1084 roticans in Papua New Guinea means that it is important determine the precise aetiology of the disease in China.
to
Goroka Base Hospital, P.O. Box 392, Goroka, Eastern Highlands Province, Papua New Guinea
FRANK SHANN
Queensland Institute of Medical Research, Herston, Queensland, Australia
GREGOR LAWRENCE
Hsin Hua Commune Hospital, Hsin Hua People’s Commune, Huaxian County, Kwangchow,
People’s Republic of China
PAN JUN-DI
SIR,-In the paper by Dr Wilson and colleagues (Feb. 10, p. 292) on retinal-artery occlusion and cardiovascular disease,
especially interested by the high association of carotidartery abnormalities with retinal-artery occlusion. In a retrospective review’ of experience at the Cleveland Clinic, we found that of 27 patients with central retinal-artery occlusion seen between 1969 and 1978 13 had had an angiogram done and 10 (76%) of these had revealed ulcerated or stenosed carotid arteries on the side of the retinal-artery occlusion; the frequency was 67% in Wilson’s series and 100% in that of Kollarits et al.2 Like Wilson et al. we noted a preponderance of hypertensive and atherosclerotic cardiovascular disease among our patients. Furthermore, in more than 50% of our cases, central-retinal-artery occlusion was the first neurovascular symptom. Our results thus confirm a high correlation between central-retinal-artery occlusion and ipsilateral carotid-artery disease.
we were
Cleveland, Ohio 44106, U.S.A. *Present address: Bascom Palmer
ROBERT L. TOMSAK* MAURICE HANSON FRONCIE A. GUTMAN Eye Institute, Miami,
Florida 33101, U.S.A.
∈-AMINOCAPROIC ACID IN PREVENTION OF SUBARACHNOID HÆMORRHAGE
SIR The report from Mr Chowdhary and colleagues (April 7, p. 741) on the spectacular success they obtained with e-aminocaproic acid (E.A.C.A.) in the prevention of recurrent bleed in subarachnoid haemorrhage (3 out of 83 E.A.C.A.treated patients versus 22 out of 82 controls) is hard to believe, especially in view of the fact that only 1 of the E.A.c.A.-treated patients died from a recurrent bleed. In a double-blind controlled study, published in the September, 1977, issue of the Annals of Neurology, we found none of these remarkable differences between treated and untreated patients followed up for 2 months. al. leave out information readers will need to evaluate the results. For how many days was E.A.C.A. administered ? Only 45‘ ,,_" the 25 recurrences were verified by lumbar puncture or necropsy; to which of the two groups did these 11 recurrences belong? Why were not all recurrences verified by lumbar puncture? E.A.C.A. was discontinued at surgery or discharge, but how many patients in each group were operated on and after how many days following admission? The contention that the two groups were comparable in respect of the interval between subarachnoid haemorrhage and admission (table III) is not substantiated. In the control group 14 more cases were admitted after the second week. Definitive surgery "differed somewhat" in the two groups-by how much and in what re-
Chowdhary
et
spect ? 1. Tomsak, R. L., Hanson, M., Gutman, F. A. Cleveland Clin Q. (in the press). 2. Kollarits, C. R., Lubow, M., Hissong, S. L. J. Am. med. Ass. 1972, 222,
1273.
Department of Neurology, University Hospital,
A. R. WINTZEN
J. VAN ROSSUM
Leiden, Netherlands
DIGOXIN IN SINUS RHYTHM
CAROTID-ARTERY DISEASE AND RETINAL-ARTERY OCCLUSION
Departments of Ophthalmology and Neurology, Cleveland Clinic,
With these doubts we do not feel that Chowdhary et ai. have substantiated their conclusion that E.A.C.A. improves the natural history of subarachnoid haemorrhage.
SIR,-The paper by Dr Johnston and Professor McDevitt (March 17, p. 567) interested us because we have investigated the use of digoxin in the management of cardiac failure in sinus rhythm using the radionuclide ejection fractionE.F. as a measure of left-ventricular performance. Eight patients with ischæmic heart-disease and a long history of cardiac decompensation were studied. All were in sinus rhythm and had no history of atrial fibrillation. Cardiac failure had responded to diuretics, and all patients were Judged to be on -adequate maintenance diuretic therapy: none was on a ’
beta-blocking agent. Without otherwise altering their treatment, we gave the patients digoxin, loading and maintenance doses of oral digoxin being calculated with reference to age, sex, weight and renal function. The patients were investigated before and 4-13 days after digoxin was started. After intravenous injection of 99m-technetium-labelled human serum albumin, resting E.c.G.-gated blood pool scans (left anterior oblique prolection were recorded and analysed with a gamma-camera/computer system (Ohio Nuclear 410: VIP-450). Average left-ventriculartime/activity curves were derived and E.F. was measured from them. The mean E.F. for the group before digoxin (0237) was low compared with the mean value (052) obtained in eleven controls. After digoxin the mean E.F. for the group was hardlv changed at 0244, and the mean difference in E.F. was 0007+_0021 (s.D.); we have tested the reproducibihty of the method and have shown that changes less than 006 are insignificant. The results indicate that the performance of the ischxmic left ventricle in sinus rhythm and at rest is not measurabh affected by digoxin, therapy over a period of a week or so. These observations lend further support to the contention that digoxin can be safely withdrawn from most patients in sinus
rhythm. Medical Unit and Department of Medical Physics, Monklands District General Hospital,
Airdrie, Lanarkshire ML60JS
M. A. K. GHOURI R. RAILTON K. C. YOUNG J. C. RODGER
TUBERCULOUS PERITONITIS AND LAPAROSCOPY SIR,-Mr woite and nis colleagues April 21, p. 852) rightlv draw attention to the risk of perforating the bowel during laparoscopy in patients with matted and extensive tuberculous adhesions. Such adhesions are common in West African patients with tuberculous peritonitis, and it was whilst working in Nigeria that I abandoned the laparoscope and mstead used a small sigmoidoscope inserted through a subumbilical incision. Adhesions in the immediate vicinity can be swept away with the finger, and the sigmoidoscope, together with its obdurator, is then gently inserted and air insufflated m the usus) way. As long as adhesions are not too dense a reasonable B ;eB’. can be obtained, and although biopsy is a little awkward owing to loss of air the method eliminates the need for blind mserucn of a sharp trochar which, in my hands on one occa,lOr.. resulted in an excellent laparoscopic view of the lumen of the transverse colon. 112
Harley Street,
London W1N 1AF
ADAM LEWS
to
Goroka Base Hospital, P.O. Box 392, Goroka, Eastern Highlands Province, Papua New Guinea
FRANK SHANN
Queensland Institute of Medical Research, Herston, Queensland, Australia
GREGOR LAWRENCE
Hsin Hua Commune Hospital, Hsin Hua People’s Commune, Huaxian County, Kwangchow,
People’s Republic of China
PAN JUN-DI
SIR,-In the paper by Dr Wilson and colleagues (Feb. 10, p. 292) on retinal-artery occlusion and cardiovascular disease,
especially interested by the high association of carotidartery abnormalities with retinal-artery occlusion. In a retrospective review’ of experience at the Cleveland Clinic, we found that of 27 patients with central retinal-artery occlusion seen between 1969 and 1978 13 had had an angiogram done and 10 (76%) of these had revealed ulcerated or stenosed carotid arteries on the side of the retinal-artery occlusion; the frequency was 67% in Wilson’s series and 100% in that of Kollarits et al.2 Like Wilson et al. we noted a preponderance of hypertensive and atherosclerotic cardiovascular disease among our patients. Furthermore, in more than 50% of our cases, central-retinal-artery occlusion was the first neurovascular symptom. Our results thus confirm a high correlation between central-retinal-artery occlusion and ipsilateral carotid-artery disease.
we were
Cleveland, Ohio 44106, U.S.A. *Present address: Bascom Palmer
ROBERT L. TOMSAK* MAURICE HANSON FRONCIE A. GUTMAN Eye Institute, Miami,
Florida 33101, U.S.A.
∈-AMINOCAPROIC ACID IN PREVENTION OF SUBARACHNOID HÆMORRHAGE
SIR The report from Mr Chowdhary and colleagues (April 7, p. 741) on the spectacular success they obtained with e-aminocaproic acid (E.A.C.A.) in the prevention of recurrent bleed in subarachnoid haemorrhage (3 out of 83 E.A.C.A.treated patients versus 22 out of 82 controls) is hard to believe, especially in view of the fact that only 1 of the E.A.c.A.-treated patients died from a recurrent bleed. In a double-blind controlled study, published in the September, 1977, issue of the Annals of Neurology, we found none of these remarkable differences between treated and untreated patients followed up for 2 months. al. leave out information readers will need to evaluate the results. For how many days was E.A.C.A. administered ? Only 45‘ ,,_" the 25 recurrences were verified by lumbar puncture or necropsy; to which of the two groups did these 11 recurrences belong? Why were not all recurrences verified by lumbar puncture? E.A.C.A. was discontinued at surgery or discharge, but how many patients in each group were operated on and after how many days following admission? The contention that the two groups were comparable in respect of the interval between subarachnoid haemorrhage and admission (table III) is not substantiated. In the control group 14 more cases were admitted after the second week. Definitive surgery "differed somewhat" in the two groups-by how much and in what re-
Chowdhary
et
spect ? 1. Tomsak, R. L., Hanson, M., Gutman, F. A. Cleveland Clin Q. (in the press). 2. Kollarits, C. R., Lubow, M., Hissong, S. L. J. Am. med. Ass. 1972, 222,
1273.
Department of Neurology, University Hospital,
A. R. WINTZEN
J. VAN ROSSUM
Leiden, Netherlands
DIGOXIN IN SINUS RHYTHM
CAROTID-ARTERY DISEASE AND RETINAL-ARTERY OCCLUSION
Departments of Ophthalmology and Neurology, Cleveland Clinic,
With these doubts we do not feel that Chowdhary et ai. have substantiated their conclusion that E.A.C.A. improves the natural history of subarachnoid haemorrhage.
SIR,-The paper by Dr Johnston and Professor McDevitt (March 17, p. 567) interested us because we have investigated the use of digoxin in the management of cardiac failure in sinus rhythm using the radionuclide ejection fractionE.F. as a measure of left-ventricular performance. Eight patients with ischæmic heart-disease and a long history of cardiac decompensation were studied. All were in sinus rhythm and had no history of atrial fibrillation. Cardiac failure had responded to diuretics, and all patients were Judged to be on -adequate maintenance diuretic therapy: none was on a ’
beta-blocking agent. Without otherwise altering their treatment, we gave the patients digoxin, loading and maintenance doses of oral digoxin being calculated with reference to age, sex, weight and renal function. The patients were investigated before and 4-13 days after digoxin was started. After intravenous injection of 99m-technetium-labelled human serum albumin, resting E.c.G.-gated blood pool scans (left anterior oblique prolection were recorded and analysed with a gamma-camera/computer system (Ohio Nuclear 410: VIP-450). Average left-ventriculartime/activity curves were derived and E.F. was measured from them. The mean E.F. for the group before digoxin (0237) was low compared with the mean value (052) obtained in eleven controls. After digoxin the mean E.F. for the group was hardlv changed at 0244, and the mean difference in E.F. was 0007+_0021 (s.D.); we have tested the reproducibihty of the method and have shown that changes less than 006 are insignificant. The results indicate that the performance of the ischxmic left ventricle in sinus rhythm and at rest is not measurabh affected by digoxin, therapy over a period of a week or so. These observations lend further support to the contention that digoxin can be safely withdrawn from most patients in sinus
rhythm. Medical Unit and Department of Medical Physics, Monklands District General Hospital,
Airdrie, Lanarkshire ML60JS
M. A. K. GHOURI R. RAILTON K. C. YOUNG J. C. RODGER
TUBERCULOUS PERITONITIS AND LAPAROSCOPY SIR,-Mr woite and nis colleagues April 21, p. 852) rightlv draw attention to the risk of perforating the bowel during laparoscopy in patients with matted and extensive tuberculous adhesions. Such adhesions are common in West African patients with tuberculous peritonitis, and it was whilst working in Nigeria that I abandoned the laparoscope and mstead used a small sigmoidoscope inserted through a subumbilical incision. Adhesions in the immediate vicinity can be swept away with the finger, and the sigmoidoscope, together with its obdurator, is then gently inserted and air insufflated m the usus) way. As long as adhesions are not too dense a reasonable B ;eB’. can be obtained, and although biopsy is a little awkward owing to loss of air the method eliminates the need for blind mserucn of a sharp trochar which, in my hands on one occa,lOr.. resulted in an excellent laparoscopic view of the lumen of the transverse colon. 112
Harley Street,
London W1N 1AF
ADAM LEWS
