- Email: [email protected]
VIRUS ISOLATION STUDIES IN SIMIAN AIDS
403 with ileorectal anastomosis seems an acceptable 3 but carcinoma of the rectum is a persistent threat,3 and the functional results are poor; liquid and frequent stools are a very likely outcome and permanent faecal incontinence may sometimes ensue. In our patient, it seems unlikely that the many rectal polyps can be controlled by endoscopic fulguration and/or spontaneous regression after colectomy. Since the whole of the gastric mucosa of this man is carpeted with polyps, the acceptable solution would be total gastrectomy. So we have a healthy young patient, completely symptom-free, who is prone to cancer in the next 10 or 20 years, and we have to propose for him radical surgery, knowing that the more radical the operation the less will be the risk of cancer. If he decides on surgery and survives it he will have to face all the consequences of total gastrectomy and, perhaps, those of a stoma; and he will almost certainly lose control of bowel movements. As surgeons we must try to convince him of the need for surgery but we must not try to hide or even play down the consequences. The decision is the patient’s and his consent must be an informed one. He has the right to decide to live a normal life as long as he can and to refuse the operation-as, perhaps, we would were we in his place.
colectomy
VIRUS ISOLATION STUDIES IN SIMIAN AIDS
alternative, 7,8
1st Surgical Service, Faculty of Medicine, Hospital de S João, 4200 Porto, Portugal
ROGÉRIO A. F. GONZAGA M. AMARANTE JUNIOR F. REIS LIMA
5-AMINOSALICYLIC ACID AS RECTAL ENEMA IN ULCERATIVE COLITIS PATIENTS UNABLE TO TAKE SULPHASALAZINE
SIR,-We can confirm that 5-aminosalicylic acid (5-ASA) is, for patients unable to take sulphasalazine, a safe form of treatment not only when given orally in slow-release form but also as a highdosage enema2in our outpatient clinic. 24 patients presenting with an acute attack of ulcerative colitis and with a history of allergic reaction to sulphasalazine (rashes in 14, autoimmune haemolytic anaemia in 1, fever and rashes in 1) or who had had to stop taking the drug because of nausea and vomiting (8 patients) were treated with 5-ASA enemas. These patients (male 13, female 11; mean age 41, range 23-71; colitis localised to rectum in 5, sigmoid colon in 13, and left colon in 6) received one, two, or three courses of 5-ASA enemas containing 2 or 4 g of 5-ASA for 15 or 30 days. Of the 32 treatment courses 28 associated with clinical improvement and 27 with were sigmoidoscopic improvement. 4 patients experienced side-effects; in 3 these were as for sulphasalazine (rashes in 2, rashes and fever in 1) while another patient reported dizziness. These reactions were few hours after the first enema, at a time when, in our experience, plasma levels of 5-ASA reach a peak (2 - 6±2 - 3 g/ml); this suggests an idiosyncratic or allergic reaction. Discontinuation of therapy in 3 cases and intravenous prednisolone (30 mg daily for 3 days) in the most severe case promptly restored the situation to normal. No gastrointestinal intolerance was observed. Our experience is limited to short-term side-effects because topical treatment is usually given to check acute attacks; whether more prolonged administration could cause other disturbances remains to be seen, but since 5-ASA does not accumulate in the plasma this seems unlikely. As a safety precaution we suggest one or two test enemas before a full treatment cycle of 5-ASA is embarked upon in a patient who has proved sensitive to sulphasalazine. noted
a
Medical Clinic I, Policlinico S Orsola, 40138 Bologna, 7
8
SIR,-A letter in last week’s Lancet (p 334) reported the isolation, the National Institutes of Health, of a retrovirus from rhesus
monkeys with simian acquired immunodeficiency syndrome (SAIDS) and the transmission of disease to normal monkeys. It was further stated that the p27 core antigen of the virus was related to that of the Mason-Pfizer monkey virus (MPMV). We would like to add at this time that we have isolated a similar virus at the California Primate Research Center and that further studies have revealed differences between our virus isolate and MPMV. Our studies will be published in Science. California Primate Research Center; and Department of Medical Pathology, University of California at Davis,
Davis, California 95616, USA
PRESTON A. MARX KENT G. OSBORN ROY V. HENRICKSON MURRAY B. GARDNER
HYPERBILIRUBINAEMIA AFTER BYPASS SURGERY
SIR,-The frequency ofhyperbilirubinaemia after cardiac surgery our department prompted us to start a prospective study last summer. We measured transaminases, alkaline phosphatase, total and conjugated serum bilirubin, haptoglobin, and free plasma haemoglobin prebperatively, immediately after the operation, and on the first, second, and fifth postoperative days. We present our preliminary results, on 118 patients, for comparison with other data. 1-3 in
Hyperbilirubinaemia (>50 pmol/1 or 3 mg/dl) was present in 59 of 118 patients (50%) on the first postoperative day and in 27 out of 117 (23%) on the second day. Median total bilirubin concentrations reached a peak on day 1 (figure) and only 9 patients reached their peak total bilirubin on the second postoperative day. After that bilirubin levels fell, except in 8 patients who showed a second peak on day 5 (followed by a steady decrease). The ratio total bilirubin to conjugated bilirubin fell from 2-7:1 on the first postoperative day to 1’ 9:1 on day 2 and 1-3:1 on day 5. If a patient’s total bilirubin was not above 3 mg/dl on day 1 it did not rise subsequently. In 7 patients alkaline phosphatases were raised (400-1200 U/1) apparently unconnected with serum bilirubin or transaminase values. Only in 2 patients was there a brief transaminase peak (up to 400 U/1). Serum haptoglobin levels dropped as bilirubin values rose4 and free plasma haemoglobin rose during surgery. out
1.
Collins JD, Ferner R, Murray A, Bassendine MF, Blesovsky A, Pearson DT. Incidence and prognostic importance of jaundice after cardiopulmonary bypass surgery.
Lancet 1983; i: 1119-23. 2. Sanderson RG, Ellison JH, Benson JA, Starr A. Jaundice following open heart surgery. Ann Surg 1967; 165: 217-24. 3. Wallace HW, Blakemore WS. Intravascular and extravascular hemolysis accompanying extracorporeal circulation. Circulation 1970; 42: 521-27. 4. Heilmann E, Ritzenhöfer A, Achatzy R, Dittrich H, Bender F. Haptoglobin and Transferrin nach künstlichem Herzklappenersatz. Herz/Kreisl 1978; 10: 84-91.
M. CAMPIERI G. A. LANFRANCHI C. BRIGNOLA G. BAZZOCCHI M. R. MINGUZZI M. T. CALARI
Gingold BS, Jagelman D, Turnbull RB. Surgical management of familial polyposis and Gardner’s syndrome. Am J Surg 1979; 137: 54-56. Harvey JC, Quan SHQ. Management of familial polyposis with preservation of the rectum. Surgery 1978; 84: 476-82.
1. Dew 2
Italy
at
MJ, Harries AD, Evans BK, Rhodes J. Treatment of ulcerative colitis with oral
5-aminosalicylic acid in patients unable to take sulphasalazine. Lancet 1983; ii: 801. Campieri M, Lanfranchi GA, Bazzocchi G, et al. Treatment of ulcerative colitis with high dosage 5-aminosalicylic acid enema. Lancet 1981; ii: 270-71.
Serum bilirubin values after
extracorporeal circulation.
colectomy
VIRUS ISOLATION STUDIES IN SIMIAN AIDS
alternative, 7,8
1st Surgical Service, Faculty of Medicine, Hospital de S João, 4200 Porto, Portugal
ROGÉRIO A. F. GONZAGA M. AMARANTE JUNIOR F. REIS LIMA
5-AMINOSALICYLIC ACID AS RECTAL ENEMA IN ULCERATIVE COLITIS PATIENTS UNABLE TO TAKE SULPHASALAZINE
SIR,-We can confirm that 5-aminosalicylic acid (5-ASA) is, for patients unable to take sulphasalazine, a safe form of treatment not only when given orally in slow-release form but also as a highdosage enema2in our outpatient clinic. 24 patients presenting with an acute attack of ulcerative colitis and with a history of allergic reaction to sulphasalazine (rashes in 14, autoimmune haemolytic anaemia in 1, fever and rashes in 1) or who had had to stop taking the drug because of nausea and vomiting (8 patients) were treated with 5-ASA enemas. These patients (male 13, female 11; mean age 41, range 23-71; colitis localised to rectum in 5, sigmoid colon in 13, and left colon in 6) received one, two, or three courses of 5-ASA enemas containing 2 or 4 g of 5-ASA for 15 or 30 days. Of the 32 treatment courses 28 associated with clinical improvement and 27 with were sigmoidoscopic improvement. 4 patients experienced side-effects; in 3 these were as for sulphasalazine (rashes in 2, rashes and fever in 1) while another patient reported dizziness. These reactions were few hours after the first enema, at a time when, in our experience, plasma levels of 5-ASA reach a peak (2 - 6±2 - 3 g/ml); this suggests an idiosyncratic or allergic reaction. Discontinuation of therapy in 3 cases and intravenous prednisolone (30 mg daily for 3 days) in the most severe case promptly restored the situation to normal. No gastrointestinal intolerance was observed. Our experience is limited to short-term side-effects because topical treatment is usually given to check acute attacks; whether more prolonged administration could cause other disturbances remains to be seen, but since 5-ASA does not accumulate in the plasma this seems unlikely. As a safety precaution we suggest one or two test enemas before a full treatment cycle of 5-ASA is embarked upon in a patient who has proved sensitive to sulphasalazine. noted
a
Medical Clinic I, Policlinico S Orsola, 40138 Bologna, 7
8
SIR,-A letter in last week’s Lancet (p 334) reported the isolation, the National Institutes of Health, of a retrovirus from rhesus
monkeys with simian acquired immunodeficiency syndrome (SAIDS) and the transmission of disease to normal monkeys. It was further stated that the p27 core antigen of the virus was related to that of the Mason-Pfizer monkey virus (MPMV). We would like to add at this time that we have isolated a similar virus at the California Primate Research Center and that further studies have revealed differences between our virus isolate and MPMV. Our studies will be published in Science. California Primate Research Center; and Department of Medical Pathology, University of California at Davis,
Davis, California 95616, USA
PRESTON A. MARX KENT G. OSBORN ROY V. HENRICKSON MURRAY B. GARDNER
HYPERBILIRUBINAEMIA AFTER BYPASS SURGERY
SIR,-The frequency ofhyperbilirubinaemia after cardiac surgery our department prompted us to start a prospective study last summer. We measured transaminases, alkaline phosphatase, total and conjugated serum bilirubin, haptoglobin, and free plasma haemoglobin prebperatively, immediately after the operation, and on the first, second, and fifth postoperative days. We present our preliminary results, on 118 patients, for comparison with other data. 1-3 in
Hyperbilirubinaemia (>50 pmol/1 or 3 mg/dl) was present in 59 of 118 patients (50%) on the first postoperative day and in 27 out of 117 (23%) on the second day. Median total bilirubin concentrations reached a peak on day 1 (figure) and only 9 patients reached their peak total bilirubin on the second postoperative day. After that bilirubin levels fell, except in 8 patients who showed a second peak on day 5 (followed by a steady decrease). The ratio total bilirubin to conjugated bilirubin fell from 2-7:1 on the first postoperative day to 1’ 9:1 on day 2 and 1-3:1 on day 5. If a patient’s total bilirubin was not above 3 mg/dl on day 1 it did not rise subsequently. In 7 patients alkaline phosphatases were raised (400-1200 U/1) apparently unconnected with serum bilirubin or transaminase values. Only in 2 patients was there a brief transaminase peak (up to 400 U/1). Serum haptoglobin levels dropped as bilirubin values rose4 and free plasma haemoglobin rose during surgery. out
1.
Collins JD, Ferner R, Murray A, Bassendine MF, Blesovsky A, Pearson DT. Incidence and prognostic importance of jaundice after cardiopulmonary bypass surgery.
Lancet 1983; i: 1119-23. 2. Sanderson RG, Ellison JH, Benson JA, Starr A. Jaundice following open heart surgery. Ann Surg 1967; 165: 217-24. 3. Wallace HW, Blakemore WS. Intravascular and extravascular hemolysis accompanying extracorporeal circulation. Circulation 1970; 42: 521-27. 4. Heilmann E, Ritzenhöfer A, Achatzy R, Dittrich H, Bender F. Haptoglobin and Transferrin nach künstlichem Herzklappenersatz. Herz/Kreisl 1978; 10: 84-91.
M. CAMPIERI G. A. LANFRANCHI C. BRIGNOLA G. BAZZOCCHI M. R. MINGUZZI M. T. CALARI
Gingold BS, Jagelman D, Turnbull RB. Surgical management of familial polyposis and Gardner’s syndrome. Am J Surg 1979; 137: 54-56. Harvey JC, Quan SHQ. Management of familial polyposis with preservation of the rectum. Surgery 1978; 84: 476-82.
1. Dew 2
Italy
at
MJ, Harries AD, Evans BK, Rhodes J. Treatment of ulcerative colitis with oral
5-aminosalicylic acid in patients unable to take sulphasalazine. Lancet 1983; ii: 801. Campieri M, Lanfranchi GA, Bazzocchi G, et al. Treatment of ulcerative colitis with high dosage 5-aminosalicylic acid enema. Lancet 1981; ii: 270-71.
Serum bilirubin values after
extracorporeal circulation.