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The elderly and antidepressants
had a Heaf test reaction of 2 +, but had received BCG vaccination. All other tests were negative (Mantoux reaction < 5 mm or Heaf reaction 0 or 1 +). In addition, questionnaires received from 55 (22%) of the 246 passengers who were not US citizens, and test results were reported for 20 (8%). 2 men from the UK had Heaf reactions of 4 + or 3 +. Chest were
radiographs were normal for both and both had histories suggestive of past exposure to M tuberculosis ; thus, these 2 were not regarded as converters. 5 others from the UK had positive skin-test reactions (4 had Heaf results of 2 +,had a Mantoux result of 8 mm), but each had received BCG vaccination. All other test results were negative. This investigation required more than 600 hours of personnel time at the Minnesota Department of Health (MDH) and lasted 3 months. Direct costs to MDH in personnel time, telephone calls, and materials exceeded$25 000. transmission. We are unable to find reports of M tuberculosis transmission among passengers on a single flight. However, the risk of exposure during air travel exists; although short term, such exposures could be intense and result in transmission.
Jeffrey W McFarland Minnesota Department of Health, PO Box 9441, Minneapolis, Minnesota 55440, USA; and Department of Field Epidemiology, Centers for Disease Control and Prevention,
Bethesda, Maryland
Cynthia Hickman, Michael T Osterholm, Kristine L MacDonald Minnesota
Department of Health
1 Sudre P, ten Dam G, Kochi A. Tuberculosis: a global overview of the situation today. Bull WHO 1992; 70: 149-59. 2 US Travel Data Center. National Travel Survey, annual. Washington,
DC, 1991. 3 US Bureau of the Census, Statistical Abstract of the United States: 1992, Washington DC, 1992. 4 US Department of State. Report of the Visa Office, Washington, DC, 1991.
The elderly and antidepressants SiR-Tallis’ commentary (June 5, p 1444) on our paper1 is dangerously misleading. If geriatricians were to regard depressed affect as "reasonable" and psychogeriatricians to consider depression simply a "social construct", suffering would immeasurably increase, as would the suicide rate in the group most at risk of killing themselves. Depressive illness is not invalid simply because diagnosis is not as objective as it is for myocardial infarction. To the untutored, a pensioner’s complaints of poverty may seem "reasonable". Is it reasonable that she kills herself in the delusional belief that her poverty merits transfer to the workhouse? Experienced psychogeriatricians all know that apparently necessary and sufficient "causes" of depression in the elderly continue to exist after recovery when patients cope well again and resume active life. Tallis falls into a common ageist error that old people lead such horrid lives they have "a right to be
depressed". Although 69 patients
randomised from
an original 219 is a subjected to survival analysis, yielded highly significant results, and no type II error was
small number,
our
tilting
data
were
observed. The reasons for non-randomisation were varied and included non-consent and physical illness. The main reason for not being randomised did not concern "identifying antidepressant-responsive sources of unhappiness" (Tallis), but inadequate recovery from a serious, potentially fatal illness after treatment with not only an antidepressant (another Tallis error) but also psychotherapy and sometimes electroconvulsive therapy and lithium. We stand corrected for not mentioning
at
windmills
over
prolonged colleagues
Robin Jacoby Bethlem
1
Although the source-case was considered highly infectious, results of this investigation did not demonstrate evidence of
drug reactions. There
were none serious. Tallis is the need for psychotherapy and monitoring: it is my practice and that of most of my to monitor and treat patients with supportive psychotherapy for years. That does not obviate the need to prevent relapse with medication. As a psychogeriatrician I am tempted to ask if I may write the next Lancet commentary on a paper which proposes prolonged treatment for elderly patients recovered from, say, heart failure. I shall not do so, however, but adhere to my normal practice of not grazing in a neighbour’s field.
adverse
Royal Hospital, Beckenham,
Kent BR3 3BX, UK
Old
Age Depression Interest Group. How long should the elderly take antidepressants? A double-blind placebo-controlled study of continuation/prophylaxis therapy with dothiepin. Br J Psychiatry 1993; 163: 175-82.
Serum
myeloperoxidase and sick building syndrome SIR—We observed increased serum concentrations of leucocyte activation markers in a household of 5 people, all of whom had respiratory disorders. Concentrations remained high for up to 9 months, the time that the patients were followed. The most notable observation was high myeloperoxidasel (MPO), suggesting neutrophil or monocyte activation. Also eosinophil cationic protein (ECP) and eosinophil protein X (EPX) were raised; this suggests eosinophil activation, which is regularly seen in asthma. The patients had no pets and were nonsmokers, 4 were non-atopic, and all lived in the same apartment in a building constructed in 1926. They could perhaps be characterised as having the poorly-defined sick building syndrome: mother, 48, had asthma for 17 years; father, 55, bronchitis for 10 years and arthritis 24 years; daughter, 21, asthma for 5 years, atopic; son, 20, chronic rhinitis and suspected asthma; and son’s girlfriend, 20, in the household for 7 months, had symptoms suggesting prolonged respiratory infections. Serum samples were obtained from each patient 2-5 times over 9 months. In every sample MPO and EPX were high, and ECP was occasionally within the reference range. Observed patient (and reference) ranges were: MPO 1300-5100 (ig/L (170-48); ECP 8-4-54-7 g/L (2-3-16); and EPX 54-250 g/L (8-2-39). Leucocyte and differential counts remained within reference ranges with the exception of one slightly raised and one slightly lowered neutrophil count; C-reactive protein remained within the reference range, and a few raised sedimentation rates were observed. As possible causes of the leucocyte activation we considered infections or indoor air pollution by mould spores or volatile organic compounds. Sera were screened for antibodies against 17 viruses, Chlamydia pneumoniae (TWAR), and Legionella pneumophila. The most notable finding was IgG (but not IgM) antibodies in moderate concentration against chlamydia in the sera of 2 patients. The daughter had an immunologically verified history of a Coxsackie B5 viral infection 3 years earlier. Mould spores in indoor air were measured on two occasions with the Andersen method. Three times the outdoor concentration was recorded once in one bedroom; otherwise concentrations were low. Mould genera identified were Penicillium (two species), Rhizopus, and Mucor. Volatile organic compounds were sought in indoor air with thermal desorption gas-chromatography/ mass-spectrometry. Tetrachloroethene (presumably from drycleaned clothes) and alkylbenzenes (from traffic exhaust, cooking, and paints) were found in moderate concentrations. 113
radiographs were normal for both and both had histories suggestive of past exposure to M tuberculosis ; thus, these 2 were not regarded as converters. 5 others from the UK had positive skin-test reactions (4 had Heaf results of 2 +,had a Mantoux result of 8 mm), but each had received BCG vaccination. All other test results were negative. This investigation required more than 600 hours of personnel time at the Minnesota Department of Health (MDH) and lasted 3 months. Direct costs to MDH in personnel time, telephone calls, and materials exceeded$25 000. transmission. We are unable to find reports of M tuberculosis transmission among passengers on a single flight. However, the risk of exposure during air travel exists; although short term, such exposures could be intense and result in transmission.
Jeffrey W McFarland Minnesota Department of Health, PO Box 9441, Minneapolis, Minnesota 55440, USA; and Department of Field Epidemiology, Centers for Disease Control and Prevention,
Bethesda, Maryland
Cynthia Hickman, Michael T Osterholm, Kristine L MacDonald Minnesota
Department of Health
1 Sudre P, ten Dam G, Kochi A. Tuberculosis: a global overview of the situation today. Bull WHO 1992; 70: 149-59. 2 US Travel Data Center. National Travel Survey, annual. Washington,
DC, 1991. 3 US Bureau of the Census, Statistical Abstract of the United States: 1992, Washington DC, 1992. 4 US Department of State. Report of the Visa Office, Washington, DC, 1991.
The elderly and antidepressants SiR-Tallis’ commentary (June 5, p 1444) on our paper1 is dangerously misleading. If geriatricians were to regard depressed affect as "reasonable" and psychogeriatricians to consider depression simply a "social construct", suffering would immeasurably increase, as would the suicide rate in the group most at risk of killing themselves. Depressive illness is not invalid simply because diagnosis is not as objective as it is for myocardial infarction. To the untutored, a pensioner’s complaints of poverty may seem "reasonable". Is it reasonable that she kills herself in the delusional belief that her poverty merits transfer to the workhouse? Experienced psychogeriatricians all know that apparently necessary and sufficient "causes" of depression in the elderly continue to exist after recovery when patients cope well again and resume active life. Tallis falls into a common ageist error that old people lead such horrid lives they have "a right to be
depressed". Although 69 patients
randomised from
an original 219 is a subjected to survival analysis, yielded highly significant results, and no type II error was
small number,
our
tilting
data
were
observed. The reasons for non-randomisation were varied and included non-consent and physical illness. The main reason for not being randomised did not concern "identifying antidepressant-responsive sources of unhappiness" (Tallis), but inadequate recovery from a serious, potentially fatal illness after treatment with not only an antidepressant (another Tallis error) but also psychotherapy and sometimes electroconvulsive therapy and lithium. We stand corrected for not mentioning
at
windmills
over
prolonged colleagues
Robin Jacoby Bethlem
1
Although the source-case was considered highly infectious, results of this investigation did not demonstrate evidence of
drug reactions. There
were none serious. Tallis is the need for psychotherapy and monitoring: it is my practice and that of most of my to monitor and treat patients with supportive psychotherapy for years. That does not obviate the need to prevent relapse with medication. As a psychogeriatrician I am tempted to ask if I may write the next Lancet commentary on a paper which proposes prolonged treatment for elderly patients recovered from, say, heart failure. I shall not do so, however, but adhere to my normal practice of not grazing in a neighbour’s field.
adverse
Royal Hospital, Beckenham,
Kent BR3 3BX, UK
Old
Age Depression Interest Group. How long should the elderly take antidepressants? A double-blind placebo-controlled study of continuation/prophylaxis therapy with dothiepin. Br J Psychiatry 1993; 163: 175-82.
Serum
myeloperoxidase and sick building syndrome SIR—We observed increased serum concentrations of leucocyte activation markers in a household of 5 people, all of whom had respiratory disorders. Concentrations remained high for up to 9 months, the time that the patients were followed. The most notable observation was high myeloperoxidasel (MPO), suggesting neutrophil or monocyte activation. Also eosinophil cationic protein (ECP) and eosinophil protein X (EPX) were raised; this suggests eosinophil activation, which is regularly seen in asthma. The patients had no pets and were nonsmokers, 4 were non-atopic, and all lived in the same apartment in a building constructed in 1926. They could perhaps be characterised as having the poorly-defined sick building syndrome: mother, 48, had asthma for 17 years; father, 55, bronchitis for 10 years and arthritis 24 years; daughter, 21, asthma for 5 years, atopic; son, 20, chronic rhinitis and suspected asthma; and son’s girlfriend, 20, in the household for 7 months, had symptoms suggesting prolonged respiratory infections. Serum samples were obtained from each patient 2-5 times over 9 months. In every sample MPO and EPX were high, and ECP was occasionally within the reference range. Observed patient (and reference) ranges were: MPO 1300-5100 (ig/L (170-48); ECP 8-4-54-7 g/L (2-3-16); and EPX 54-250 g/L (8-2-39). Leucocyte and differential counts remained within reference ranges with the exception of one slightly raised and one slightly lowered neutrophil count; C-reactive protein remained within the reference range, and a few raised sedimentation rates were observed. As possible causes of the leucocyte activation we considered infections or indoor air pollution by mould spores or volatile organic compounds. Sera were screened for antibodies against 17 viruses, Chlamydia pneumoniae (TWAR), and Legionella pneumophila. The most notable finding was IgG (but not IgM) antibodies in moderate concentration against chlamydia in the sera of 2 patients. The daughter had an immunologically verified history of a Coxsackie B5 viral infection 3 years earlier. Mould spores in indoor air were measured on two occasions with the Andersen method. Three times the outdoor concentration was recorded once in one bedroom; otherwise concentrations were low. Mould genera identified were Penicillium (two species), Rhizopus, and Mucor. Volatile organic compounds were sought in indoor air with thermal desorption gas-chromatography/ mass-spectrometry. Tetrachloroethene (presumably from drycleaned clothes) and alkylbenzenes (from traffic exhaust, cooking, and paints) were found in moderate concentrations. 113