- Email: [email protected]
SMOKING AND ORAL CARCINOMA
671 1977. Venous blood-samples were obtained between 1.30 and P.M. No viral infections were prevalent in school during
2.30
that term.
Platelet-counts below 150 x 109/1 are generally considered abnormal, and 14 of the 35 children had at least one low count. 10 children had one or more platelet-counts between 45 and 110 x 10’/1. Of the 35 children in school on Sept. 5, 1977, 8 were taking anticonvulsant drugs other than sodium valproate, and 2 of these had platelet-counts of less than 110 x 109/1. 5 of the 10 children whose sole anticonvulsant was sodium valproate had platelet-counts of 110 x 109/1 or below, as had 3 of the 17 children who were taking sodium valproate with other drugs. No platelet-counts below 110 x 109/1 were recorded amongst 5 children on the highest doses of sodium valproate (520-1320 mg per day above the preferred daily dosage of 40 mg/kg bodyweight) or amongst the 8 children with the longest duration of -
treatment
(27-48 months).
Seizure control was not affected in children on sodium valproate whose platelet-counts were low. The white-cell count, red-cell count, and haemoglobin were unaffected. Clinically important disturbances of haemostasis were unusual. A boy on sodium valproate alone had a platelet-count of 40 x 109/1 after emergency appendicectomy in June 1977. There was no evidence of undue bleeding. In September a 9 x 10 cm bruise was noted on his right buttock with other smaller bruises on the left buttock and legs. A week earlier his platelet-count had been 80 x 109/1. After carbamazepine had been substituted, sodium valproate was tapered off and when he stopped taking valproate his platelet-count was 150 x 109/1; a month later it had risen to 270 x 109/1. We have heard of similar cases, including a female whose platelet-count rose from 40 x 109/1 to 290 109/1 within two weeks of sodium valproate being stopped. 5 other children at the school who were taking this drug bruised easily (an unusual site was over the Achilles tendon where the upper rim of the shoe exerts pressure). A nurse recalled a boy who had presented in February, 1977, with an unexplained oval hsematoma 5 x 12 cm on his scalp; his platelet-count in June was 110 x 109/1. Another girl had bruising and incontinence, both of which stopped after valproate was discontinued. The fact that 27 of the 35 children in school were on sodium valproate alone or in combination with other drugs is an indication of the usefulness of this drug in the management of children with severe epilepsy needing residential management. In only 2 cases did the drug have to be discontinued, although dosages are being kept as low as possible. It would seem advisable to check the platelet-count before surgery on a child on ,
long-term anticonvulsant therapy. Lancaster Royal Lancaster
Infirmary,
R. E. RAWORTH G. BIRCHALL
DISAPPEARANCE OF HÆMATOLOGIST IN ARGENTINA
SiR,—On March 8, Dr Beatriz Iparraguirre de Weinstein arrested in Argentina and has not been seen since. Dr de Weinstein, married with two daughters, is head of the clinical haematology service of the Ramos Mejia Hospital in Buenos Aires. She is a research-worker and is well known in North and South America for her work on abnormal haemoglobins and thalassfemia. In collaboration with British scientists she played a major role in the discovery of the Hb Buenos
was
Aires. Several members of haematology departments in the U.K. who have known her have received urgent telegrams from Argentina asking for immediate action to save her life, and then to contact Argentinian government officials. Dr de Weinstein was not involved in any political activities. The list of people who have disappeared in Argentina since
March, 1976, occupies 22 pages of the latest report of Amnesty
International, and includes many physicians and scientists. Department of Hæmatology, Royal Postgraduate Medical School,
D. CATOVSKY
London W12
SMOKING AND ORAL CARCINOMA
SIR,-Dr Trell and his colleagues (Jan. 14, p. 109) state that "although oral carcinomas form a heterogeneous group, we included only squamous-cell varieties which have been shown to be clearly associated with smoking". This implies a causal relationship between smoking and squamous-cell carcinoma in the mouth, but the work that Trell et al. cite in support of their assertion is concerned with the effects of smoking on bronchial epithelium. The search for causes underlying the development of oral cancer could be diverted by assumptions that oral epithelium is vulnerable to the same carcinogenic influences as affect the respiratory tract. Department of Dental Science, Royal College of Surgeons of England,
B. COHEN
London WC2A 3PN
*<* This letter has been shown lows.-ED.L.
to
Dr
Trell, whose reply fol-
SIR,-We would like to take the opportunity here to draw attention to the ample published evidence for a relation between smoking and carcinoma, in particular squamous-cell varieties, of the oral cavity. 1-7 In our letter we were concerned with brevity and chose to refer to only one comprehensive work on the relationship between smoking and squamous-cell transformation, albeit in the respiratory tract. The search for other possible causes underlying the development of oral cancer is clearly of major importance and warrants further elucidation. Section of Preventive Medicine,
Department of Internal medicine, University of Lund Malmö General Hospital Malmö, Sweden
ERIK TRELL
Department of Tumour Cytogenetics, Wallenberg Laboratory, University of Lund
ROLF KORSGAARD
MATERNAL HYPERTHERMIA AND ANENCEPHALY
SiR,—The account by Mr Miller and his colleagues (March 11, p. 519) of ten to twelve cases in which hyperthermia dur-
ing the third and fourth weeks of gestation was followed by the birth of an anencephalic is certainly interesting, butthere are at least two unacknowledged weaknesses in the reasons they give for thinking that the relationship between the hyperthermia and the defect may be causal. Firstly, they do not consider the fallibility of human memory as a possible explanation for their finding that episodes of hyperthermia were recalled by a much higher proportion of mothers of anencephalics than of their two control groups. The women in one of these control groups, like the cases’ mothers, were interviewed up to ten years after the relevant birth-plenty of time for the mother of a normal child to forget and the mother of an anencephalic to embroider 1. The Health
Consequences of Smoking. D.H.E.W. Publication no. 76-8704; pp. 43, 50. Atlanta, Georgia, 1975. 2. Fortier, R. A.J. Can. dent. Ass. 1975, 44, 235. 3. Andrieu-Guitrancourt, J. Quest méd. 1976, 29, 309. 4. Jafarey, N. A., Zaidi, S. H. M. Trop. Doctor, 1976, 6, 63. 5. Wahi, P. N. in Cancer in Asia: Opportunities for Prevention, Detection and Treatment (edited by T. Hirayama); p. 19. Tokyo, 1976. 6. Binnie, W. H. Proc. R. Soc. Med. 1976, 69, 737. 7. William, R. R., Horm. J. W. J. nat. Cancer Inst. 1977, 58, 525.
2.30
that term.
Platelet-counts below 150 x 109/1 are generally considered abnormal, and 14 of the 35 children had at least one low count. 10 children had one or more platelet-counts between 45 and 110 x 10’/1. Of the 35 children in school on Sept. 5, 1977, 8 were taking anticonvulsant drugs other than sodium valproate, and 2 of these had platelet-counts of less than 110 x 109/1. 5 of the 10 children whose sole anticonvulsant was sodium valproate had platelet-counts of 110 x 109/1 or below, as had 3 of the 17 children who were taking sodium valproate with other drugs. No platelet-counts below 110 x 109/1 were recorded amongst 5 children on the highest doses of sodium valproate (520-1320 mg per day above the preferred daily dosage of 40 mg/kg bodyweight) or amongst the 8 children with the longest duration of -
treatment
(27-48 months).
Seizure control was not affected in children on sodium valproate whose platelet-counts were low. The white-cell count, red-cell count, and haemoglobin were unaffected. Clinically important disturbances of haemostasis were unusual. A boy on sodium valproate alone had a platelet-count of 40 x 109/1 after emergency appendicectomy in June 1977. There was no evidence of undue bleeding. In September a 9 x 10 cm bruise was noted on his right buttock with other smaller bruises on the left buttock and legs. A week earlier his platelet-count had been 80 x 109/1. After carbamazepine had been substituted, sodium valproate was tapered off and when he stopped taking valproate his platelet-count was 150 x 109/1; a month later it had risen to 270 x 109/1. We have heard of similar cases, including a female whose platelet-count rose from 40 x 109/1 to 290 109/1 within two weeks of sodium valproate being stopped. 5 other children at the school who were taking this drug bruised easily (an unusual site was over the Achilles tendon where the upper rim of the shoe exerts pressure). A nurse recalled a boy who had presented in February, 1977, with an unexplained oval hsematoma 5 x 12 cm on his scalp; his platelet-count in June was 110 x 109/1. Another girl had bruising and incontinence, both of which stopped after valproate was discontinued. The fact that 27 of the 35 children in school were on sodium valproate alone or in combination with other drugs is an indication of the usefulness of this drug in the management of children with severe epilepsy needing residential management. In only 2 cases did the drug have to be discontinued, although dosages are being kept as low as possible. It would seem advisable to check the platelet-count before surgery on a child on ,
long-term anticonvulsant therapy. Lancaster Royal Lancaster
Infirmary,
R. E. RAWORTH G. BIRCHALL
DISAPPEARANCE OF HÆMATOLOGIST IN ARGENTINA
SiR,—On March 8, Dr Beatriz Iparraguirre de Weinstein arrested in Argentina and has not been seen since. Dr de Weinstein, married with two daughters, is head of the clinical haematology service of the Ramos Mejia Hospital in Buenos Aires. She is a research-worker and is well known in North and South America for her work on abnormal haemoglobins and thalassfemia. In collaboration with British scientists she played a major role in the discovery of the Hb Buenos
was
Aires. Several members of haematology departments in the U.K. who have known her have received urgent telegrams from Argentina asking for immediate action to save her life, and then to contact Argentinian government officials. Dr de Weinstein was not involved in any political activities. The list of people who have disappeared in Argentina since
March, 1976, occupies 22 pages of the latest report of Amnesty
International, and includes many physicians and scientists. Department of Hæmatology, Royal Postgraduate Medical School,
D. CATOVSKY
London W12
SMOKING AND ORAL CARCINOMA
SIR,-Dr Trell and his colleagues (Jan. 14, p. 109) state that "although oral carcinomas form a heterogeneous group, we included only squamous-cell varieties which have been shown to be clearly associated with smoking". This implies a causal relationship between smoking and squamous-cell carcinoma in the mouth, but the work that Trell et al. cite in support of their assertion is concerned with the effects of smoking on bronchial epithelium. The search for causes underlying the development of oral cancer could be diverted by assumptions that oral epithelium is vulnerable to the same carcinogenic influences as affect the respiratory tract. Department of Dental Science, Royal College of Surgeons of England,
B. COHEN
London WC2A 3PN
*<* This letter has been shown lows.-ED.L.
to
Dr
Trell, whose reply fol-
SIR,-We would like to take the opportunity here to draw attention to the ample published evidence for a relation between smoking and carcinoma, in particular squamous-cell varieties, of the oral cavity. 1-7 In our letter we were concerned with brevity and chose to refer to only one comprehensive work on the relationship between smoking and squamous-cell transformation, albeit in the respiratory tract. The search for other possible causes underlying the development of oral cancer is clearly of major importance and warrants further elucidation. Section of Preventive Medicine,
Department of Internal medicine, University of Lund Malmö General Hospital Malmö, Sweden
ERIK TRELL
Department of Tumour Cytogenetics, Wallenberg Laboratory, University of Lund
ROLF KORSGAARD
MATERNAL HYPERTHERMIA AND ANENCEPHALY
SiR,—The account by Mr Miller and his colleagues (March 11, p. 519) of ten to twelve cases in which hyperthermia dur-
ing the third and fourth weeks of gestation was followed by the birth of an anencephalic is certainly interesting, butthere are at least two unacknowledged weaknesses in the reasons they give for thinking that the relationship between the hyperthermia and the defect may be causal. Firstly, they do not consider the fallibility of human memory as a possible explanation for their finding that episodes of hyperthermia were recalled by a much higher proportion of mothers of anencephalics than of their two control groups. The women in one of these control groups, like the cases’ mothers, were interviewed up to ten years after the relevant birth-plenty of time for the mother of a normal child to forget and the mother of an anencephalic to embroider 1. The Health
Consequences of Smoking. D.H.E.W. Publication no. 76-8704; pp. 43, 50. Atlanta, Georgia, 1975. 2. Fortier, R. A.J. Can. dent. Ass. 1975, 44, 235. 3. Andrieu-Guitrancourt, J. Quest méd. 1976, 29, 309. 4. Jafarey, N. A., Zaidi, S. H. M. Trop. Doctor, 1976, 6, 63. 5. Wahi, P. N. in Cancer in Asia: Opportunities for Prevention, Detection and Treatment (edited by T. Hirayama); p. 19. Tokyo, 1976. 6. Binnie, W. H. Proc. R. Soc. Med. 1976, 69, 737. 7. William, R. R., Horm. J. W. J. nat. Cancer Inst. 1977, 58, 525.