609
because many of these cases were and still are subsequently for testing by DNA fingerprinting so that an unequivocal answer can be given. You go on to say that magistrates can understand simple blood groups and similar serological systems. Our experience, having made presentations to well over half the magistrates in England, is that this is certainly not the case, and the message constantly given to us is that the reports produced after testing with conventional blood grouping methods can be confusing and frequently inconclusive. With DNA fingerprinting magistrates receive clear unequivocal be
so
sent to us
case
reports.
Our experience of solving over three thousand paternity disputes by means of DNA fingerprinting backs our opinions and is further supported by the fact that almost all such cases are now thankfully solved with this new and powerful technique. Cellmark
Diagnostics,
Abingdon Business Park, Abingdon, Oxfordshire OX14 1 DY, UK
Illegal acts of Scottish Health
PHILIP WEBB
Minister
SIR,-Mr Hunter (Feb 17, p 414), who has had a wealth of Scottish Health Service experience, asserts that Mr Michael Forsyth has broken the law in abolishing the National Medical Consultative Committee together with the other NCCs which were set up by statute. He may well be right but the NCCs were, I was informed, not abolished but suspended, which is apparently at least within the letter of the law. He is certainly right that the NCCs were not consulted in the process leading up to the White Paper. But who were? A characteristic of this Government is the certainty with which it holds its own convictions and that any expert dissent is always
self-seeking. His advice to us, however, may not be right. The NMCC and the other NCCs all made their apprehensions known before their suspension. In this new and unheeding environment what good would come from us reconvening and publishing what would be repetitive advice? As chairman of the NMCC and chairman of the new nonstatutory National Medical Advisory Committee I believe it and the other NACs, although curtailed in their powers, must continue to advise the Minister on what we believe are often unworkable proposals which seem not to be based on knowledge of how the National Health Service works, of how patients think, and of what doctors do. As the difficulties multiply, as they must, the Government may then be prepared to listen, and the effects on our patients could at least be ameliorated. If, however, it becomes apparent that our advice is consistently ignored then the calibre of the membership of the NACs will drop and their function wither. Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
J. W. CRAWFORD
Paroxysmal precordial purring sign in epiglottitis SiR,—The diagnosis of acute epiglottitis (supraglottitis) in an adult with a sore throat is difficult to prove on the basis of clinical history and physical examination.1 Lateral neck X-rays and/or laryngoscopy are often required. The number of patients seen with acute pharyngitis is large, and further diagnostic evaluation is time-consuming and expensive. However, diagnosis of epiglottitis is critically important since the disease can run a fulminating, even fatal, course even in the absence of alarming presenting symptoms and signs. One of us (H. C. L.), a 66-year-old physician, was admitted to hospital with a sore throat. His symptoms were those of a severe pharyngitis with hoarseness, fever, throat pain, difficulty swallowing, oropharyngeal secretions, and dyspnoea. He also noted a purring or fluttering sensation in the precordium. At first, the patient thought that this sensation was cardiac in origin but it was not reminiscent of palpitations, it occurred only during exhalation, and he had a normal cardiovascular examination. Respiratory
examination revealed only inspiratory stridor. Soft tissue filins of the neck revealed a swollen epiglottis angled over swollen supraglottic structures. He was kept under observation in the intensive care unit, and given antibiotics, oxygen, and dexamethasone. The purring or fluttering sensation resolved as his dyspnoea and stridor abated. Clinical resolution of all symptoms was rapid and the patient was discharged after 3 days. Following convalescence, the patient mimicked the fluttering sensation for others by placing the tip of his tongue against the anterior portion of the hard palate; forcing air between the two caused vibration of the tongue in a trill-like manner. We suspect that air rushing from the glottis and around the swollen epiglottis perched over it set up eddy currents or turbulence which caused the epiglottis to waver or flutter much like a sail luffing in the breeze. This probably resulted in the purring sensation during exhalation. Have other patients with epiglottitis noted precordial purring? Is exhalational epiglottal flutter the cause? Can a physical sign of such fluttering be appreciated and used to help establish the diagnosis of acute epiglottitis and follow the course of the illness? Department of Medicine, Miriam Hospital, Brown University, Providence, Rhode Island 02906, USA
FRED J. SCHIFFMAN HERBERT C. LICHTMAN
1.
Shapiro J, Eavey RD, Baker AS. Adult supraglottitis: a prospective analysis. JAMA
2.
1988; 259: 563-67. Mayo Smith MF, Hirsch PJ, Wodzinski SF, Schiffman FJ. Acute epiglottitis in adults: an eight year experience in the State of Rhode Island. N Engl J Med 1986;
314: 1133-39. 3. Baker AS, Eavey RD. Adult 1185-86.
supraglottitis (epiglottitis). N Engl J Med 1986; 314:
Differentiation between specific and non-specific hepatitis C antibodies in chronic liver disease SiR,—We have used the Ortho Diagnostics System enzyme immunoassay for detecting antibodies to hepatitis C virus (HCV)l to assess the incidence of HCV infection in patients with chronic liver disease. Sera were collected from 100 potential liver transplant patients and we found 6 anti-HCV positive patients with liver diseases not normally associated with virus infection (table i). This could indicate infection with HCV during transfusions of blood and blood products, but it could also be interpreted as false-positive reactions with non-specific antibodies cross-reacting with the recombinant HCV antigen. Table 11 shows the optical density (OD) values for the positive samples. Samples from patients with cryptogenic cirrhosis all had OD values greater than 11(mean 2-38) while 6 samples from patients with liver disease associated with obstruction or metabolic or immunological changes had OD values of 09 or less (mean 0-69). To find out if the low OD values seen with some samples were non-specific, all anti-HCV-positive samples were retested twiceas previously and again with an 8 mol/1 urea wash during the first ELISA washing procedure. This urea wash should dissociate weak-binding or low-avidity antibodies from the antigen.2,3 The avidity of immunoglobulin G during the acute phase of viral TABLE I-HCV ANTIBODY STATUS OF PATIENTS WITH CHRONIC LIVER DISEASE
because many of these cases were and still are subsequently for testing by DNA fingerprinting so that an unequivocal answer can be given. You go on to say that magistrates can understand simple blood groups and similar serological systems. Our experience, having made presentations to well over half the magistrates in England, is that this is certainly not the case, and the message constantly given to us is that the reports produced after testing with conventional blood grouping methods can be confusing and frequently inconclusive. With DNA fingerprinting magistrates receive clear unequivocal be
so
sent to us
case
reports.
Our experience of solving over three thousand paternity disputes by means of DNA fingerprinting backs our opinions and is further supported by the fact that almost all such cases are now thankfully solved with this new and powerful technique. Cellmark
Diagnostics,
Abingdon Business Park, Abingdon, Oxfordshire OX14 1 DY, UK
Illegal acts of Scottish Health
PHILIP WEBB
Minister
SIR,-Mr Hunter (Feb 17, p 414), who has had a wealth of Scottish Health Service experience, asserts that Mr Michael Forsyth has broken the law in abolishing the National Medical Consultative Committee together with the other NCCs which were set up by statute. He may well be right but the NCCs were, I was informed, not abolished but suspended, which is apparently at least within the letter of the law. He is certainly right that the NCCs were not consulted in the process leading up to the White Paper. But who were? A characteristic of this Government is the certainty with which it holds its own convictions and that any expert dissent is always
self-seeking. His advice to us, however, may not be right. The NMCC and the other NCCs all made their apprehensions known before their suspension. In this new and unheeding environment what good would come from us reconvening and publishing what would be repetitive advice? As chairman of the NMCC and chairman of the new nonstatutory National Medical Advisory Committee I believe it and the other NACs, although curtailed in their powers, must continue to advise the Minister on what we believe are often unworkable proposals which seem not to be based on knowledge of how the National Health Service works, of how patients think, and of what doctors do. As the difficulties multiply, as they must, the Government may then be prepared to listen, and the effects on our patients could at least be ameliorated. If, however, it becomes apparent that our advice is consistently ignored then the calibre of the membership of the NACs will drop and their function wither. Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
J. W. CRAWFORD
Paroxysmal precordial purring sign in epiglottitis SiR,—The diagnosis of acute epiglottitis (supraglottitis) in an adult with a sore throat is difficult to prove on the basis of clinical history and physical examination.1 Lateral neck X-rays and/or laryngoscopy are often required. The number of patients seen with acute pharyngitis is large, and further diagnostic evaluation is time-consuming and expensive. However, diagnosis of epiglottitis is critically important since the disease can run a fulminating, even fatal, course even in the absence of alarming presenting symptoms and signs. One of us (H. C. L.), a 66-year-old physician, was admitted to hospital with a sore throat. His symptoms were those of a severe pharyngitis with hoarseness, fever, throat pain, difficulty swallowing, oropharyngeal secretions, and dyspnoea. He also noted a purring or fluttering sensation in the precordium. At first, the patient thought that this sensation was cardiac in origin but it was not reminiscent of palpitations, it occurred only during exhalation, and he had a normal cardiovascular examination. Respiratory
examination revealed only inspiratory stridor. Soft tissue filins of the neck revealed a swollen epiglottis angled over swollen supraglottic structures. He was kept under observation in the intensive care unit, and given antibiotics, oxygen, and dexamethasone. The purring or fluttering sensation resolved as his dyspnoea and stridor abated. Clinical resolution of all symptoms was rapid and the patient was discharged after 3 days. Following convalescence, the patient mimicked the fluttering sensation for others by placing the tip of his tongue against the anterior portion of the hard palate; forcing air between the two caused vibration of the tongue in a trill-like manner. We suspect that air rushing from the glottis and around the swollen epiglottis perched over it set up eddy currents or turbulence which caused the epiglottis to waver or flutter much like a sail luffing in the breeze. This probably resulted in the purring sensation during exhalation. Have other patients with epiglottitis noted precordial purring? Is exhalational epiglottal flutter the cause? Can a physical sign of such fluttering be appreciated and used to help establish the diagnosis of acute epiglottitis and follow the course of the illness? Department of Medicine, Miriam Hospital, Brown University, Providence, Rhode Island 02906, USA
FRED J. SCHIFFMAN HERBERT C. LICHTMAN
1.
Shapiro J, Eavey RD, Baker AS. Adult supraglottitis: a prospective analysis. JAMA
2.
1988; 259: 563-67. Mayo Smith MF, Hirsch PJ, Wodzinski SF, Schiffman FJ. Acute epiglottitis in adults: an eight year experience in the State of Rhode Island. N Engl J Med 1986;
314: 1133-39. 3. Baker AS, Eavey RD. Adult 1185-86.
supraglottitis (epiglottitis). N Engl J Med 1986; 314:
Differentiation between specific and non-specific hepatitis C antibodies in chronic liver disease SiR,—We have used the Ortho Diagnostics System enzyme immunoassay for detecting antibodies to hepatitis C virus (HCV)l to assess the incidence of HCV infection in patients with chronic liver disease. Sera were collected from 100 potential liver transplant patients and we found 6 anti-HCV positive patients with liver diseases not normally associated with virus infection (table i). This could indicate infection with HCV during transfusions of blood and blood products, but it could also be interpreted as false-positive reactions with non-specific antibodies cross-reacting with the recombinant HCV antigen. Table 11 shows the optical density (OD) values for the positive samples. Samples from patients with cryptogenic cirrhosis all had OD values greater than 11(mean 2-38) while 6 samples from patients with liver disease associated with obstruction or metabolic or immunological changes had OD values of 09 or less (mean 0-69). To find out if the low OD values seen with some samples were non-specific, all anti-HCV-positive samples were retested twiceas previously and again with an 8 mol/1 urea wash during the first ELISA washing procedure. This urea wash should dissociate weak-binding or low-avidity antibodies from the antigen.2,3 The avidity of immunoglobulin G during the acute phase of viral TABLE I-HCV ANTIBODY STATUS OF PATIENTS WITH CHRONIC LIVER DISEASE
