
from the blood
(RHG