- Email: [email protected]
RECURRENCES OF TEGUMENTARY LEISHMANIASIS
557 There are over 430 fellows and more than 200 student members. Candidates for fellowship are required to complete written and oral examinations and to study subjects such as administration,
management, finance, law, biostatistics, psychosocial medicine, and
personnel
epidemiology and
advances in medicine. These subjects are offered by the College or by approved institutes. 38% of the general managers of Australia’s large, general teaching hospitals are medically qualified.The RACMA has provided a professional focus for medical administrators and the extensive training programme necessary to enable them to fulfil their role within the health care system. The increasing complexity of the health services area has highlighted the importance of the skilled and innovative manager. Physicians are in a unique position to contribute to this management. A professional body, such as the RACMA, with its emphasis on education, professional development, and peer review is ideally placed to provide those managers who will uphold the professional integrity of the physician and their emphasis on patient care. Alfred
Hospital,
Prahran, Victoria, Australia
recent
TREVOR J. WOOD SUSAN E. THOMAS
ADVERTISING DOCTORS’ SERVICES
SIR,—Your July 27 editorial on advertising by general practitioners draws attention to the relation between good advertising and such determinants of good practice as information for and education of patients and the stimulation of "stagnant practitioners". Unfortunately, the "interests of established doctors" are well taken care of in other countries too. The Italian Federation of Local Medical Councils (roughly equivalent to the General Medical Council in the UK) has lately succeeded in pushing a law on medical advertising through Parliament. The main points of this new law are: (1) Advertising is allowed only through nameplates affixed to the doctor’s door and through entries in telephone directories. (2) Advertisements may carry only the doctor’s name, address, telephone number, surgery times, and professional qualifications. (3) Acceptable professional qualifications are only those awarded by Italian universities and those officially recognised by the Italian Government. (4) A doctor’s special interest in a particular branch of medicine may be mentioned only if he or she has completed a given number of years in the relevant hospital department. Among the consequences of this law are that older and wellestablished practitioners may continue to dazzle patients by using such obsolete and meaningless titles as "professor", while younger doctors cannot encourage their patients to ask for useful screening procedures such as cervical smears, breast examinations, or occult blood tests. Moreover, patients will keep going to famous cardiologists who have never bought an electrocardiograph or to famous gynaecologists who spurn colposcopy, letting young and less known specialists follow in their steps or go broke, since particular medical procedures may not be mentioned in advertisements. Via Bezzecca’29, 22053 Lecco(CO), Italy
ANTONIO ATTANASIO
There may well be a few new incubators that are not working, but toilet and washing facilities are inadequate. Slogans such as "Health for All" are not enough. The Decade of Women conference in Nairobi was billed by Dame Nikito Baroas a "happening or experience", but women have had enough experience. They need action. The conference merely demonstrated how powerless women are, how few women are in high office, and how they are bound by a child-oriented system. As long as men decide on which women will speak for women, we will not be able to address the real needs of poor women, even in the health care arena. "The principle that needs stating, is that the person best qualified in the particular community concerned should be trained to do whatever needs to be done in that place regardless of that person’s previous educational attainment."3If need be then, midwives or even traditional birth attendants could carry out caesarean sections. They would only need basic training and adequate supplies. The ideal, however, would be to upgrade maternity centres, make them accessible, establish a high standard of basic hygiene, provide for blood transfusions and for caesarean sections, and ensure post-delivery follow-up. Until there are more women in the upper echelons of health planning women will remain impotent. For all the money that was wasted on the Decade of Women conference so that "important ladies" could occupy the stage, we could have had a women’s health institute or something more tangible than an "experience" as a response to the challenge of maternal mortality. Washington Secretariat, World Federation of Public Health Association, c/o American Public Health Association, Washington, DC 20005, USA 1.
NAOMI BAUMSLAG
Baumslag N Women’s status and health: World considerations. Adv Int Health 1985; 5. 15, 1985. in the developing world: What the community needs. London: Royal College of Obstetricians and Gynaecologists, 1979: 123.
2. Editorial. Washington Post, July 3. Philpott RH. Maternity services
RECURRENCES OF TEGUMENTARY LEISHMANIASIS
SIR,-We read Sampaio and colleagues’ letterl with interest because information on the response to treatment of New World dermal leishmaniasis is indeed limited. We here report preliminary observations in Colombia on the recurrence of dermal leishmaniasis after antimonial treatment. Parasitologically diagnosed patients were treated with intramuscular meglumine antimonate (’Glucantime’), 20 mg/kg SbY daily in two divided doses, up to a maximum daily dose of 850 mg Sbv. Patients received at least 10 days’ treatment followed by clinical assessment. Any sign of persistent activity or inflammation was treated with additional
10-day cycles of glucantime. So far, 121 patients have been treated and followed up for at least 6 months; 45 of these have been observed for a year. 11 patients (9’1%) presented clinical signs of recurrent leishmaniasis-4 at the original skin site, 3 near a previous lesion, and 4 at a distant site. 9 had recurrences at single sites; 2 children had many lesions, distant from the initial sores. All recurrences were cutaneous. (The 12 mucosal cases that have been treated and followed up have not recurred.) Recurrences began one month (1), 2 months (3), 3 months (2), 6 months (3), 7 months (1), and 10 months (1) after completion of treatment. These recurrent lesions have healed with further
glucantime treatment. WOMEN’S DECADE: CELEBRATION OR WAKE?
SIR,-I endorse Dr Rosenfield and Ms Maine’s plea (July 13, p 83) for donor agencies and ministries of health to stop ignoring horrifyingly high maternal mortality rates. Women die in childbirth while traditional birth attendants or midwives in rural areas look on-unable to do a caesarean section, control a haemorrhage, or deal with an obstructed labour. Infections are rampant. Where maternity centres exist, the poor are bundled together in hospitals or clinics with no antibiotics and inadequate hygiene, often two to a bed, with no sheets and filth everywhere. Not surprisingly more than 80% of caesarean sections in such institutions turn septic.
The low recurrence rate in our study (9.1%) compared with that in Walton’s report(25 - 2%) implies that more aggressive therapy reduces the likelihood of recurrence. Shorter treatment courses may have been a factor in our 11 recurrences since in 8 of them (73%) the patient had received less than 20 days of treatment whereas only 46.4% of the 126 patients whose lesions have remained inactive received less than 20 days’ therapy. Treatment is, however, only one of several determinants of the prognosis of dermal leishmaniasis. Leishmania dermal pathogens seem to differ in their propensity for recurrences.3-5 However, the subspecies identity of parasite stocks recovered from recurrent lesions have not been determined previously. We did this for Leishmania parasites recovered from 9 of
558 using isoenzyme and monoclonal antibody enzyme migration patterns of the stocks isolated from the recurrent lesions closely resembled the profile of the L b panamensis reference strain (HOM/PA/71/LS94) and were clearly distinct from that of L braziliensis braziliensis reference strain (HOMJBR/75/M2903). These promastigote stocks also reacted with monoclonal antibody (VII 5G3F3) specific for an L b
the
recurrent cases,
methods.The
panamensis epitope7in
an indirect immunofluorescent antibody Pairs of stocks from the primary and secondary lesions of assay. three patients were identical by monoclonal and isoenzyme analysis. Repeat skin biopsy and sequential measurements of antibody titres have been suggested as means of assessing the efficacy of chemotherapy for leishmaniasis8-10 but we have found them to be of limited usefulness in the routine care of Leishmania patients. Repeat biopsies of both recurrent and healed cases 6 months after completion of treatment have not demonstrated amastigotes. The decline in antibody that often parallels healing of lesions arid the persistence of antibody in some cases which recur have led to the recommendation that changes in antibody titre be used to predict treatment failure.2 The antibody titres measured at time of recurrence persisted in 5 of our cases; in 4 they had fallen by one dilution. Only 1 case was seronegative by the indirect immunofluorescent antibody assay. Surprisingly, the sequential antibody titres of the recurrent cases did not differ statistically from those of non-recurrent cases. Antibody in the 44 healed patients who resided in endemic areas tended to persist. By 6 months the titre of 25% of this group had increased, while in 18% it remained unchanged; in only 57% had titres fallen (and 29% were seronegative). In contrast, the titres of 19 of 20 healed patients who had visited an endemic area only temporarily declined, none rose, and in 13 antibody was undetectable by 6 months after treatment. We interpret the persistence of antibody in the residents of endemic areas as evidence of continued exposure to exogenous antigenic stimuli. These results lead us to doubt the clinical value of persistent antibody titres in predicting a recurrence of dermal leishmaniasis in an endemic setting. Perhaps monitoring antibody titres is most useful in evaluating the treatment of patients who are only temporarily exposed to Leishmania transmission.
Centro Internacional de Investigaciones Médicas (CIDEIM), Tulane University-Colciencias, Cali, Colombia
K. A. WEIGLE* L. VALDERRAMA C. SANTRICH N. G. SARAVIA
makes these findings highly suspect in light of earlier negative reports of isolation attempts in similar settings. Dawson et all recovered C trachomatis from only 2 of 181 satisfactory middle ear aspirates from aboriginal children in Western Australia. In the United States, Hammerschlag et al2 recovered this organism from none of 68 children with chronic otitis media, and Chang et al3 found it in middle ear fluids in only 1 of 14 children with persistent otitis media and 2 of 12 children with acute otitis. We were unable to isolate chlamydiae from any of 164 children with upper respiratory tract infections,4 and Shehab et al5 isolated it only from 9 of 227 children aged 1 to 3 years with lower respiratory tract infection. 4 of the children in Shehab’s series were also infected with recognised
respiratory pathogens. The validity of the ’MicroTrak’ test system, which Banks et al claim, has been achieved in examining cervical and urethral specimens and conjunctival specimens from infants with symptomatic ophthalmia neonatorum.However, when this test is used in populations who probably carry the organism at very low prevalences, most positive tests will be false positive. The fact that many of the specimens reported by Banks et al had less than 10 inclusions per slide supports this likelihood. Such false positives may be due to non-specific binding by protein-A-bearing staphylococci.7 Until this or other potential cross-reactions are eliminated and C trachomatis in such children is confirmed by isolation, the results published by Banks et al must be suspect. Department of Pediatrics, Division of Infectious Diseases, Oklahoma Children’s Memorial Hospital, Oklahoma City, Oklahoma 73104, USA 1. Dawson
2
3 4. 5. 6.
VM, Coelen RJ, Murphy S, et al. Microbiology of chronic otitis media with effusion among Australian aboriginal children. Role of Chlamydia trachomatis. Aust J Exp Biol Med Sci 1985; 63: 99-107 Hammerschlag MR, Hammerschlag PE, Alexander ER. The role of Chlamydia trachomatis in middle ear effusions in children. Pediatrics 1984; 66: 615-17. Chang MJ, Rodriguez WJ, Mohla C. Chlamydia trachomatis in otitis media in children Pediatr Infect Dis 1982; 1: 95-97. San Joaquin VH, Retting PJ, Marks MI. Lack of Chlamydia trachomatis (CT) in upper respiratory tract infections of children. Pediatr Res 1982; 16: 153A. Shehab ZM, Ray CG, Minnich LL, et al. Chlamydia-associated lower respiratory tract infections in children over 1 year of age. Pediatr Res 1985; 19: 304A. Bell TA, Kuo C-C, Stamm WE, et al. Direct fluorescent monoclonal antibody stain for rapid detection of infant Chlamydia trachomatis infections. Pediatrics 1984; 74:
224-28 7 Krech T, Gerhard-Fsadni
the detection 1985; i: 1161-62.
aureus in
*Present address: Department of Epidemiology, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland 21205, USA Marsden PD Pentavalent antimonial treatment in mucosal leishmaniasis. Lancet 1985, i: 1097. 2 Walton BC Evaluation of chemotherapy of American leishmaniasis by the indirect fluorescent antibody test. Am J Trop Med Hyg, 1980, 29: 747-52 3 Guirges SY Natural and experimental re-infection of man with Oriental sore. Ann Trop 1
PHILIP J. RETTIG
D, Hofmann N, Miller SM. Interference of Staphylococcus of Chlamydia trachomatis by monoclonal antibodies. Lancet
Sampaio RNR, Sampaio JHD,
Med Parasitol 1971, 65: 197. MFV, Marsden PD, Cuba CC, Barreto AC. Further trials of nifurtimox in mucocutaneous leishmaniasis Trans Roy Soc Trop Med Hyg 1981; 75: 335-37. 5. Mayrink W, Raso P, Melo MN, et al. American cutaneous leishmaniasis: Disappearance of amastigotes from lesions during antimonial therapy Rev Inst Med Trop Sao Paulo 1983; 25: 265-69. 6 Saravia NG, Holguin AF, McMahon-Pratt D, D’Alessandro A. Mucocutaneous leishmaniasis in Colombia: Leishmania braziliensis subspecies diversity Am J Trop Med Hyg 1985, 34: 714-20 7. McMahon-Pratt D, Bennett E, David JR Monoclonal antibodies that distinguish subspecies of Leishmania braziliensis. JImmunol 1982, 129: 926-27 8 Marsden PD, Cuba CC, Barreto AC, Sampaio RN, Rocha RAA. Nifurtimox in the treatment of South America leishmaniasis. Trans Roy Soc Trop Med Hyg 1979, 73: 4 Guerra
391-94. 9 World
Health Organisation Report of an informal consultation on further development of diagnostic methods for tropical diseases 1981 UNDP/World Bank/WHO/Special Programme for Research and Training in Tropical Diseases. 10 Marinkelle CJ. The control of leishmanoasis. Bull WHO 1980, 58: 807-18.
&agr;-GLIADIN ANTIBODIES IN CHILDHOOD COELIAC DISEASE to
SIR,—Professor Cacciari and co-workers (June 29, p 1469) appear consider that the children who had partial villous atrophy (group
3) do not have childhood coeliac disease (CCD). Mavromichalis et all reported that 3 of 12 untreated coeliac children had partial villous atrophy, and a study in an Irish population has also strated that partial villous atrophy is indicative of CCD.2demonIf this were true
for the Italian group, there could have been 16 coeliac chil-
dren, of whom at most 11had gliadin antibodies. The sensitivity of the gliadin antibody assay for the detection of CCD would thus be 69%. We too have used the detection of IgG antibodies to wheat protein to screen for CCD. In our hands, the ELISA system with a-gliadin is more sensitive and specific than assays with other wheat protein fractions. In a prospective study of 71 children suspected of having
malabsorption,
CHLAMYDIA AND OTITIS MEDIA
SIR,—The report of Dr Banks and colleagues (Aug 3, p 278) of apparently positive direct fluorescent antibody tests for Chlamydia trachomatis in 67% of middle ear fluids, 50% ofconjunctival smears, and 44% of throat swabs in 18 Australian children clearly merits "further work". The lack of confirmation of these results by culture
17 were diagnosed histologically as having CCD,
16
of whom had raised a-gliadin antibodies (sensitivity 94%). Of 54 subjects with normal small-intestinal mucosa, a-gliadin antibody levels were normal in 48 (specificity 88%). Like others,4,5 we have found that when testing for IgA antibodies, the specificity increased (94%). However, with a-gliadin, the sensitivity of the assay was significantly reduced (52%). Since total immunoglobulin levels increase from birth,we did a serial study of a-gliadin antibodies in children at different ages.3 Although the specific antibody titre rises throughout the first de-
management, finance, law, biostatistics, psychosocial medicine, and
personnel
epidemiology and
advances in medicine. These subjects are offered by the College or by approved institutes. 38% of the general managers of Australia’s large, general teaching hospitals are medically qualified.The RACMA has provided a professional focus for medical administrators and the extensive training programme necessary to enable them to fulfil their role within the health care system. The increasing complexity of the health services area has highlighted the importance of the skilled and innovative manager. Physicians are in a unique position to contribute to this management. A professional body, such as the RACMA, with its emphasis on education, professional development, and peer review is ideally placed to provide those managers who will uphold the professional integrity of the physician and their emphasis on patient care. Alfred
Hospital,
Prahran, Victoria, Australia
recent
TREVOR J. WOOD SUSAN E. THOMAS
ADVERTISING DOCTORS’ SERVICES
SIR,—Your July 27 editorial on advertising by general practitioners draws attention to the relation between good advertising and such determinants of good practice as information for and education of patients and the stimulation of "stagnant practitioners". Unfortunately, the "interests of established doctors" are well taken care of in other countries too. The Italian Federation of Local Medical Councils (roughly equivalent to the General Medical Council in the UK) has lately succeeded in pushing a law on medical advertising through Parliament. The main points of this new law are: (1) Advertising is allowed only through nameplates affixed to the doctor’s door and through entries in telephone directories. (2) Advertisements may carry only the doctor’s name, address, telephone number, surgery times, and professional qualifications. (3) Acceptable professional qualifications are only those awarded by Italian universities and those officially recognised by the Italian Government. (4) A doctor’s special interest in a particular branch of medicine may be mentioned only if he or she has completed a given number of years in the relevant hospital department. Among the consequences of this law are that older and wellestablished practitioners may continue to dazzle patients by using such obsolete and meaningless titles as "professor", while younger doctors cannot encourage their patients to ask for useful screening procedures such as cervical smears, breast examinations, or occult blood tests. Moreover, patients will keep going to famous cardiologists who have never bought an electrocardiograph or to famous gynaecologists who spurn colposcopy, letting young and less known specialists follow in their steps or go broke, since particular medical procedures may not be mentioned in advertisements. Via Bezzecca’29, 22053 Lecco(CO), Italy
ANTONIO ATTANASIO
There may well be a few new incubators that are not working, but toilet and washing facilities are inadequate. Slogans such as "Health for All" are not enough. The Decade of Women conference in Nairobi was billed by Dame Nikito Baroas a "happening or experience", but women have had enough experience. They need action. The conference merely demonstrated how powerless women are, how few women are in high office, and how they are bound by a child-oriented system. As long as men decide on which women will speak for women, we will not be able to address the real needs of poor women, even in the health care arena. "The principle that needs stating, is that the person best qualified in the particular community concerned should be trained to do whatever needs to be done in that place regardless of that person’s previous educational attainment."3If need be then, midwives or even traditional birth attendants could carry out caesarean sections. They would only need basic training and adequate supplies. The ideal, however, would be to upgrade maternity centres, make them accessible, establish a high standard of basic hygiene, provide for blood transfusions and for caesarean sections, and ensure post-delivery follow-up. Until there are more women in the upper echelons of health planning women will remain impotent. For all the money that was wasted on the Decade of Women conference so that "important ladies" could occupy the stage, we could have had a women’s health institute or something more tangible than an "experience" as a response to the challenge of maternal mortality. Washington Secretariat, World Federation of Public Health Association, c/o American Public Health Association, Washington, DC 20005, USA 1.
NAOMI BAUMSLAG
Baumslag N Women’s status and health: World considerations. Adv Int Health 1985; 5. 15, 1985. in the developing world: What the community needs. London: Royal College of Obstetricians and Gynaecologists, 1979: 123.
2. Editorial. Washington Post, July 3. Philpott RH. Maternity services
RECURRENCES OF TEGUMENTARY LEISHMANIASIS
SIR,-We read Sampaio and colleagues’ letterl with interest because information on the response to treatment of New World dermal leishmaniasis is indeed limited. We here report preliminary observations in Colombia on the recurrence of dermal leishmaniasis after antimonial treatment. Parasitologically diagnosed patients were treated with intramuscular meglumine antimonate (’Glucantime’), 20 mg/kg SbY daily in two divided doses, up to a maximum daily dose of 850 mg Sbv. Patients received at least 10 days’ treatment followed by clinical assessment. Any sign of persistent activity or inflammation was treated with additional
10-day cycles of glucantime. So far, 121 patients have been treated and followed up for at least 6 months; 45 of these have been observed for a year. 11 patients (9’1%) presented clinical signs of recurrent leishmaniasis-4 at the original skin site, 3 near a previous lesion, and 4 at a distant site. 9 had recurrences at single sites; 2 children had many lesions, distant from the initial sores. All recurrences were cutaneous. (The 12 mucosal cases that have been treated and followed up have not recurred.) Recurrences began one month (1), 2 months (3), 3 months (2), 6 months (3), 7 months (1), and 10 months (1) after completion of treatment. These recurrent lesions have healed with further
glucantime treatment. WOMEN’S DECADE: CELEBRATION OR WAKE?
SIR,-I endorse Dr Rosenfield and Ms Maine’s plea (July 13, p 83) for donor agencies and ministries of health to stop ignoring horrifyingly high maternal mortality rates. Women die in childbirth while traditional birth attendants or midwives in rural areas look on-unable to do a caesarean section, control a haemorrhage, or deal with an obstructed labour. Infections are rampant. Where maternity centres exist, the poor are bundled together in hospitals or clinics with no antibiotics and inadequate hygiene, often two to a bed, with no sheets and filth everywhere. Not surprisingly more than 80% of caesarean sections in such institutions turn septic.
The low recurrence rate in our study (9.1%) compared with that in Walton’s report(25 - 2%) implies that more aggressive therapy reduces the likelihood of recurrence. Shorter treatment courses may have been a factor in our 11 recurrences since in 8 of them (73%) the patient had received less than 20 days of treatment whereas only 46.4% of the 126 patients whose lesions have remained inactive received less than 20 days’ therapy. Treatment is, however, only one of several determinants of the prognosis of dermal leishmaniasis. Leishmania dermal pathogens seem to differ in their propensity for recurrences.3-5 However, the subspecies identity of parasite stocks recovered from recurrent lesions have not been determined previously. We did this for Leishmania parasites recovered from 9 of
558 using isoenzyme and monoclonal antibody enzyme migration patterns of the stocks isolated from the recurrent lesions closely resembled the profile of the L b panamensis reference strain (HOM/PA/71/LS94) and were clearly distinct from that of L braziliensis braziliensis reference strain (HOMJBR/75/M2903). These promastigote stocks also reacted with monoclonal antibody (VII 5G3F3) specific for an L b
the
recurrent cases,
methods.The
panamensis epitope7in
an indirect immunofluorescent antibody Pairs of stocks from the primary and secondary lesions of assay. three patients were identical by monoclonal and isoenzyme analysis. Repeat skin biopsy and sequential measurements of antibody titres have been suggested as means of assessing the efficacy of chemotherapy for leishmaniasis8-10 but we have found them to be of limited usefulness in the routine care of Leishmania patients. Repeat biopsies of both recurrent and healed cases 6 months after completion of treatment have not demonstrated amastigotes. The decline in antibody that often parallels healing of lesions arid the persistence of antibody in some cases which recur have led to the recommendation that changes in antibody titre be used to predict treatment failure.2 The antibody titres measured at time of recurrence persisted in 5 of our cases; in 4 they had fallen by one dilution. Only 1 case was seronegative by the indirect immunofluorescent antibody assay. Surprisingly, the sequential antibody titres of the recurrent cases did not differ statistically from those of non-recurrent cases. Antibody in the 44 healed patients who resided in endemic areas tended to persist. By 6 months the titre of 25% of this group had increased, while in 18% it remained unchanged; in only 57% had titres fallen (and 29% were seronegative). In contrast, the titres of 19 of 20 healed patients who had visited an endemic area only temporarily declined, none rose, and in 13 antibody was undetectable by 6 months after treatment. We interpret the persistence of antibody in the residents of endemic areas as evidence of continued exposure to exogenous antigenic stimuli. These results lead us to doubt the clinical value of persistent antibody titres in predicting a recurrence of dermal leishmaniasis in an endemic setting. Perhaps monitoring antibody titres is most useful in evaluating the treatment of patients who are only temporarily exposed to Leishmania transmission.
Centro Internacional de Investigaciones Médicas (CIDEIM), Tulane University-Colciencias, Cali, Colombia
K. A. WEIGLE* L. VALDERRAMA C. SANTRICH N. G. SARAVIA
makes these findings highly suspect in light of earlier negative reports of isolation attempts in similar settings. Dawson et all recovered C trachomatis from only 2 of 181 satisfactory middle ear aspirates from aboriginal children in Western Australia. In the United States, Hammerschlag et al2 recovered this organism from none of 68 children with chronic otitis media, and Chang et al3 found it in middle ear fluids in only 1 of 14 children with persistent otitis media and 2 of 12 children with acute otitis. We were unable to isolate chlamydiae from any of 164 children with upper respiratory tract infections,4 and Shehab et al5 isolated it only from 9 of 227 children aged 1 to 3 years with lower respiratory tract infection. 4 of the children in Shehab’s series were also infected with recognised
respiratory pathogens. The validity of the ’MicroTrak’ test system, which Banks et al claim, has been achieved in examining cervical and urethral specimens and conjunctival specimens from infants with symptomatic ophthalmia neonatorum.However, when this test is used in populations who probably carry the organism at very low prevalences, most positive tests will be false positive. The fact that many of the specimens reported by Banks et al had less than 10 inclusions per slide supports this likelihood. Such false positives may be due to non-specific binding by protein-A-bearing staphylococci.7 Until this or other potential cross-reactions are eliminated and C trachomatis in such children is confirmed by isolation, the results published by Banks et al must be suspect. Department of Pediatrics, Division of Infectious Diseases, Oklahoma Children’s Memorial Hospital, Oklahoma City, Oklahoma 73104, USA 1. Dawson
2
3 4. 5. 6.
VM, Coelen RJ, Murphy S, et al. Microbiology of chronic otitis media with effusion among Australian aboriginal children. Role of Chlamydia trachomatis. Aust J Exp Biol Med Sci 1985; 63: 99-107 Hammerschlag MR, Hammerschlag PE, Alexander ER. The role of Chlamydia trachomatis in middle ear effusions in children. Pediatrics 1984; 66: 615-17. Chang MJ, Rodriguez WJ, Mohla C. Chlamydia trachomatis in otitis media in children Pediatr Infect Dis 1982; 1: 95-97. San Joaquin VH, Retting PJ, Marks MI. Lack of Chlamydia trachomatis (CT) in upper respiratory tract infections of children. Pediatr Res 1982; 16: 153A. Shehab ZM, Ray CG, Minnich LL, et al. Chlamydia-associated lower respiratory tract infections in children over 1 year of age. Pediatr Res 1985; 19: 304A. Bell TA, Kuo C-C, Stamm WE, et al. Direct fluorescent monoclonal antibody stain for rapid detection of infant Chlamydia trachomatis infections. Pediatrics 1984; 74:
224-28 7 Krech T, Gerhard-Fsadni
the detection 1985; i: 1161-62.
aureus in
*Present address: Department of Epidemiology, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland 21205, USA Marsden PD Pentavalent antimonial treatment in mucosal leishmaniasis. Lancet 1985, i: 1097. 2 Walton BC Evaluation of chemotherapy of American leishmaniasis by the indirect fluorescent antibody test. Am J Trop Med Hyg, 1980, 29: 747-52 3 Guirges SY Natural and experimental re-infection of man with Oriental sore. Ann Trop 1
PHILIP J. RETTIG
D, Hofmann N, Miller SM. Interference of Staphylococcus of Chlamydia trachomatis by monoclonal antibodies. Lancet
Sampaio RNR, Sampaio JHD,
Med Parasitol 1971, 65: 197. MFV, Marsden PD, Cuba CC, Barreto AC. Further trials of nifurtimox in mucocutaneous leishmaniasis Trans Roy Soc Trop Med Hyg 1981; 75: 335-37. 5. Mayrink W, Raso P, Melo MN, et al. American cutaneous leishmaniasis: Disappearance of amastigotes from lesions during antimonial therapy Rev Inst Med Trop Sao Paulo 1983; 25: 265-69. 6 Saravia NG, Holguin AF, McMahon-Pratt D, D’Alessandro A. Mucocutaneous leishmaniasis in Colombia: Leishmania braziliensis subspecies diversity Am J Trop Med Hyg 1985, 34: 714-20 7. McMahon-Pratt D, Bennett E, David JR Monoclonal antibodies that distinguish subspecies of Leishmania braziliensis. JImmunol 1982, 129: 926-27 8 Marsden PD, Cuba CC, Barreto AC, Sampaio RN, Rocha RAA. Nifurtimox in the treatment of South America leishmaniasis. Trans Roy Soc Trop Med Hyg 1979, 73: 4 Guerra
391-94. 9 World
Health Organisation Report of an informal consultation on further development of diagnostic methods for tropical diseases 1981 UNDP/World Bank/WHO/Special Programme for Research and Training in Tropical Diseases. 10 Marinkelle CJ. The control of leishmanoasis. Bull WHO 1980, 58: 807-18.
&agr;-GLIADIN ANTIBODIES IN CHILDHOOD COELIAC DISEASE to
SIR,—Professor Cacciari and co-workers (June 29, p 1469) appear consider that the children who had partial villous atrophy (group
3) do not have childhood coeliac disease (CCD). Mavromichalis et all reported that 3 of 12 untreated coeliac children had partial villous atrophy, and a study in an Irish population has also strated that partial villous atrophy is indicative of CCD.2demonIf this were true
for the Italian group, there could have been 16 coeliac chil-
dren, of whom at most 11had gliadin antibodies. The sensitivity of the gliadin antibody assay for the detection of CCD would thus be 69%. We too have used the detection of IgG antibodies to wheat protein to screen for CCD. In our hands, the ELISA system with a-gliadin is more sensitive and specific than assays with other wheat protein fractions. In a prospective study of 71 children suspected of having
malabsorption,
CHLAMYDIA AND OTITIS MEDIA
SIR,—The report of Dr Banks and colleagues (Aug 3, p 278) of apparently positive direct fluorescent antibody tests for Chlamydia trachomatis in 67% of middle ear fluids, 50% ofconjunctival smears, and 44% of throat swabs in 18 Australian children clearly merits "further work". The lack of confirmation of these results by culture
17 were diagnosed histologically as having CCD,
16
of whom had raised a-gliadin antibodies (sensitivity 94%). Of 54 subjects with normal small-intestinal mucosa, a-gliadin antibody levels were normal in 48 (specificity 88%). Like others,4,5 we have found that when testing for IgA antibodies, the specificity increased (94%). However, with a-gliadin, the sensitivity of the assay was significantly reduced (52%). Since total immunoglobulin levels increase from birth,we did a serial study of a-gliadin antibodies in children at different ages.3 Although the specific antibody titre rises throughout the first de-