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RECOVERY AFTER PROLONGED FLAT EEG IN HEPATIC COMA
1379 BRAIN DEATH AND THE CORNEAL REFLEX
SIR,-In investigating the possibility of brainstem death neurologists test for the presence of several reflexes. One diagnostic test involves touching the cornea-typically with a wisp of cottonwool-to see if the patient blinks (corneal reflex). Corneal sensitivity is usually quantified using the Cochet-Bonnet aesthesiometer. The corneal touch threshold measured with this in-
eyelids have been closed. The maximum duration of lid closure was 60 h, after which the threshold had increased by 300%. The rate of elevation of threshold at this time was in the region of 100% every 40 h, and was declining. We suggest that caution should be used in interpreting the absence of the corneal reflex in people who have been unconscious for several days, and that more attention should be given to the other reflexes tested. These will not be affected in the same fashion. This caution is especially important in Black people, who normally have 2 a much less sensitive cornea than blue-eyed people.2 In people who have only been unconscious for a short time (15 h or less) corneal sensitivity is not likely to have been grossly depressed by lid closure, and so the corneal reflex test can be used with strument increases when the
After eight plasma exchanges and four charcoal haemoperfusions, the patient awoke from a coma of 7 days’ duration. During the coma, her EEG was recorded every 3 or 4 h on an eight-channel mini-type recorder. Following the e and/or 6 waves phase, the EEG became isoelectric on the 4th day of unconsciousness (Figure, a). This flat pattern continued for over 62 h. Immediately after the sixth plasma exchange, the EEG showed moderate amount of a and e (5-7 Hz) range waves (b), and the patient woke up about 40 h after the appearance of EEG activity. The patient recovered completely from the hepatitis, with no neuropsychological sequelae, in about 50 days. This case illustrates that, in encephalopathy due to acute hepatic failure, a prolonged flat EEG does not necessarily mean irreversibility of conciousness, and that, even if the EEG becomes flat, efforts to save the patient should be continued as long as some vital signs exist and no other serious complications appear. Department of Medicine, Division of Blood Transfusion, and Department of Infectious Disease, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
SATOSHI TANAKA YUZO YANO HISAHIRO SAKAMOTO AKIRA OHBAYASHI
equanimity. Department of Optometry, U.W.I.S.T,
D. J. O’LEARY M. MILLODOT
Cardiff CF1 3AE
TOPICAL ASPIRIN FOR WASP STINGS
SIR,-Your editorial ofNov. 1, 1980, is timely enough for those of where the introduced European wasp is now crawling out of hibernation to plague us at picnics. The wheal-and-flare reaction of immediate hypersensitivity and the subsequent itching and irritation caused by insect stings can be considerably reduced by the use of topically applied soluble aspirin. After moistening the area of the sting a coating of aspirin is applied by rubbing a soluble aspirin onto the area. When the initial relief (possibly from evaporative cooling) has passed, the aspirin powder can be moistened again and the effect will persist. It seems likely that topical absorption of soluble aspirin is sufficient to dampen the inflammatory reaction and provide local analgesia. This simple treatment usually helps in calming fright-
us
RECOVERY AFTER PROLONGED FLAT EEG IN HEPATIC COMA
SIR,-A 26-year-old nurse acquired acute hepatitis B on Feb. 17, 1980, 19 weeks after an accidental puncture with a needle, despite
having an injection of anti-HBs antibody human immunoglobulin soon after exposure. 4 days after the beginning of the illness, she became drowsy and rapidly fell into a deep coma. At that time, she had severe hepatic dysfunction: bilirubin 9-22 mg/dl, glutamic pyruvic transaminase 3240 IU/1, prothrombin time 36 - 8 s (control 12 4 s), urea nitrogen 1 mg/dl, and ammonia 314 g/dl.
Millodot M, O’Leary DJ. Loss of corneal sensitivity with eyelid closure in humans Exp Eye Res 1979, 29: 417-21. 2. Millodot M. Do blue eyed people have more sensitive corneas than brown eyed people? 1.
Nature 1975; 255: 151-52.
ened children and does not have the side effects of antihistamines. I do not suggest it would be sufficient on its own for people with severe allergy, but it may provide effective treatment for those who have considerable local reactions to hymenoptera and other insects. Department of Chemical Pathology, Royal Hobart Hospital, Hobart, Tasmania 7001, Australia
RICHARD J. VON WITT
(+ )-CYANIDANOL-3 IN ACUTE VIRAL HEPATITIS SIR,-Blum and colleagues I described the use of(+)-cyanidanol-33 in acute viral hepatitis. In a randomised double-blind study they recorded accelerated disappearance of hepatitis-B surface antigen (HBsAg) from the blood in 51 patients who received the drug (2 g
daily) compared with 49 receiving placebo tablets. They also noted lowered serum-bilirubin levels, and relief of symptoms such as anorexia, nausea, and pruritus. The drug was well tolerated. We have investigated the effect of this drug during a 2-month treatment period. 50 consecutive adults with acute viral hepatitis were treated at random with (+)-cyanidanol-3 (3 g daily) or placebo. Both groups were comparable for age, weight, and number of days between appearance of first symptoms and beginning of treatment. They all had a viral hepatitis diagnosed on history, clinical examinatests between 5 and twelve weeks before inclusion in the study, when they had persistent symptoms or abnormal laboratory results associated with relapse or prolonged hepatitis. 25 of them-12 belonging to the (+)-cyanidanol-3 group and 13 to the placebo group-were HBsAg-positive by radioimmunoassay (Ausria II, Abbott) at that time; and a further assay was recorded at the end of the treatment period. The results appear in the accompanying table.
tion, and liver-function
EEG recorded
at a
sensitivity of 10 /lV/mm in intensive
care
unit.
(a) Although some slight artifacts could not be avoided, the same isoelectric activity was also shown at a sensitivity of 5 V/mm. This flat pattern was noted in
all EEG records from I A.M.
(b) EEG at 7 P.M. activity.
EEG
on
on
Feb. 24
to
3 P.M.
Feb. 26, showing mixed
on
Feb. 26.
frequency (o
and e
waves)
1 Blum AL, Berthet P, Doelle W, Goebell H, Kortüm K, Pelloni S, Peter P, Poulsen H, Strohmeyer G, Tygstrup N. Lancet, 1977; ii: 1153-55.
SIR,-In investigating the possibility of brainstem death neurologists test for the presence of several reflexes. One diagnostic test involves touching the cornea-typically with a wisp of cottonwool-to see if the patient blinks (corneal reflex). Corneal sensitivity is usually quantified using the Cochet-Bonnet aesthesiometer. The corneal touch threshold measured with this in-
eyelids have been closed. The maximum duration of lid closure was 60 h, after which the threshold had increased by 300%. The rate of elevation of threshold at this time was in the region of 100% every 40 h, and was declining. We suggest that caution should be used in interpreting the absence of the corneal reflex in people who have been unconscious for several days, and that more attention should be given to the other reflexes tested. These will not be affected in the same fashion. This caution is especially important in Black people, who normally have 2 a much less sensitive cornea than blue-eyed people.2 In people who have only been unconscious for a short time (15 h or less) corneal sensitivity is not likely to have been grossly depressed by lid closure, and so the corneal reflex test can be used with strument increases when the
After eight plasma exchanges and four charcoal haemoperfusions, the patient awoke from a coma of 7 days’ duration. During the coma, her EEG was recorded every 3 or 4 h on an eight-channel mini-type recorder. Following the e and/or 6 waves phase, the EEG became isoelectric on the 4th day of unconsciousness (Figure, a). This flat pattern continued for over 62 h. Immediately after the sixth plasma exchange, the EEG showed moderate amount of a and e (5-7 Hz) range waves (b), and the patient woke up about 40 h after the appearance of EEG activity. The patient recovered completely from the hepatitis, with no neuropsychological sequelae, in about 50 days. This case illustrates that, in encephalopathy due to acute hepatic failure, a prolonged flat EEG does not necessarily mean irreversibility of conciousness, and that, even if the EEG becomes flat, efforts to save the patient should be continued as long as some vital signs exist and no other serious complications appear. Department of Medicine, Division of Blood Transfusion, and Department of Infectious Disease, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
SATOSHI TANAKA YUZO YANO HISAHIRO SAKAMOTO AKIRA OHBAYASHI
equanimity. Department of Optometry, U.W.I.S.T,
D. J. O’LEARY M. MILLODOT
Cardiff CF1 3AE
TOPICAL ASPIRIN FOR WASP STINGS
SIR,-Your editorial ofNov. 1, 1980, is timely enough for those of where the introduced European wasp is now crawling out of hibernation to plague us at picnics. The wheal-and-flare reaction of immediate hypersensitivity and the subsequent itching and irritation caused by insect stings can be considerably reduced by the use of topically applied soluble aspirin. After moistening the area of the sting a coating of aspirin is applied by rubbing a soluble aspirin onto the area. When the initial relief (possibly from evaporative cooling) has passed, the aspirin powder can be moistened again and the effect will persist. It seems likely that topical absorption of soluble aspirin is sufficient to dampen the inflammatory reaction and provide local analgesia. This simple treatment usually helps in calming fright-
us
RECOVERY AFTER PROLONGED FLAT EEG IN HEPATIC COMA
SIR,-A 26-year-old nurse acquired acute hepatitis B on Feb. 17, 1980, 19 weeks after an accidental puncture with a needle, despite
having an injection of anti-HBs antibody human immunoglobulin soon after exposure. 4 days after the beginning of the illness, she became drowsy and rapidly fell into a deep coma. At that time, she had severe hepatic dysfunction: bilirubin 9-22 mg/dl, glutamic pyruvic transaminase 3240 IU/1, prothrombin time 36 - 8 s (control 12 4 s), urea nitrogen 1 mg/dl, and ammonia 314 g/dl.
Millodot M, O’Leary DJ. Loss of corneal sensitivity with eyelid closure in humans Exp Eye Res 1979, 29: 417-21. 2. Millodot M. Do blue eyed people have more sensitive corneas than brown eyed people? 1.
Nature 1975; 255: 151-52.
ened children and does not have the side effects of antihistamines. I do not suggest it would be sufficient on its own for people with severe allergy, but it may provide effective treatment for those who have considerable local reactions to hymenoptera and other insects. Department of Chemical Pathology, Royal Hobart Hospital, Hobart, Tasmania 7001, Australia
RICHARD J. VON WITT
(+ )-CYANIDANOL-3 IN ACUTE VIRAL HEPATITIS SIR,-Blum and colleagues I described the use of(+)-cyanidanol-33 in acute viral hepatitis. In a randomised double-blind study they recorded accelerated disappearance of hepatitis-B surface antigen (HBsAg) from the blood in 51 patients who received the drug (2 g
daily) compared with 49 receiving placebo tablets. They also noted lowered serum-bilirubin levels, and relief of symptoms such as anorexia, nausea, and pruritus. The drug was well tolerated. We have investigated the effect of this drug during a 2-month treatment period. 50 consecutive adults with acute viral hepatitis were treated at random with (+)-cyanidanol-3 (3 g daily) or placebo. Both groups were comparable for age, weight, and number of days between appearance of first symptoms and beginning of treatment. They all had a viral hepatitis diagnosed on history, clinical examinatests between 5 and twelve weeks before inclusion in the study, when they had persistent symptoms or abnormal laboratory results associated with relapse or prolonged hepatitis. 25 of them-12 belonging to the (+)-cyanidanol-3 group and 13 to the placebo group-were HBsAg-positive by radioimmunoassay (Ausria II, Abbott) at that time; and a further assay was recorded at the end of the treatment period. The results appear in the accompanying table.
tion, and liver-function
EEG recorded
at a
sensitivity of 10 /lV/mm in intensive
care
unit.
(a) Although some slight artifacts could not be avoided, the same isoelectric activity was also shown at a sensitivity of 5 V/mm. This flat pattern was noted in
all EEG records from I A.M.
(b) EEG at 7 P.M. activity.
EEG
on
on
Feb. 24
to
3 P.M.
Feb. 26, showing mixed
on
Feb. 26.
frequency (o
and e
waves)
1 Blum AL, Berthet P, Doelle W, Goebell H, Kortüm K, Pelloni S, Peter P, Poulsen H, Strohmeyer G, Tygstrup N. Lancet, 1977; ii: 1153-55.