494
Screening identified mainly those patients who would probably not diagnosed, since the tumour would have regressed spontaneously, nor did it diagnose some of the patients who proved have been
to have disseminated disease. There are no reports about the effectiveness of screening high-risk populations (familial cases, patients with neurofibromatosis, nesidioblastosis, or fetal hydantoin
syndrome) .3 Our results need to be confirmed by other studies, but we suggest that urinary vanillylmandelic acid screening for high-risk populations, including infants bom to mothers treated by hormones, should be considered. Institute of Haematology and Department of Gynaecology, Chaim Sheba Medical Centre, Tel-Hashomer and Sackler School of Medicine, Tel-Aviv University, Tel-Hashomer 52 621, Israel
A. TOREN M. MANDEL G. RECHAVI
J. DOR I. BEN-BASSAT Y. NEUMANN
1. Bolande RP, Mayer DC. The cytolysis of human neuroblastoma cells by a natural IgM antibody complement system in pregnancy serum. Cancer Invest 1990; 8: 603-11. 2. Murphy SB, Cohn SL, Craft AW. Do children benefit from mass screening for neuroblastoma. Lancet 1991; 337: 344-45. 3. Pizzo PA, Poplack DC, eds. Principles and practice of pediatric oncology. Philadelphia: J. B. Lippincott, 1989.
Anaphylactic shock induced by intravenous gadopentetate dimeglumine SIR,-Since its introduction as a contrast agent for magnetic imaging (MRI), the efficacy and safety of gadopentetate dimeglumine have been well demonstrated. However, minor anaphylactoid reactions can arise. We report a case of anaphylactic shock that occurred after the administration of intravenous (iv) gadopentetate dimeglumine. A 40-year-old man was referred for MRI because of chronic spinal-cord injury. His medical history included pollen allergy and anaphylactic shock induced by iodine-based contrast agent during iv urography done 2 months earlier. Steroid administration was not judged necessary before MRI and 0.1mmol/kg iv gadopentetate dimeglumine was given. Shortly afterwards, the patient complained of generalised pruritus and difficulty in breathing, and was removed from the imager. Physical examination showed striking periorbital oedema, generalised erythema, and diffuse wheezing. His blood pressure was 90 mm Hg with regular tachycardia. He was immediately given 80 mg of iv methylprednisolone and oxygen by face mask. His condition did not improve and blood pressure dropped to 50 mm Hg. An additional 1 mg of adrenaline and 1 litre of gelatin fluid were given iv 5 minutes later. The patient was then resonance
admitted
to
intensive
care
for observation. Further clinical
improvement was seen a few hours later with additional iv gelatin fluid and methylprednisolone. Studies of gadopentetate dimeglumine in both adults and children have demonstrated a high safety margin compared, for example, with iodinated contrast material.’ The total prevalence of adverse reactions is about 2,4%,2 among which are headache, nausea, vomiting, local burning, and severe hypertension. There have been six reported deaths temporally associated with the administration of gadopentetate dimeglumine.3 The actual relation between these deaths and the use of the drug is still unclear. The 50% lethal dose (LD) in animals is 5-15 mmol/kg. This is 50 to 150 times greater than the 0-1 mmol/kg dose in patients, and compares favourably with a safety index (animal LDS°/clinical dose) of 10 for iodinated contrast materia1.4 Renal impairment or raised levels of zinc or copper such as seen in Wilson disease may increase the plasma concentration of free gadolinium ion which is highly toxic. The safety of gadopentetate in these conditions has not been demonstrated clearly, although in one study it was well tolerated.s Gadopentetate dimeglumine is also a poor activator of the complement system, which is thought to play a part in the induction of anaphylactoid reactions.4 However, as far as we are aware only five cases of anaphylactic reactions have been reported, and details of clinical presentation are provided in only one of them. In this last patient blood pressure was not decreased; nevertheless, because of
respiratory distress, adrenaline and methylprednisolone succinate were given. In our patient iodinated contrast agent allergy was the sole risk factor, and we are not aware of allergy crossreaction between gadopentetate and iodine-based contrast agents. It is too early to establish the frequency of anaphylactoid reactions associated with gadopentetate dimeglumine. Nevertheless, this agent seems not to be innocuous, and although the chance of life-threatening reaction is low, resuscitation materials and personnel trained in their use should be available as a minumum severe
safety measure. B. TARDY
Departments of Emergency Medicine, Toxicology, and Radiology, Hôpital Bellevue, Saint-Etienne 42023, France 1. Goldstein HA, Kashanian FK, Blumetti RF, Holyoak WL, DM. Safety assessment of gadopentetate dimeglumine
C. GUY G. BARRAL Y. PAGE M. OLLAGNIER J. C. BERTRAND Hugo FP, Blumenfield in
U.S. clinical trials.
Radiology 1990; 174: 17-23. 2. Laflore J, Goldstein HA, Rogan R, Keelan T, Ewell A. A prospective evaluation of adverse experiences following the administration of Magnevist (gadopentetate dimeglumine) injection (abstr). In. Book of abstracts: Society of Magnetic Resonance in Medicine 1989. Berkeley: SMRM, 1989: 1067. 3. Kanal E, Shellock FG, Talagala L. Safety considerations in MR imaging. Radiology 1990; 176: 593-606. 4. Bronen RA, Sze G. Magnetic resonance imaging contrast agents: theory and application to the central nervous system. J Neurosurg 1990; 73: 820-39. 5. Haustein J, Niendorf HP, Louton T. Renal tolerance of Gd-DTPA a retrospective evaluation of 1171 patients. Magn Reson Imaging 1990; 8: 467-81. 6. Tishler S, Hoffman JC. Anaphylactoid reactions to IV gadopentetate dimeglumine. AJNR 1990; 174: 17-23.
Counting birds, bees, and NCDs SIR,—Why is it that we know more about the number of sandhill butterflies, sperm whales, and bison, than we know about the number of new heart attacks, cancers, injuries, and asthma attacks? It is because population biologists are better able to "count" animals than we are able to "count" diseases. Perhaps it is time to start counting non-communicable diseases (NCD) in much the same manner as wildlife biologists count sandhill cranes. As we enter into the 21 st century we face an increasing burden of chronic diseases in developing and developed countries alike; yet we know surprisingly little of the frequency of these diseases. A primary goal is the prevention of these disorders, prevention meaning a reduction in the incidence of disease.’ How can prevention programmes for NCDs be successful unless geographical and temporal patterns of incidence are known. We need to break away from the traditional public-health approaches to the counting of NCDs-surveillance, registries, and death certificates. These systems are too inaccurate (surveillance), too costly (population based registries), or too late (death certificates) for the broad monitoring of changing patterns. Perhaps we should begin to use population biology methods such as capture-mark-recapture?2-4 In the capture-mark-recapture method (figure) wildlife are caught, tagged, and released and later recaputured. By this means one can estimate the number of fish in Loch Ness, for example; on the basis of the proportion of the sample recaptured. Wildlife biologists recognised long ago that it would be impossible to count every fish by capturing them all and that the identification of all the fish is not necessary to an accurate estimate of their numbers. By contrast, we in public health are just beginning to recogriise that it is very important to obtain accurate incidence data for NCD but that it is too costly to register all the new cases in the UK, the USA, Japan, Brazil, or anywhere else. Complete enumeration of every incidence cranes, monarch
case is not necessary to accurate incidence rates. National census offices are just beginning to accept this5 and public health should do so too.
New NCDs can be identified from several rosters (eg, hospitals, families, self-report, physicians, pharmacies, or ambulances). Unique identifiers serve as "tags" (eg, health insurance or social security number or name). By noting how many people appear in different "captures" (rosters), an accurate estimate of the total number of cases in the community can be derived, rather as is done with tagging fish.
Screening identified mainly those patients who would probably not diagnosed, since the tumour would have regressed spontaneously, nor did it diagnose some of the patients who proved have been
to have disseminated disease. There are no reports about the effectiveness of screening high-risk populations (familial cases, patients with neurofibromatosis, nesidioblastosis, or fetal hydantoin
syndrome) .3 Our results need to be confirmed by other studies, but we suggest that urinary vanillylmandelic acid screening for high-risk populations, including infants bom to mothers treated by hormones, should be considered. Institute of Haematology and Department of Gynaecology, Chaim Sheba Medical Centre, Tel-Hashomer and Sackler School of Medicine, Tel-Aviv University, Tel-Hashomer 52 621, Israel
A. TOREN M. MANDEL G. RECHAVI
J. DOR I. BEN-BASSAT Y. NEUMANN
1. Bolande RP, Mayer DC. The cytolysis of human neuroblastoma cells by a natural IgM antibody complement system in pregnancy serum. Cancer Invest 1990; 8: 603-11. 2. Murphy SB, Cohn SL, Craft AW. Do children benefit from mass screening for neuroblastoma. Lancet 1991; 337: 344-45. 3. Pizzo PA, Poplack DC, eds. Principles and practice of pediatric oncology. Philadelphia: J. B. Lippincott, 1989.
Anaphylactic shock induced by intravenous gadopentetate dimeglumine SIR,-Since its introduction as a contrast agent for magnetic imaging (MRI), the efficacy and safety of gadopentetate dimeglumine have been well demonstrated. However, minor anaphylactoid reactions can arise. We report a case of anaphylactic shock that occurred after the administration of intravenous (iv) gadopentetate dimeglumine. A 40-year-old man was referred for MRI because of chronic spinal-cord injury. His medical history included pollen allergy and anaphylactic shock induced by iodine-based contrast agent during iv urography done 2 months earlier. Steroid administration was not judged necessary before MRI and 0.1mmol/kg iv gadopentetate dimeglumine was given. Shortly afterwards, the patient complained of generalised pruritus and difficulty in breathing, and was removed from the imager. Physical examination showed striking periorbital oedema, generalised erythema, and diffuse wheezing. His blood pressure was 90 mm Hg with regular tachycardia. He was immediately given 80 mg of iv methylprednisolone and oxygen by face mask. His condition did not improve and blood pressure dropped to 50 mm Hg. An additional 1 mg of adrenaline and 1 litre of gelatin fluid were given iv 5 minutes later. The patient was then resonance
admitted
to
intensive
care
for observation. Further clinical
improvement was seen a few hours later with additional iv gelatin fluid and methylprednisolone. Studies of gadopentetate dimeglumine in both adults and children have demonstrated a high safety margin compared, for example, with iodinated contrast material.’ The total prevalence of adverse reactions is about 2,4%,2 among which are headache, nausea, vomiting, local burning, and severe hypertension. There have been six reported deaths temporally associated with the administration of gadopentetate dimeglumine.3 The actual relation between these deaths and the use of the drug is still unclear. The 50% lethal dose (LD) in animals is 5-15 mmol/kg. This is 50 to 150 times greater than the 0-1 mmol/kg dose in patients, and compares favourably with a safety index (animal LDS°/clinical dose) of 10 for iodinated contrast materia1.4 Renal impairment or raised levels of zinc or copper such as seen in Wilson disease may increase the plasma concentration of free gadolinium ion which is highly toxic. The safety of gadopentetate in these conditions has not been demonstrated clearly, although in one study it was well tolerated.s Gadopentetate dimeglumine is also a poor activator of the complement system, which is thought to play a part in the induction of anaphylactoid reactions.4 However, as far as we are aware only five cases of anaphylactic reactions have been reported, and details of clinical presentation are provided in only one of them. In this last patient blood pressure was not decreased; nevertheless, because of
respiratory distress, adrenaline and methylprednisolone succinate were given. In our patient iodinated contrast agent allergy was the sole risk factor, and we are not aware of allergy crossreaction between gadopentetate and iodine-based contrast agents. It is too early to establish the frequency of anaphylactoid reactions associated with gadopentetate dimeglumine. Nevertheless, this agent seems not to be innocuous, and although the chance of life-threatening reaction is low, resuscitation materials and personnel trained in their use should be available as a minumum severe
safety measure. B. TARDY
Departments of Emergency Medicine, Toxicology, and Radiology, Hôpital Bellevue, Saint-Etienne 42023, France 1. Goldstein HA, Kashanian FK, Blumetti RF, Holyoak WL, DM. Safety assessment of gadopentetate dimeglumine
C. GUY G. BARRAL Y. PAGE M. OLLAGNIER J. C. BERTRAND Hugo FP, Blumenfield in
U.S. clinical trials.
Radiology 1990; 174: 17-23. 2. Laflore J, Goldstein HA, Rogan R, Keelan T, Ewell A. A prospective evaluation of adverse experiences following the administration of Magnevist (gadopentetate dimeglumine) injection (abstr). In. Book of abstracts: Society of Magnetic Resonance in Medicine 1989. Berkeley: SMRM, 1989: 1067. 3. Kanal E, Shellock FG, Talagala L. Safety considerations in MR imaging. Radiology 1990; 176: 593-606. 4. Bronen RA, Sze G. Magnetic resonance imaging contrast agents: theory and application to the central nervous system. J Neurosurg 1990; 73: 820-39. 5. Haustein J, Niendorf HP, Louton T. Renal tolerance of Gd-DTPA a retrospective evaluation of 1171 patients. Magn Reson Imaging 1990; 8: 467-81. 6. Tishler S, Hoffman JC. Anaphylactoid reactions to IV gadopentetate dimeglumine. AJNR 1990; 174: 17-23.
Counting birds, bees, and NCDs SIR,—Why is it that we know more about the number of sandhill butterflies, sperm whales, and bison, than we know about the number of new heart attacks, cancers, injuries, and asthma attacks? It is because population biologists are better able to "count" animals than we are able to "count" diseases. Perhaps it is time to start counting non-communicable diseases (NCD) in much the same manner as wildlife biologists count sandhill cranes. As we enter into the 21 st century we face an increasing burden of chronic diseases in developing and developed countries alike; yet we know surprisingly little of the frequency of these diseases. A primary goal is the prevention of these disorders, prevention meaning a reduction in the incidence of disease.’ How can prevention programmes for NCDs be successful unless geographical and temporal patterns of incidence are known. We need to break away from the traditional public-health approaches to the counting of NCDs-surveillance, registries, and death certificates. These systems are too inaccurate (surveillance), too costly (population based registries), or too late (death certificates) for the broad monitoring of changing patterns. Perhaps we should begin to use population biology methods such as capture-mark-recapture?2-4 In the capture-mark-recapture method (figure) wildlife are caught, tagged, and released and later recaputured. By this means one can estimate the number of fish in Loch Ness, for example; on the basis of the proportion of the sample recaptured. Wildlife biologists recognised long ago that it would be impossible to count every fish by capturing them all and that the identification of all the fish is not necessary to an accurate estimate of their numbers. By contrast, we in public health are just beginning to recogriise that it is very important to obtain accurate incidence data for NCD but that it is too costly to register all the new cases in the UK, the USA, Japan, Brazil, or anywhere else. Complete enumeration of every incidence cranes, monarch
case is not necessary to accurate incidence rates. National census offices are just beginning to accept this5 and public health should do so too.
New NCDs can be identified from several rosters (eg, hospitals, families, self-report, physicians, pharmacies, or ambulances). Unique identifiers serve as "tags" (eg, health insurance or social security number or name). By noting how many people appear in different "captures" (rosters), an accurate estimate of the total number of cases in the community can be derived, rather as is done with tagging fish.
