- Email: [email protected]
RED-CELL ALLOANTIBODY RESPONSE IN AIDS
575 30 000 women. His ideas have since been put to good use around the world, to the ultimate benefit of both mother and baby.2-4
The latent phase of labour varies in length and may last up to 20 h. Most normal patients, however, do not arrive in the delivery rooms of our hospitals until this phase is’ virtually complete and are usually established in the active phase when they are first seen by the midwifery and obstetric staff. To suggest that this phase is normally accompanied by severe pain or, should pain be present, that relief is denied is misleading. The aspirations of many of our patients is one of expectancy in that they will not be given analgesia until such time as they feel they need it. My own policy is to discuss methods of pain relief with my patients some weeks before the expected date of delivery, and in this I receive the willing cooperation of my anaesthetist colleagues. Pain relief is thus anticipated before labour begins and the needs of individual patients can be properly and adequately met without the need for debate as Crawford suggests. Obstetricians have been aware for many years of the influence of
patient position upon contractions and most are nursed either erect or on their side. The decision not to give solid food to labouring women was the result of death associated with the need for emergency anaesthesia and was largely promulgated by the anaesthetists. Although Crawford considers this policy to be unnecessary in certain
cases
this is
not
the view of
some
of his
colleagues. With reference to his views on the second stage of labour, the obstetric staff do distinguish between anatomical and physiological full dilatation. Women are not encouraged to bear down before the presenting part has reached the perineum and a period of inactivity to allow descent to the perineum is the rule rather than the exception. The change from the first to the second stage of labour is usually well appreciated by our patients who then move from a morale lowering period of frequent and powerful contractions to one of meaningful and progressive activity interspaced by a welcome relief of pain between contractions. Much as I appreciate the technical care that is given to some ofmy patients by my anaesthetist colleagues I cannot agree that they are necessarily able to assess the progress of labour with such skill and lack of prejudice as has been suggested. Our knowledge of labour has a long history and I would recommend Crawford to consult the words ofSmellie,6 an obstetrician well ahead of his time, working without the benefit of adequate pain relief, but many of whose observations are as true today as they were in the 18th century. Princess Mary Maternity Hospital, Newcastle upon Tyne NE2 3BD
DEREK TACCHI
DRUG USERS AND URINE TESTING
SIR,-The differences described by Dr Strang (Aug 13, p 400) between his experiences in London and Manchester may (among other possible reasons) be fortuitous, caused by different policies in different police squads, or be influenced by the increase in the black market which is constantly taking place. The position of urine testing in all this is not clear. A full urine analysis may be desirable every time an addict is seen by his doctor. It does, however, have disadvantages. When an addict knows that his urine will be tested he is likely, unless he is too stupid, inept, or uncontrolled to do so, to cheat on the test. Suitable urine is for sale on the black market or can easily be made up at home. A typical description by an addict is: "I used to take my son’s pee and add a bit of methadone. The clinic never noticed". If the test is to have any value the patient must be watched as he passes the specimen. Even then, if he knows he will be watched, he is likely to adapt his drug intake for the previous 24 hours to what he knows the doctor wishes to find-and return afterwards to his old habits. So 2 3 4
Phillpott RH, Castle WM. Cervicographs in the management of labour m primigravidae.J Obster Gynaecol Br Commonw 1972; 79: 592-602. Hendricks CH, Brenner WE, Kraus F. Normal cervical dilatation pattern in late pregnancy and labour. Am J Obstet Gynecol 1970; 1065-81. O’Driscoll K, Meagher D. The active managementof labour.London:W.B.Saunders, 1980.
5
Department
of Health and Social Security. Reports on confidential enquiries into maternal deaths in England and Wales 1973-75. London: HMSO, 1976-78. 6. Smellie W. A treatise on the theory and practice of midwifery. 1752.
the idea that the doctor has control of the situation is false. A test whose results are unreliable is less valuable than no test at all. In my experience an occasional spot test, unexpected and immediate, is likely to reveal more reliable results than routine testing-and also makes less demand on scarce resources. 13 Devonshire Place, London W1N 1PB
ANN DALLY
RED-CELL ALLOANTIBODY RESPONSE IN AIDS
SIR,-Patients with acquired immunodeficiency syndrome have a profoundly depressed cellular immune function. However, the presence of elevated serum immunoglobulins and the
(AIDS)
continued production of pre-existing antiviral antibodies suggests residual humoral immune function. We report a patient with AIDS who mounted a brisk secondary antibody response to a red-cell antigen despite his immunosuppressed status. Pneumocystis carinii pneumonia developed in a 28-year-old male homosexual with a 6-month history of weight-loss, diarrhoea, lymphadenopathy, and lymphopenia. No previous transfusions were known. Initial screening for serum anti-red-cell antibodies at 37°C and with an antiglobulin technique (AGT) was negative. He received two units of red cells on day 2, and then again on day 7, without incident. On both days the antibody screen remained negative. On day 9 the antibody screen was 2-3 + at 37°C and AGT, and an anti-M red-cell antibody was identified. The patient’s red cells typed as M-negative. All 4 transfused units were M-positive. Tested retrospectively, a homozygous M-positive screening cell reacted 1 + with pretransfusion serum at 25°C. On day 11 the direct AGT was weakly positive and anti-M was eluted from the patient’s red cells. He was subsequently transfused with M-negative red cells. The Pneumocystis pneumonia was unresponsive to therapy, and the patient died on day 19. Necropsy revealed disseminated cytomegalovirus, pulmonary herpes, and striking lymphoid depletion. Thus a secondary immune response to a blood-group antigen can be made despite the severe cellular immunodeficiency of AIDS. Blood Bank and Department of Pathology and Laboratory Medicine, University of Rochester, Rochester, New York 14642, USA
GLENN RAMSEY MARK STOLER NEIL BLUMBERG
AIDS AND THE PAID DONOR
SIR,-Dr Rickard and his colleagues (July 2, p 50) write about the absence of acquired immunodeficiency syndrome (AIDS) in haemophiliacs in Australia. I take exception to the suggestion that plasma from an all-volunteer donor base could have a lower incidence of AIDS than plasma from paid donors. In the first place, there is no established criterion for determining the presence or absence of an AIDS agent in plasma. Secondly, paid donors were the first donors to be screened for AIDS anywhere. Alpha Therapeutic Corporation started to screen donors at high risk for AIDS on Dec 21, 1982. There are many blood donors among those high-risk groups, particularly the more affluent, socially well established homosexual populations in major AIDS cities such as New York, San Francisco, and Los Angeles. Alpha Therapeutic Corporation does not use plasma collected from paid or volunteer donors in any of these cities. In the absence of means to screen plasma for AIDS, there is little sense in Rickard and colleagues’ claim of non-presence in non-commercial blood products collected from an entirely volunteer system as in Australia. Plasma Supply, Alpha Therapeutic Corporation, Los Angeles, California 90032, USA
DAVID
J. GURY
A(H)TLV AND LYMPHOID MALIGNANCIES SIR,-Professor Fleming and his colleagues (Aug 6, p 334) have detected antibodies to adult (human) T-cell lymphoma leukaemia virus (ATLV, HTLV) in a small number of patients with lymphopoietic diseases in Nigeria as well as in some apparently healthy blood donors. The suggestion that "ATLV or a related agent is being transmitted in northern Nigeria" would seem to be
The latent phase of labour varies in length and may last up to 20 h. Most normal patients, however, do not arrive in the delivery rooms of our hospitals until this phase is’ virtually complete and are usually established in the active phase when they are first seen by the midwifery and obstetric staff. To suggest that this phase is normally accompanied by severe pain or, should pain be present, that relief is denied is misleading. The aspirations of many of our patients is one of expectancy in that they will not be given analgesia until such time as they feel they need it. My own policy is to discuss methods of pain relief with my patients some weeks before the expected date of delivery, and in this I receive the willing cooperation of my anaesthetist colleagues. Pain relief is thus anticipated before labour begins and the needs of individual patients can be properly and adequately met without the need for debate as Crawford suggests. Obstetricians have been aware for many years of the influence of
patient position upon contractions and most are nursed either erect or on their side. The decision not to give solid food to labouring women was the result of death associated with the need for emergency anaesthesia and was largely promulgated by the anaesthetists. Although Crawford considers this policy to be unnecessary in certain
cases
this is
not
the view of
some
of his
colleagues. With reference to his views on the second stage of labour, the obstetric staff do distinguish between anatomical and physiological full dilatation. Women are not encouraged to bear down before the presenting part has reached the perineum and a period of inactivity to allow descent to the perineum is the rule rather than the exception. The change from the first to the second stage of labour is usually well appreciated by our patients who then move from a morale lowering period of frequent and powerful contractions to one of meaningful and progressive activity interspaced by a welcome relief of pain between contractions. Much as I appreciate the technical care that is given to some ofmy patients by my anaesthetist colleagues I cannot agree that they are necessarily able to assess the progress of labour with such skill and lack of prejudice as has been suggested. Our knowledge of labour has a long history and I would recommend Crawford to consult the words ofSmellie,6 an obstetrician well ahead of his time, working without the benefit of adequate pain relief, but many of whose observations are as true today as they were in the 18th century. Princess Mary Maternity Hospital, Newcastle upon Tyne NE2 3BD
DEREK TACCHI
DRUG USERS AND URINE TESTING
SIR,-The differences described by Dr Strang (Aug 13, p 400) between his experiences in London and Manchester may (among other possible reasons) be fortuitous, caused by different policies in different police squads, or be influenced by the increase in the black market which is constantly taking place. The position of urine testing in all this is not clear. A full urine analysis may be desirable every time an addict is seen by his doctor. It does, however, have disadvantages. When an addict knows that his urine will be tested he is likely, unless he is too stupid, inept, or uncontrolled to do so, to cheat on the test. Suitable urine is for sale on the black market or can easily be made up at home. A typical description by an addict is: "I used to take my son’s pee and add a bit of methadone. The clinic never noticed". If the test is to have any value the patient must be watched as he passes the specimen. Even then, if he knows he will be watched, he is likely to adapt his drug intake for the previous 24 hours to what he knows the doctor wishes to find-and return afterwards to his old habits. So 2 3 4
Phillpott RH, Castle WM. Cervicographs in the management of labour m primigravidae.J Obster Gynaecol Br Commonw 1972; 79: 592-602. Hendricks CH, Brenner WE, Kraus F. Normal cervical dilatation pattern in late pregnancy and labour. Am J Obstet Gynecol 1970; 1065-81. O’Driscoll K, Meagher D. The active managementof labour.London:W.B.Saunders, 1980.
5
Department
of Health and Social Security. Reports on confidential enquiries into maternal deaths in England and Wales 1973-75. London: HMSO, 1976-78. 6. Smellie W. A treatise on the theory and practice of midwifery. 1752.
the idea that the doctor has control of the situation is false. A test whose results are unreliable is less valuable than no test at all. In my experience an occasional spot test, unexpected and immediate, is likely to reveal more reliable results than routine testing-and also makes less demand on scarce resources. 13 Devonshire Place, London W1N 1PB
ANN DALLY
RED-CELL ALLOANTIBODY RESPONSE IN AIDS
SIR,-Patients with acquired immunodeficiency syndrome have a profoundly depressed cellular immune function. However, the presence of elevated serum immunoglobulins and the
(AIDS)
continued production of pre-existing antiviral antibodies suggests residual humoral immune function. We report a patient with AIDS who mounted a brisk secondary antibody response to a red-cell antigen despite his immunosuppressed status. Pneumocystis carinii pneumonia developed in a 28-year-old male homosexual with a 6-month history of weight-loss, diarrhoea, lymphadenopathy, and lymphopenia. No previous transfusions were known. Initial screening for serum anti-red-cell antibodies at 37°C and with an antiglobulin technique (AGT) was negative. He received two units of red cells on day 2, and then again on day 7, without incident. On both days the antibody screen remained negative. On day 9 the antibody screen was 2-3 + at 37°C and AGT, and an anti-M red-cell antibody was identified. The patient’s red cells typed as M-negative. All 4 transfused units were M-positive. Tested retrospectively, a homozygous M-positive screening cell reacted 1 + with pretransfusion serum at 25°C. On day 11 the direct AGT was weakly positive and anti-M was eluted from the patient’s red cells. He was subsequently transfused with M-negative red cells. The Pneumocystis pneumonia was unresponsive to therapy, and the patient died on day 19. Necropsy revealed disseminated cytomegalovirus, pulmonary herpes, and striking lymphoid depletion. Thus a secondary immune response to a blood-group antigen can be made despite the severe cellular immunodeficiency of AIDS. Blood Bank and Department of Pathology and Laboratory Medicine, University of Rochester, Rochester, New York 14642, USA
GLENN RAMSEY MARK STOLER NEIL BLUMBERG
AIDS AND THE PAID DONOR
SIR,-Dr Rickard and his colleagues (July 2, p 50) write about the absence of acquired immunodeficiency syndrome (AIDS) in haemophiliacs in Australia. I take exception to the suggestion that plasma from an all-volunteer donor base could have a lower incidence of AIDS than plasma from paid donors. In the first place, there is no established criterion for determining the presence or absence of an AIDS agent in plasma. Secondly, paid donors were the first donors to be screened for AIDS anywhere. Alpha Therapeutic Corporation started to screen donors at high risk for AIDS on Dec 21, 1982. There are many blood donors among those high-risk groups, particularly the more affluent, socially well established homosexual populations in major AIDS cities such as New York, San Francisco, and Los Angeles. Alpha Therapeutic Corporation does not use plasma collected from paid or volunteer donors in any of these cities. In the absence of means to screen plasma for AIDS, there is little sense in Rickard and colleagues’ claim of non-presence in non-commercial blood products collected from an entirely volunteer system as in Australia. Plasma Supply, Alpha Therapeutic Corporation, Los Angeles, California 90032, USA
DAVID
J. GURY
A(H)TLV AND LYMPHOID MALIGNANCIES SIR,-Professor Fleming and his colleagues (Aug 6, p 334) have detected antibodies to adult (human) T-cell lymphoma leukaemia virus (ATLV, HTLV) in a small number of patients with lymphopoietic diseases in Nigeria as well as in some apparently healthy blood donors. The suggestion that "ATLV or a related agent is being transmitted in northern Nigeria" would seem to be