1009
Condom
use
and failure
SiR,—Iwas surprised that in your Sept 22 note "A good fit?" you reproduce the London Rubber Company’s statement that "most condom failure is due to incorrect usage", without exercising the same critical evaluation that applies to the rest of your journal. We have shown that 52% of those who had obtained condoms from our family planning clinic had one or more either burst or slip off in the three months before our survey.l As might be expected, regular users reported more accidents than occasional users, and I do not believe that most of these failures were due to snagging with finger nails, use of oil-based vaginal lubricants, or use of out-of date stock. I fmnly support the general move towards the use of barrier methods of birth control; but we do the public no favour by promoting the idea among medical staff that it is all the fault of the user when things go wrong. Family Planning Centre, Department of Obstetrics and Gynaecology, University of Manchester, Withington, Manchester M20 9LJ, UK 1. Kirkman RJE, Morris J, Webb AMC. User Fam Plan 1990; 15: 107-11.
ROSEMARY KIRKMAN experience: Mates® v Nuforms®. Br J
_
operator tube, the diaphragm returns to its resting position under its own elasticity. This creates a positive pressure below the diaphragm which causes the internal valve to close and the external valve to open, allowing the air below the diaphragm to be vented out. Adequate total suction is achieved with a repeated suck/release action being applied by the operator, rather than greater and longer suction effort as required by conventional mucus extractors. Tests in the department of virology at this hospital with poliovirus failed to detect any viral transmission across the diaphragm, thus demonstrating the effectiveness of the diaphragm in the prevention of even viral aerosol cross-contamination. Initial clinical trials of our device, conducted in several hospitals in the UK, have shown that an adequate suction pressure is achieved, allowing satisfactory clearance of the mouth and upper airways of the newborn baby. The midwives participating in these trials generally found the device easy to use and felt reassured by the presence of the latex barrier between themselves and the baby, preventing not only the unpleasant experience of accidental ingestion of meconium, but also keeping to a minimum the transmission of infection. This device is now being manufactured by Surgicraft, Redditch, England, and is being used routinely in many maternity units in this
country.
Orally operated mucus extractors made safe SIR,-We are surprised by Dr Baker and Dr Knuppel’s (Sept 8, p 636) description of yet another alternative to orally operated mucus extractors used to clear the upper airways of newborn babies. It has long been recognised that the presence of a simple mucus trap does not completely prevent the risk of cross-contamination between operator and patient;l however, despite the availability of many alternatives, including hand operated pumps,2-S orally
operated devices continue to be used in many centres. This suggests that such devices have substantial advantages over the alternativesnamely, that conventional devices are cheap, disposable, single use, sterile, portable, single-hand operated, and have easily controllable suction pressure. We have developed an orally operated mucus extractor that retains the advantages of conventional devices while removing the risk of operator/patient cross-contamination. The device has a latex diaphragm (manufactured to British standards as laid down for the production of condoms, BS3704), thus creating a complete internal barrier between operator and patient (figure). Two one-way valves (an external vent valve and an internal suction valve) are closed in their neutral (resting) position and allow airflow only in one direction-away from the patient. Suction applied to the operator tube causes the diaphragm to be raised, creating a negative pressure below it. This causes the internal valve to open, producing a negative pressure in the lower chamber. This negative pressure allows suction from the patient. When the suction is released on the
Diagram of mucus extractor (cross section).
Department of Applied Physiology, Hospital Medical School,
St Thomas’s
D. G. PENMAN D. M. BAND
UMDS, London SE1 7EH, UK
1. Fraser MS. Mucus catheters Br Med J 1951; i: 165-67. 2. Saher NF, Salt RA. A portable suction apparatus not dependent on a source of electricity. Br Med J 1943; i: 790. 3. Pretlow RA. Hand-powered apparatus for aspiration of meconium from the airway. Pediatrics 1987; 79: 642-13. 4. Eisner P. Sucrioning meconium from the trachea: a new solution to an old problem. Pediatrics 1986; 78: 713. 5. Asman B. Device cuts physicians’ risk of contracting AIDS during delivery. Pediatric News 1986; 20: 69.
Use of oral
rehydration salt in diabetic ketoacidosis
SIR,-Diabetic ketoacidosis
can
be life
threatening and
warrants
prompt and effective treatment. I report two patients with diabetic ketoacidosis treated at a rural clinic in Pakistan successfully managed by oral rehydration salt (ORS) therapy and insulin. Patient 1. (35-year-old woman with insulin dependent diabetes, 5-day history of generalised weakness, vomiting, diarrhoea, and
fever.) 12 days earlier she had stopped insulin injections and was taking herbs on the advice of a hakim. Her blood glucose 4 days before presentation was 22 mmol/l. She was conscious but drowsy, dehydrated with sunken eyes, and had a dry tongue and decreased skin turgor. Pulse rate was 115/min, blood pressure 85/60 mm Hgrespiratory rate 30/min, and temperature 37-8°C. Urinary glucose was about 110 mmol/1 (’Diastix’ 4 +) and ketones between 8 and 16 mmol/1 (’Multistix’ +). The patient was given World Health Organisation recommended ORS-one pack was dissolved in 1 litre of water. 1,2 2 litres of this solution was given orally in 1 h and then 1 litre was given hourly. Soluble insulin 20 units intravenously (iv), 20 units intramuscularly (im), and 20 units subcutaneously (sc) were given immediately, followed by 10 units (sc) hourly until the urine glucose test became negative. Glucose and ketone levels steadily declined after treatment was started and by 10 hours of treatment were no longer detected in urine. ORS was given for 10 hours. The patient looked well and was rehydrated. Her pulse rate became 100/min and her blood pressure 115/80 mm Hg. Co-trimoxazole (two tablets each containing trimethroprim 80 mg and sulphamethoxazole 400 mg, twice daily) was also given for gasteroenteritis and fever. Her diabetes is now well controlled on 20 units sc soluble insulin twice daily and by diet. Patient 2. (50-year-old bedridden man with insulin dependent diabetes, history of polydipsia, polyuria for the past 20 days, and severe vomiting, dysuria, poor food intake, and generalised weakness for 10 days.) He had stopped insulin 20 days earlier on advice from a homoeopathic doctor. His last known blood glucose was 20-9 mmol/l, done at Jinnah Postgraduate Medical Centre. He
Condom
use
and failure
SiR,—Iwas surprised that in your Sept 22 note "A good fit?" you reproduce the London Rubber Company’s statement that "most condom failure is due to incorrect usage", without exercising the same critical evaluation that applies to the rest of your journal. We have shown that 52% of those who had obtained condoms from our family planning clinic had one or more either burst or slip off in the three months before our survey.l As might be expected, regular users reported more accidents than occasional users, and I do not believe that most of these failures were due to snagging with finger nails, use of oil-based vaginal lubricants, or use of out-of date stock. I fmnly support the general move towards the use of barrier methods of birth control; but we do the public no favour by promoting the idea among medical staff that it is all the fault of the user when things go wrong. Family Planning Centre, Department of Obstetrics and Gynaecology, University of Manchester, Withington, Manchester M20 9LJ, UK 1. Kirkman RJE, Morris J, Webb AMC. User Fam Plan 1990; 15: 107-11.
ROSEMARY KIRKMAN experience: Mates® v Nuforms®. Br J
_
operator tube, the diaphragm returns to its resting position under its own elasticity. This creates a positive pressure below the diaphragm which causes the internal valve to close and the external valve to open, allowing the air below the diaphragm to be vented out. Adequate total suction is achieved with a repeated suck/release action being applied by the operator, rather than greater and longer suction effort as required by conventional mucus extractors. Tests in the department of virology at this hospital with poliovirus failed to detect any viral transmission across the diaphragm, thus demonstrating the effectiveness of the diaphragm in the prevention of even viral aerosol cross-contamination. Initial clinical trials of our device, conducted in several hospitals in the UK, have shown that an adequate suction pressure is achieved, allowing satisfactory clearance of the mouth and upper airways of the newborn baby. The midwives participating in these trials generally found the device easy to use and felt reassured by the presence of the latex barrier between themselves and the baby, preventing not only the unpleasant experience of accidental ingestion of meconium, but also keeping to a minimum the transmission of infection. This device is now being manufactured by Surgicraft, Redditch, England, and is being used routinely in many maternity units in this
country.
Orally operated mucus extractors made safe SIR,-We are surprised by Dr Baker and Dr Knuppel’s (Sept 8, p 636) description of yet another alternative to orally operated mucus extractors used to clear the upper airways of newborn babies. It has long been recognised that the presence of a simple mucus trap does not completely prevent the risk of cross-contamination between operator and patient;l however, despite the availability of many alternatives, including hand operated pumps,2-S orally
operated devices continue to be used in many centres. This suggests that such devices have substantial advantages over the alternativesnamely, that conventional devices are cheap, disposable, single use, sterile, portable, single-hand operated, and have easily controllable suction pressure. We have developed an orally operated mucus extractor that retains the advantages of conventional devices while removing the risk of operator/patient cross-contamination. The device has a latex diaphragm (manufactured to British standards as laid down for the production of condoms, BS3704), thus creating a complete internal barrier between operator and patient (figure). Two one-way valves (an external vent valve and an internal suction valve) are closed in their neutral (resting) position and allow airflow only in one direction-away from the patient. Suction applied to the operator tube causes the diaphragm to be raised, creating a negative pressure below it. This causes the internal valve to open, producing a negative pressure in the lower chamber. This negative pressure allows suction from the patient. When the suction is released on the
Diagram of mucus extractor (cross section).
Department of Applied Physiology, Hospital Medical School,
St Thomas’s
D. G. PENMAN D. M. BAND
UMDS, London SE1 7EH, UK
1. Fraser MS. Mucus catheters Br Med J 1951; i: 165-67. 2. Saher NF, Salt RA. A portable suction apparatus not dependent on a source of electricity. Br Med J 1943; i: 790. 3. Pretlow RA. Hand-powered apparatus for aspiration of meconium from the airway. Pediatrics 1987; 79: 642-13. 4. Eisner P. Sucrioning meconium from the trachea: a new solution to an old problem. Pediatrics 1986; 78: 713. 5. Asman B. Device cuts physicians’ risk of contracting AIDS during delivery. Pediatric News 1986; 20: 69.
Use of oral
rehydration salt in diabetic ketoacidosis
SIR,-Diabetic ketoacidosis
can
be life
threatening and
warrants
prompt and effective treatment. I report two patients with diabetic ketoacidosis treated at a rural clinic in Pakistan successfully managed by oral rehydration salt (ORS) therapy and insulin. Patient 1. (35-year-old woman with insulin dependent diabetes, 5-day history of generalised weakness, vomiting, diarrhoea, and
fever.) 12 days earlier she had stopped insulin injections and was taking herbs on the advice of a hakim. Her blood glucose 4 days before presentation was 22 mmol/l. She was conscious but drowsy, dehydrated with sunken eyes, and had a dry tongue and decreased skin turgor. Pulse rate was 115/min, blood pressure 85/60 mm Hgrespiratory rate 30/min, and temperature 37-8°C. Urinary glucose was about 110 mmol/1 (’Diastix’ 4 +) and ketones between 8 and 16 mmol/1 (’Multistix’ +). The patient was given World Health Organisation recommended ORS-one pack was dissolved in 1 litre of water. 1,2 2 litres of this solution was given orally in 1 h and then 1 litre was given hourly. Soluble insulin 20 units intravenously (iv), 20 units intramuscularly (im), and 20 units subcutaneously (sc) were given immediately, followed by 10 units (sc) hourly until the urine glucose test became negative. Glucose and ketone levels steadily declined after treatment was started and by 10 hours of treatment were no longer detected in urine. ORS was given for 10 hours. The patient looked well and was rehydrated. Her pulse rate became 100/min and her blood pressure 115/80 mm Hg. Co-trimoxazole (two tablets each containing trimethroprim 80 mg and sulphamethoxazole 400 mg, twice daily) was also given for gasteroenteritis and fever. Her diabetes is now well controlled on 20 units sc soluble insulin twice daily and by diet. Patient 2. (50-year-old bedridden man with insulin dependent diabetes, history of polydipsia, polyuria for the past 20 days, and severe vomiting, dysuria, poor food intake, and generalised weakness for 10 days.) He had stopped insulin 20 days earlier on advice from a homoeopathic doctor. His last known blood glucose was 20-9 mmol/l, done at Jinnah Postgraduate Medical Centre. He
