- Email: [email protected]
RAPID LATEX-SCREENING TEST FOR URINE F.D.P.
1057
regards the prescription of analgesics, including those recognised as potentially addictive-the qualifying adjective is important. At the 1972 meeting of the World Federation, the chairman of the medical advisory committee, Dr Shelby Dietrich, of the Los Angeles Orthopedic Hospital Center, expressed the consensus and subsequently wrote: " Among our hundreds of hemophilic patients with thousands of hospital days, we have not created a single problem of drug abuse by using narcotics in the hospital." She also stated her belief that " all physicians should be aware of the dangers of creating drug dependence, but to withhold pain relief because of the misconception that drug addiction will be rapidly achieved is a serious mistake ".2 Unwarranted insinuations that a particular haemophiliac is addicted or dependent are naturally resented by the suffering patient, and emotional damage follows. Furthermore, such an attitude on the part of as
of nurses may lead to delay in treatment or even to mistaken or overlooked diagnosis, the patient’s life sometimes being placed in jeopardy, all of which I have doctors
seen
or
of implantation endometriosis which sometimes becomes a clinical problem many years after the original operation. John Radcliffe Hospital, Headington, Oxford.
JOHN STALLWORTHY.
RAPID LATEX-SCREENING TEST FOR
URINE F.D.P.
SIR,-The paper by Dr Hulme and Mrs Pitcher (Jan. 6, 6) and the letters of Dr Clarkson (Jan. 13, p. 109) and of Dr Cash and his co-workers (Jan. 20, p. 153) prompt us to report briefly our experience with the rapid latextest Well come screening (’ Thrombo-Wellcotest ’, for the of Reagents) semi-quantitation urinary fibrinogenp.
related material. COMPARISON OF RESULTS WITH THE THROMBO-WELLCOTEST AND THE T.R.C.H.1.1. IN 30 URINE SAMPLES BEFORE AND AFTER CONCENTRATION
happen.
On the other hand, I would say to Mr Harvey that we simply do not have the perfect drug and that what is the best available varies from patient to patient and from time to time. Myself, I generally prescribe as background a relaxant, such as diazepam or promazine, together with specific analgesics, such as acetaminophen (paracetamol), pentazocine, codeine, or meperidine (pethidine), in ascending order. I very rarely use morphine. In a group of late adolescents and of adults which has grown since 1954 to 49 active cases, I have been faced with only 2 episodes of true addiction, 1 with codeine and 1 with pethidine; both were easily recognised and managed without difficulty by immediate " cold-turkey " withdrawal. Instances of drift towards drug dependence are more common and their evaluation indicates the importance, nay, the necessity of continuing contact between patients and physicians familiar both with the disease and with the individual patients. Once the drift is appreciated, superficial psychotherapy coupled, if need be, with drug substitution usually permits prompt correction. In summary, far more harm, physical and mental, comes to hxmophiliacs by inadequate relief of pain and by insinuations of addiction than by what is exceptional, the actual creation of addiction by liberal usage of analgesics. St. Mary’s Hospital, 3830 Lacombe Avenue, Montreal 249.
CECIL HARRIS.
ABDOMINAL HYSTEROTOMY
SiR,—Dr Higginbottom (April 28, p. 937) is to be congratulated on the immediate results of his 242 hysIn his next series, if he continues with this technique, he might find it possible to reduce the incidence of thrombosis and embolism by the intravenous infusion of dextran 70 during the operation. More important, however, was the fact that 4 (1’6%) patients developed scar endometriosis several months after operation. As his series extends over only four years, time
terotomies.
has yet to show how many others will present at a later date with this complication. It was because our Swedish colleagues, from an extensive experience of hysterotomy by both the abdominal and the vaginal route, found that endometriosis became a problem that some of them ceased using this operation and experimented with other techniques such as intra-amniotic injections. While agreeing with all that Dr Higginbottom says in his final paragraph concerning the immediate advantages of the operation, we have none the less abandoned it because
T .R.C.H.I.I. = tanned-red-cell haemagglutination inhibition immunoassay.
A group of 30 urine samples from transplanted patients (see table) were tested with both the tanned-red-cell heemagglutination inhibition immunoassay1 and the
Thrombo-Wellcotest
Dietrich, S. L. Personal communication, 1972.
and
after
concentration
unreliable results with the Thrombo-Wellcotest in unconcentrated urines tested without special precautions. However, in contrast to the report of Dr Cash and his colleagues, no false positivity was found in the same samples tested after concentration: probably, non-specific latex agglutinins or whatever causes the false positivity in fresh urines is adsorbed by the dialysis membrane during concentration. We think, therefore, that the Thrombo1.
2.
before
(dialysis against polyethylene glycol during 48 hours at 4°C). Like other workers, we have found completely
Merskey, C., Lalezari, P., Johnson, A. J. Proc. Soc. exp. Biol. Med. 1969, 131, 871.
1058 Wellcotest reliably measures fibrinogen-related material in urine concentrates. Laboratory of Blood Coagulation, NICOLA SEMERARO Medical Research University of
Department, Leuven,
Leuven, Belgium.
MARIA BENEDETTA DONATI
JOZEF VERMYLEN.
The trial did not, however, establish the efficacy of antiseptic sprays in appendicectomies that were neither drained nor enlarged. Practically, therefore, iodine sprays were justified only in about one-fifth of all the appendicectomies in that series. Routine spraying of every wound, as recommended by the authors, was superfluous or ineffective in 80% of all these operations. The effects of two factors important enough to be mentioned in the report were not analysed. The first was the relative frequency of wound infection among the 15 surgeons. Did their rate vary as much within the surgical staff as between various hospitals (see table) ? The second factor was the influence of systemic antibiotics on the incidence of wound infection in the three groups. In view of the questions which have been raised regarding 8 consequences of placing drains into the peritoneal cavity, after of removal the efficacy of iodine spraying perforated appendices without drainage should be evaluated. The results of such a trial might help to clarify the effect of drains on the spread of infections; and they would be appreciated by surgeons who do not resort to drainage. Departments of Surgery
U.S.A. 1. 2. 3.
4.
5. 6. 7. 8.
MOHAN C. AIRAN H. D. LEVINE JEAN SICÉ.
Gilmore, O. J. A., Martin, T. D. M., Fletcher, B. N. Lancet, Feb. 3, 1973, p. 220. Feinstein, A. R. Clin. Pharmac. Ther. 1972, 13, 755. Magarey, C. J., Chant, A. D. B., Rickford, C. R. K., Magarey, J. R. Lancet, 1971, ii, 179. Bird, G. G., Bunch, G. A., Croft, C. B., Hoffmann, D. C., Humphrey, C. S., Rhind, J. R., Rosenberg, I. L., Whittaker, M., Wilkinson, A. R., Hall, R. Br. J. Surg. 1971, 58, 447. Crosfill, M., Hall, R., London, D. ibid. 1969, 56, 906. Mountain, J. C., Seal, P. V. Br. J. clin. Pract. 1970, 24, 111. Rickett, J. W. S., Jackson, B. T. Br. med. J. 1969, iv, 206. Lancet, 1971, ii, 195.
FREQUENCY
SIR,-The letters in your issue of April 28 (p. 944) request information about the numbers involved in trials in the different schools. They are: Females: 40.
PREVENTION OF WOUND INFECTION SiR,—The report of Mr Gilmore and his colleagues1 illustrates the difficulty of classifying the complex factors which can affect the conclusions of controlled trials.2They showed that two sprayings with a povidone-iodine powder could prevent 62 % of the wound infections which would have occurred in 65% of the appendicectomies involving drainage or wound enlargement (X2= 7-03, p < 0 05). This finding is all the more important because the 32 wounds which were drained or enlarged accounted for 21 of the 23 infections observed in patients who had not received iodine sprays:
and Pharmacology, University of Health Sciences, Chicago, Illinois 60612,
VITAMIN C AND COLDS
MG placebo 43,
our
200 mg. 51; CG 200 mg. 47, 500 mg.
Males: MB placebo 69, 200 mg. 67; MO 200 mg. 52,500 mg. 52.
Definition of Toxic (T), Catarrhal (C), and Whole (W) cold complexes is based on data from approximately 10,000 symptom-pair correlations in each treatment group. In our preliminary communication we deliberately drew attention to the important points in the design and interpretation of studies on the common cold and vitamin C, so that any studies being planned for investigation of next winter’s colds could be taken into account by other investigators before the appearance of our full reports. We pointed out that investigation of the effect of exogenous vitamin C on the symptoms of the common cold cannot be examined in the same fashion as any other foreign chemotherapeutic agent because ascorbic acid is normally present in the tissues in continually varying concentrations. This affects the design and conclusions drawn from such trials. In our papers we have drawn attention to the difference between the prophylactic and therapeutic effects of vitamin C on cold symptoms. Its prophylactic action occurs when its administration is continued daily over a prolonged, defined period, and it is measured in terms of change of cold incidence, in comparison with a placebo. The therapeutic action is measured in terms of cold severity and duration. Both prophylactic and therapeutic effects are assessed in terms of total symptom intensity. Our preliminary communication makes it clear that neither dose of vitamin C affected Toxic cold (T-cold) incidence, but that these doses did have a significant effect on severity and total intensity of Catarrhal colds (C-colds) and on Whole colds (W-colds) in girls. When investigating the action of vitamin C on cold symptoms, it is necessary to define whether prophylactic or therapeutic effects of vitamin C are being examined in terms of the variables which are being measured. In our preliminary communication we further showed that the relative frequencies of the different types of colds were beneficially, but differently, affected by administration of vitamin C to the two sexes. The relevance to our paper of the table in the letter by Dr Kinlen and Mr Peto can be discovered only by tedious study, since their terminology was confused and incorrect by our definitions, and the column and line headings in their table bear no relation at all to the data we presented. In our preliminary communication we drew particular attention to the difference between the sexes in their ascorbic-acid metabolism, and consequent differences in the effect of vitamin C on their cold symptoms. Dr Kinlen and Mr Peto chose to ignore this when they wrote " we feel that the authors were unwise to draw any conclusions from these 4 mild significant tests ". These positive tests occurred only in females. No statistically significant results
OF WOUND INFECTION AFTER APPENDICECTOMY IN RECENT RANDOMISED CONTROL GROUPS OF PROSPECTIVE TRIALS PERFORMED IN GENERAL HOSPITALS
regards the prescription of analgesics, including those recognised as potentially addictive-the qualifying adjective is important. At the 1972 meeting of the World Federation, the chairman of the medical advisory committee, Dr Shelby Dietrich, of the Los Angeles Orthopedic Hospital Center, expressed the consensus and subsequently wrote: " Among our hundreds of hemophilic patients with thousands of hospital days, we have not created a single problem of drug abuse by using narcotics in the hospital." She also stated her belief that " all physicians should be aware of the dangers of creating drug dependence, but to withhold pain relief because of the misconception that drug addiction will be rapidly achieved is a serious mistake ".2 Unwarranted insinuations that a particular haemophiliac is addicted or dependent are naturally resented by the suffering patient, and emotional damage follows. Furthermore, such an attitude on the part of as
of nurses may lead to delay in treatment or even to mistaken or overlooked diagnosis, the patient’s life sometimes being placed in jeopardy, all of which I have doctors
seen
or
of implantation endometriosis which sometimes becomes a clinical problem many years after the original operation. John Radcliffe Hospital, Headington, Oxford.
JOHN STALLWORTHY.
RAPID LATEX-SCREENING TEST FOR
URINE F.D.P.
SIR,-The paper by Dr Hulme and Mrs Pitcher (Jan. 6, 6) and the letters of Dr Clarkson (Jan. 13, p. 109) and of Dr Cash and his co-workers (Jan. 20, p. 153) prompt us to report briefly our experience with the rapid latextest Well come screening (’ Thrombo-Wellcotest ’, for the of Reagents) semi-quantitation urinary fibrinogenp.
related material. COMPARISON OF RESULTS WITH THE THROMBO-WELLCOTEST AND THE T.R.C.H.1.1. IN 30 URINE SAMPLES BEFORE AND AFTER CONCENTRATION
happen.
On the other hand, I would say to Mr Harvey that we simply do not have the perfect drug and that what is the best available varies from patient to patient and from time to time. Myself, I generally prescribe as background a relaxant, such as diazepam or promazine, together with specific analgesics, such as acetaminophen (paracetamol), pentazocine, codeine, or meperidine (pethidine), in ascending order. I very rarely use morphine. In a group of late adolescents and of adults which has grown since 1954 to 49 active cases, I have been faced with only 2 episodes of true addiction, 1 with codeine and 1 with pethidine; both were easily recognised and managed without difficulty by immediate " cold-turkey " withdrawal. Instances of drift towards drug dependence are more common and their evaluation indicates the importance, nay, the necessity of continuing contact between patients and physicians familiar both with the disease and with the individual patients. Once the drift is appreciated, superficial psychotherapy coupled, if need be, with drug substitution usually permits prompt correction. In summary, far more harm, physical and mental, comes to hxmophiliacs by inadequate relief of pain and by insinuations of addiction than by what is exceptional, the actual creation of addiction by liberal usage of analgesics. St. Mary’s Hospital, 3830 Lacombe Avenue, Montreal 249.
CECIL HARRIS.
ABDOMINAL HYSTEROTOMY
SiR,—Dr Higginbottom (April 28, p. 937) is to be congratulated on the immediate results of his 242 hysIn his next series, if he continues with this technique, he might find it possible to reduce the incidence of thrombosis and embolism by the intravenous infusion of dextran 70 during the operation. More important, however, was the fact that 4 (1’6%) patients developed scar endometriosis several months after operation. As his series extends over only four years, time
terotomies.
has yet to show how many others will present at a later date with this complication. It was because our Swedish colleagues, from an extensive experience of hysterotomy by both the abdominal and the vaginal route, found that endometriosis became a problem that some of them ceased using this operation and experimented with other techniques such as intra-amniotic injections. While agreeing with all that Dr Higginbottom says in his final paragraph concerning the immediate advantages of the operation, we have none the less abandoned it because
T .R.C.H.I.I. = tanned-red-cell haemagglutination inhibition immunoassay.
A group of 30 urine samples from transplanted patients (see table) were tested with both the tanned-red-cell heemagglutination inhibition immunoassay1 and the
Thrombo-Wellcotest
Dietrich, S. L. Personal communication, 1972.
and
after
concentration
unreliable results with the Thrombo-Wellcotest in unconcentrated urines tested without special precautions. However, in contrast to the report of Dr Cash and his colleagues, no false positivity was found in the same samples tested after concentration: probably, non-specific latex agglutinins or whatever causes the false positivity in fresh urines is adsorbed by the dialysis membrane during concentration. We think, therefore, that the Thrombo1.
2.
before
(dialysis against polyethylene glycol during 48 hours at 4°C). Like other workers, we have found completely
Merskey, C., Lalezari, P., Johnson, A. J. Proc. Soc. exp. Biol. Med. 1969, 131, 871.
1058 Wellcotest reliably measures fibrinogen-related material in urine concentrates. Laboratory of Blood Coagulation, NICOLA SEMERARO Medical Research University of
Department, Leuven,
Leuven, Belgium.
MARIA BENEDETTA DONATI
JOZEF VERMYLEN.
The trial did not, however, establish the efficacy of antiseptic sprays in appendicectomies that were neither drained nor enlarged. Practically, therefore, iodine sprays were justified only in about one-fifth of all the appendicectomies in that series. Routine spraying of every wound, as recommended by the authors, was superfluous or ineffective in 80% of all these operations. The effects of two factors important enough to be mentioned in the report were not analysed. The first was the relative frequency of wound infection among the 15 surgeons. Did their rate vary as much within the surgical staff as between various hospitals (see table) ? The second factor was the influence of systemic antibiotics on the incidence of wound infection in the three groups. In view of the questions which have been raised regarding 8 consequences of placing drains into the peritoneal cavity, after of removal the efficacy of iodine spraying perforated appendices without drainage should be evaluated. The results of such a trial might help to clarify the effect of drains on the spread of infections; and they would be appreciated by surgeons who do not resort to drainage. Departments of Surgery
U.S.A. 1. 2. 3.
4.
5. 6. 7. 8.
MOHAN C. AIRAN H. D. LEVINE JEAN SICÉ.
Gilmore, O. J. A., Martin, T. D. M., Fletcher, B. N. Lancet, Feb. 3, 1973, p. 220. Feinstein, A. R. Clin. Pharmac. Ther. 1972, 13, 755. Magarey, C. J., Chant, A. D. B., Rickford, C. R. K., Magarey, J. R. Lancet, 1971, ii, 179. Bird, G. G., Bunch, G. A., Croft, C. B., Hoffmann, D. C., Humphrey, C. S., Rhind, J. R., Rosenberg, I. L., Whittaker, M., Wilkinson, A. R., Hall, R. Br. J. Surg. 1971, 58, 447. Crosfill, M., Hall, R., London, D. ibid. 1969, 56, 906. Mountain, J. C., Seal, P. V. Br. J. clin. Pract. 1970, 24, 111. Rickett, J. W. S., Jackson, B. T. Br. med. J. 1969, iv, 206. Lancet, 1971, ii, 195.
FREQUENCY
SIR,-The letters in your issue of April 28 (p. 944) request information about the numbers involved in trials in the different schools. They are: Females: 40.
PREVENTION OF WOUND INFECTION SiR,—The report of Mr Gilmore and his colleagues1 illustrates the difficulty of classifying the complex factors which can affect the conclusions of controlled trials.2They showed that two sprayings with a povidone-iodine powder could prevent 62 % of the wound infections which would have occurred in 65% of the appendicectomies involving drainage or wound enlargement (X2= 7-03, p < 0 05). This finding is all the more important because the 32 wounds which were drained or enlarged accounted for 21 of the 23 infections observed in patients who had not received iodine sprays:
and Pharmacology, University of Health Sciences, Chicago, Illinois 60612,
VITAMIN C AND COLDS
MG placebo 43,
our
200 mg. 51; CG 200 mg. 47, 500 mg.
Males: MB placebo 69, 200 mg. 67; MO 200 mg. 52,500 mg. 52.
Definition of Toxic (T), Catarrhal (C), and Whole (W) cold complexes is based on data from approximately 10,000 symptom-pair correlations in each treatment group. In our preliminary communication we deliberately drew attention to the important points in the design and interpretation of studies on the common cold and vitamin C, so that any studies being planned for investigation of next winter’s colds could be taken into account by other investigators before the appearance of our full reports. We pointed out that investigation of the effect of exogenous vitamin C on the symptoms of the common cold cannot be examined in the same fashion as any other foreign chemotherapeutic agent because ascorbic acid is normally present in the tissues in continually varying concentrations. This affects the design and conclusions drawn from such trials. In our papers we have drawn attention to the difference between the prophylactic and therapeutic effects of vitamin C on cold symptoms. Its prophylactic action occurs when its administration is continued daily over a prolonged, defined period, and it is measured in terms of change of cold incidence, in comparison with a placebo. The therapeutic action is measured in terms of cold severity and duration. Both prophylactic and therapeutic effects are assessed in terms of total symptom intensity. Our preliminary communication makes it clear that neither dose of vitamin C affected Toxic cold (T-cold) incidence, but that these doses did have a significant effect on severity and total intensity of Catarrhal colds (C-colds) and on Whole colds (W-colds) in girls. When investigating the action of vitamin C on cold symptoms, it is necessary to define whether prophylactic or therapeutic effects of vitamin C are being examined in terms of the variables which are being measured. In our preliminary communication we further showed that the relative frequencies of the different types of colds were beneficially, but differently, affected by administration of vitamin C to the two sexes. The relevance to our paper of the table in the letter by Dr Kinlen and Mr Peto can be discovered only by tedious study, since their terminology was confused and incorrect by our definitions, and the column and line headings in their table bear no relation at all to the data we presented. In our preliminary communication we drew particular attention to the difference between the sexes in their ascorbic-acid metabolism, and consequent differences in the effect of vitamin C on their cold symptoms. Dr Kinlen and Mr Peto chose to ignore this when they wrote " we feel that the authors were unwise to draw any conclusions from these 4 mild significant tests ". These positive tests occurred only in females. No statistically significant results
OF WOUND INFECTION AFTER APPENDICECTOMY IN RECENT RANDOMISED CONTROL GROUPS OF PROSPECTIVE TRIALS PERFORMED IN GENERAL HOSPITALS