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SPIRAMYCIN PROPHYLAXIS IN SURGERY
246 within the lumen of the bowel. There was no contamination of the peritoneal space. This case was the exception to the rule that the peritoneal catheter should always be passed at a distance from previous operative sites. Dialysis Unit, Veterans Administration Hospital, BARUCH J. HURWICH. Bronx, New York 10468.
passed
CORTICOSTEROIDS IN PREGNANCY
SiR,—The article by Mr. Warrell and Miss Taylor (Jan. 20, p. 117) prompts me to record some figures on corticosteroid therapy in pregnancy. By a search of the published reports I have found 62 cases of acute leukaemia and 10 cases of chronic leukxmia in which corticosteroids (63 cases) or corticotrophin (9 cases) were given during pregnancies since 1955. 19 pregnancies ended before the 28th week: 9 mothers died undelivered, and 10 aborted (1 induced). Cytotoxic drugs were also given in 13 of these pregnancies. 53 pregnancies continued beyond the 28th week. These resulted in 45 surviving babies (one set of twins), 5 stillbirths, and 4 neonatal deaths. Cytotoxic drugs were also given in 27 of these pregnancies. 2 of the 5 mothers who had stillbirths were given corticotrophin alone. The 4 neonatal deaths occurred after delivery at 30 weeks, 7-8 months, 36 weeks, and 38 weeks. The birthweights of 31 of the 54 babies delivered after the 28th week were recorded (cytotoxic drugs were also administered in 14 of these 31). 4 birthweights fell below the 10th smoothed percentile.1 Another 4 babies were reported as being " mature ". All 9 mothers who lost their babies, and 13 out of the 44 whose babies survived, died within a fortnight of confinement. Thus, despite severe maternal disease and corticosteroid therapy (though not necessarily throughout pregnancy), there was no significant incidence of placental insufficiency in these
reported
cases.
Queen Elizabeth Hospital, Birmingham.
H. OLIPHANT NICHOLSON.
SIR,-The article by Mr. Warrell and Miss Taylor (Jan. 20,
117) is of interest. It is perhaps a little unfortunate that patients who aborted were not traced, since this leaves the findings open to the criticism, first advanced I believe by Dr. D. H. M. Woollam, that glucocorticoids actually protect some damaged embryos against abortion and enable them to survive until the perinatal period, when they die or exhibit malIf the outcome of all pregnancies, including formations. those ending in abortion, were known, this type of argument could if necessary be countered. Such an approach has, for example, been used in the Royal College of General Practitioners survey2 on the outcome of pregnancy. p.
Lowestoft, Suffolk.
M. P. CARTER.
SPIRAMYCIN PROPHYLAXIS IN SURGERY not contend that antibiotics should be used for
SIR, We do
prophylaxis in surgery, as suggested by the comments (Jan. 6, p. 1) by Dr. Stokes last week (p. 204). We feel, however, that there is a place for prophylaxis for a special group of patients at risk against a specific organism. In this area elderly men awaiting prostatectomy in a general surgical ward were found to have a high incidence (63%) of pre-existing chest disease, and experience over the years has shown that they were very liable to develop postoperative staphylococcal sepsis.
routine on our
paper
Double-blind trials may be ideal, but on many occasions are impracticable. On this occasion the other patients in the surgical Lubchenco, L. O., Hansman, C., Dressler, M., Boyd, E. Pediatrics, Springfield, 1963, 32, 793. 2. Slater, B. C. S. in A Symposium on Embryopathic Activity of Drugs, p. 241. London, 1965. 1.
ward acted as " controls ", in that they were nursed in the same environment and were hence under the same risks as the prostatectomy patients. Our results showed that there were more cases of staphylococcal infection in this " control " group than in those undergoing prostatectomy (see our table v). Less than twenty isolations have been made of spiramycinresistant strains of Staphylococcus aureus despite the increasing use of this antibiotic in various units in the hospital. At the time of writing, no spiramycin-resistant strains causing sepsis are known to be present in the hospital. Not to use an antibiotic in a selected group of patients because resistance might develop does not seem to us a valid argument. A. A. B. MITCHELL Law Hospital, J. A. MACFARLANE. Carluke, Lanarkshire.
PLATELET BEHAVIOUR IN MULTIPLE SCLEROSIS SIR,-Prompted by the findings of several studies demonstrating increased glass-adhesiveness of platelets from multiple sclerosis (M.S.) patients Dr. Bolton and his colleagues (Jan. 20, p. 99) advance convincing evidence of abnormal plasma factors in the disease. Yet they are rightly cautious before attributing increased glass-adhesiveness to the disturbed plasmaphospholipid patterns they describe. For in the group of chronic M.S. patients in whom the more specific electrophoretic responses are encountered, the available evidence indicates that platelet adhesiveness is likely to be within normal limits.l By contrast, in two patients with acute M.S., who might have been expected to have high platelet adhesiveness, they found the same electrophoretic responses as in any acutely ill patient. Dr. Bolton and his colleagues raise again the possibility that in the adhesiveness reaction the platelets act as indicators of a primary abnormality of the red blood-cells in patients with M.S., which release excessive quantities of adenosine diphosphate (A.D.P.). This problem has recently been investigated in this unit in two ways. Firstly, an attempt was made to correlate measurements of red-cell osmotic fragility and platelet adhesiveness. Secondly, the effect of adding adenosine to bloodsamples from M.S. patients immediately before estimating platelet adhesiveness was noted.
Method 1. Red-blood-cell osmotic fragility was measured (by Mrs. Francis the method of Parpart et awl. as described by Caspary et al. Platelet adhesiveness was estimated by a minor modification of Payling Wright’s rotating-bulb technique, as I have described.4 Both measurements were carried out simultaneously on the same bloodsample. Blood-samples were collected from 26 subjects: 14 M.S. patients, 7 patients with other neurological diseases, and 5 healthy volunteers. 2. Adenosine (Sigma) was diluted with isotonic saline solution to give a solution such that addition of 0-1 ml. to the 2 ml. blood-sample used for measuring platelet adhesiveness resulted in a final concentration of adenosine in blood of 10--3M. Blood-samples from 29 subjects were studied-10 M.S. patients who had recently relapsed, 10 M.S. patients with inactive disease, and 9 healthy people. In each case platelet adhesiveness was measured in duplicate blood-samples, to one of which 0-1 ml. adenosine was added immediately before rotation; no addition was made to the other sample. The rotationtime used during measurement of platelet adhesiveness in this experiment was reduced from 30 to 20 minutes, since this showed the effect of adenosine to better advantage.
Sewell) using
Results No relation (r 0- 06) was found between red-blood-cell osmotic fragility and platelet adhesiveness. In patients with active M.S. the effect of adding adenosine was different from that in both inactive patients and healthy subjects (see table 1). Nathanson, M., Savitsky, J. P. Bull. N.Y. Acad. Med. 1952, 28, 462. Millar, J. H. D., Merrett, J. D., Dalby, A. M. J. Neurol. Neurosurg. Psychiat. 1966, 29, 187. 2. Parpart, A. K., Lorenz, P. B., Parpart, E. R., Chase, A. M. J. clin. Invest. 1947, 26, 636. 3. Caspary, E. A., Sewell, F., Field, E. J. Br. med. J. 1967, ii, 610. 4. Millac, P. ibid. 1967, iv, 25. 1.
passed
CORTICOSTEROIDS IN PREGNANCY
SiR,—The article by Mr. Warrell and Miss Taylor (Jan. 20, p. 117) prompts me to record some figures on corticosteroid therapy in pregnancy. By a search of the published reports I have found 62 cases of acute leukaemia and 10 cases of chronic leukxmia in which corticosteroids (63 cases) or corticotrophin (9 cases) were given during pregnancies since 1955. 19 pregnancies ended before the 28th week: 9 mothers died undelivered, and 10 aborted (1 induced). Cytotoxic drugs were also given in 13 of these pregnancies. 53 pregnancies continued beyond the 28th week. These resulted in 45 surviving babies (one set of twins), 5 stillbirths, and 4 neonatal deaths. Cytotoxic drugs were also given in 27 of these pregnancies. 2 of the 5 mothers who had stillbirths were given corticotrophin alone. The 4 neonatal deaths occurred after delivery at 30 weeks, 7-8 months, 36 weeks, and 38 weeks. The birthweights of 31 of the 54 babies delivered after the 28th week were recorded (cytotoxic drugs were also administered in 14 of these 31). 4 birthweights fell below the 10th smoothed percentile.1 Another 4 babies were reported as being " mature ". All 9 mothers who lost their babies, and 13 out of the 44 whose babies survived, died within a fortnight of confinement. Thus, despite severe maternal disease and corticosteroid therapy (though not necessarily throughout pregnancy), there was no significant incidence of placental insufficiency in these
reported
cases.
Queen Elizabeth Hospital, Birmingham.
H. OLIPHANT NICHOLSON.
SIR,-The article by Mr. Warrell and Miss Taylor (Jan. 20,
117) is of interest. It is perhaps a little unfortunate that patients who aborted were not traced, since this leaves the findings open to the criticism, first advanced I believe by Dr. D. H. M. Woollam, that glucocorticoids actually protect some damaged embryos against abortion and enable them to survive until the perinatal period, when they die or exhibit malIf the outcome of all pregnancies, including formations. those ending in abortion, were known, this type of argument could if necessary be countered. Such an approach has, for example, been used in the Royal College of General Practitioners survey2 on the outcome of pregnancy. p.
Lowestoft, Suffolk.
M. P. CARTER.
SPIRAMYCIN PROPHYLAXIS IN SURGERY not contend that antibiotics should be used for
SIR, We do
prophylaxis in surgery, as suggested by the comments (Jan. 6, p. 1) by Dr. Stokes last week (p. 204). We feel, however, that there is a place for prophylaxis for a special group of patients at risk against a specific organism. In this area elderly men awaiting prostatectomy in a general surgical ward were found to have a high incidence (63%) of pre-existing chest disease, and experience over the years has shown that they were very liable to develop postoperative staphylococcal sepsis.
routine on our
paper
Double-blind trials may be ideal, but on many occasions are impracticable. On this occasion the other patients in the surgical Lubchenco, L. O., Hansman, C., Dressler, M., Boyd, E. Pediatrics, Springfield, 1963, 32, 793. 2. Slater, B. C. S. in A Symposium on Embryopathic Activity of Drugs, p. 241. London, 1965. 1.
ward acted as " controls ", in that they were nursed in the same environment and were hence under the same risks as the prostatectomy patients. Our results showed that there were more cases of staphylococcal infection in this " control " group than in those undergoing prostatectomy (see our table v). Less than twenty isolations have been made of spiramycinresistant strains of Staphylococcus aureus despite the increasing use of this antibiotic in various units in the hospital. At the time of writing, no spiramycin-resistant strains causing sepsis are known to be present in the hospital. Not to use an antibiotic in a selected group of patients because resistance might develop does not seem to us a valid argument. A. A. B. MITCHELL Law Hospital, J. A. MACFARLANE. Carluke, Lanarkshire.
PLATELET BEHAVIOUR IN MULTIPLE SCLEROSIS SIR,-Prompted by the findings of several studies demonstrating increased glass-adhesiveness of platelets from multiple sclerosis (M.S.) patients Dr. Bolton and his colleagues (Jan. 20, p. 99) advance convincing evidence of abnormal plasma factors in the disease. Yet they are rightly cautious before attributing increased glass-adhesiveness to the disturbed plasmaphospholipid patterns they describe. For in the group of chronic M.S. patients in whom the more specific electrophoretic responses are encountered, the available evidence indicates that platelet adhesiveness is likely to be within normal limits.l By contrast, in two patients with acute M.S., who might have been expected to have high platelet adhesiveness, they found the same electrophoretic responses as in any acutely ill patient. Dr. Bolton and his colleagues raise again the possibility that in the adhesiveness reaction the platelets act as indicators of a primary abnormality of the red blood-cells in patients with M.S., which release excessive quantities of adenosine diphosphate (A.D.P.). This problem has recently been investigated in this unit in two ways. Firstly, an attempt was made to correlate measurements of red-cell osmotic fragility and platelet adhesiveness. Secondly, the effect of adding adenosine to bloodsamples from M.S. patients immediately before estimating platelet adhesiveness was noted.
Method 1. Red-blood-cell osmotic fragility was measured (by Mrs. Francis the method of Parpart et awl. as described by Caspary et al. Platelet adhesiveness was estimated by a minor modification of Payling Wright’s rotating-bulb technique, as I have described.4 Both measurements were carried out simultaneously on the same bloodsample. Blood-samples were collected from 26 subjects: 14 M.S. patients, 7 patients with other neurological diseases, and 5 healthy volunteers. 2. Adenosine (Sigma) was diluted with isotonic saline solution to give a solution such that addition of 0-1 ml. to the 2 ml. blood-sample used for measuring platelet adhesiveness resulted in a final concentration of adenosine in blood of 10--3M. Blood-samples from 29 subjects were studied-10 M.S. patients who had recently relapsed, 10 M.S. patients with inactive disease, and 9 healthy people. In each case platelet adhesiveness was measured in duplicate blood-samples, to one of which 0-1 ml. adenosine was added immediately before rotation; no addition was made to the other sample. The rotationtime used during measurement of platelet adhesiveness in this experiment was reduced from 30 to 20 minutes, since this showed the effect of adenosine to better advantage.
Sewell) using
Results No relation (r 0- 06) was found between red-blood-cell osmotic fragility and platelet adhesiveness. In patients with active M.S. the effect of adding adenosine was different from that in both inactive patients and healthy subjects (see table 1). Nathanson, M., Savitsky, J. P. Bull. N.Y. Acad. Med. 1952, 28, 462. Millar, J. H. D., Merrett, J. D., Dalby, A. M. J. Neurol. Neurosurg. Psychiat. 1966, 29, 187. 2. Parpart, A. K., Lorenz, P. B., Parpart, E. R., Chase, A. M. J. clin. Invest. 1947, 26, 636. 3. Caspary, E. A., Sewell, F., Field, E. J. Br. med. J. 1967, ii, 610. 4. Millac, P. ibid. 1967, iv, 25. 1.