BRITISH MEDICAL JOURNAL

14 OCTOBER 1978

Further investigation has shown that the incorrect Reflomat result may have resulted from inserting the Reflomat strip into the machine upside down, which can give spurious readings up to 4 0 mmol/l. Incorrect insertion of the strip is, of course, more likely when testing for hypoglycaemia since the test surface fails to show significant colour change in this situation. This problem does not appear to be significant with the more recently available Reflotest-Hypoglycemie strips, though false results may occur. if either of the strips is not fully inserted into the machine. Although all laboratory results should be interpreted in the context of the clinical findings, we should like to alert your readers to this potential cause of error and suggest that the manufacturers alter the colour of the blank reverse side of the strip to obviate this risk. We should like to emphasise, however, that provided that the instructions are followed and the strips used correctly the Reflomat method has proved reproducible, accurate, and reliable. J H REYNOLDS

S G BARBER J H SMITH A D WRIGHT. General Hospital, Birmingham

***The authors sent a copy of this letter to the Boehringer Corporation, whose reply is printed below.-ED, BM7. SIR,-The Reflomat and Reflotest system was designed to be simple and reliable to operAte both in the laboratory and in the hands of the appropriate staff throughout the hospital, and thus Boehringer Mannheim and the Boehringer Corporation (London) regret that this mishap has occurred. We have not been able to reproduce the results reported since using the standard Reflotest strip upside down in the instrument gives a low (virtually zero) reading on the scale and not a higher result as indicated in the letter. Thus inserting the strip upside down cannot lead tO overlooking a possible hypoglycaemia. The only way that we feel this result could have occurred is by inadvertently reading a Reflotest-Hypoglycemie strip by means of the normal black Reflotest scale instead of the correct Reflotest-Hypoglycemie scale, which is coloured grey. Our tests showed that if this occurred with a sample- containing 0-6 mmol/l a result of 4-2 mmol/l (75 7 mg/ 100 ml) could be erroneously obtained. At present normal Reflotest scales are coloured black and Reflotest-Hypoglycemie scales are grey with a corresponding grey marking on the Reflotest-Hypoglycemie strips. Reflotest-Glucose strips do. not at present have any colouring on the reverse side. While we are sure that even the best possible system cannot exclude human error, we are always eager to improve the safety and quality of our products and therefore take this letter seriously. Accordingly, future batches will be redesigned so that the labels of both types of strip are different and the possibility of producing a coloured reverse- side to the Reflotest-Glucose strip will be investigated. P PROETZSCH H WENDEL Mannheim, Germany

Scientific ManagementRapid Diagnostics_ Boehringer Mannheim

Erythema chronicum migrans in Britain SIR,-Further to your recent leading article "Ticks, tourists, and encephalitis" (26 August, p 587), we would like to report six cases of erythema chronicum migrans (ECM) seen in that area of East Anglia served by the Cambridge department of dermatology in the past three years. ECM is a clinically distinctive variant of the rather heterogeneous group of annular erythemas but its aetiology remains obscure, although it is generally considered to be due to a tick-borne non-bacterial infectious agent. Until recently cases of ECM originating outside Scandinavia and certain other parts of Europe were rare and most European reports incriminate the tick Ixodes ricinus as vector. All the patients, four of whom were male adults, gave similar histories. An irritable primary reaction would be followed by the appearance of. an erythematous, slightly indurated ring which' slowly extended with central clearing over successive months until' they sought treatment. The width of the erythematous band at the time of examination was' approximately 2 cm and the diameter of the largest of the ring's was, about 75 cm. Clearance occurred within a few days of starting a course of oral penicillin. Little or no systemic upset was reported by our patients, although' one had a penicillin reaction. Routine blood counts were normal and no elevation of Weil-Felix titres was detected. Biopsy was performed on one lesion and a mild perivascular lymphocytic infiltrate was seen in the mid-dermis. Rickettsiae, spirochaetes, and viruses have all at times been incriminated as infecting organisms and perhaps the speed of resolution following treatment with penicillin, erythromycin, or tetracycline might favour a rickettsial

infection.

1087 The figure shown illustrates the right big toe nail ingrowing and the anterior nail fold in a.boy aged 9 months. The condition was asymptomatic until he started wearing shoes around the age of 18 months, when the lateral and medial nail folds became inflamed. However, he" is now 2 years 8 months old and, although- the nail remains ingrown, he is not troubled at all because he wears wide-toed shoes.. In addition, over the past six months or

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Right big toe with prominent anterior nail fold in male infant aged 9 month so the skin at the toe tip has ceased to overhang and looks normal. In this particular infant the big toe nail has never required trimming because it grows very slowly. The left big toe and nail are normal. The boy's father has had long-standing trouble with an ingrowing big toe nail which has recurred despite avulsion of the toe nail on two occasions in his teens. As a general rule, surgery should be avoided both because of the likelihood of recurrence and because some cases do improve spontaneously. Pressure trauma to the skin around the nail must be minimised and topical antiseptics/antibiotics may be required for paronychia. JULIAN VERBOV

While most of our patients felt they had been bitten by an insect, none considered it had been a tick. Four cases came from the region of the Thetford Forest, where ticks reputedly exist, and one patient was bitten by something while walking' in the forest. Royal Liverpool Children's Hospital, Another case has been reported from south- Liverpool east Scotland.' DAVID GOLDIN Health of King Henry VIII Kent and Canterbury Hospital, Canterbury

R H CHAMPION SIR,-May we acknowledge the reply of Dr ARTHUR ROOK R J Hetherington (30 September, p 956) S O B ROBERTS which, in part, indicates the reports in The Complete Peerage of the hearsay evidence of an Addenbrooke's Hospital, illegitimate son, Henry Carey, not recognised Cambridge by the King during his lifetime? NotwithObasi, 0 E, British Journal of Dermatology, 1977, 97, standing the retrospective reports of the 459. hearsay evidence, one illegitimate birth, where fathering, putative or not, is attributed to the King, does not significantly affect the total of Ingrowing toenails in infancy surviving births (two females and two males after multiple partners) over the long period SIR,-I agree with Mr F B Bailie and Mr D M of 38 years (2 September, p 700). Against Evans (9 September, p 737) that ingrowing which matters of undoubted fact we may now toenail certainly occurs in infants but is balance and weigh by other criteria the eviuncommon. In my e,xperience the usual cause dence of a contemporary, independent inforin an infant is unduly prominent skin at the mant who secretly communicates for posterity extreme tip of the big toe forming an anterior at the risk of his life on dangerous matters nail fold which encourages ingrowing and without possibility of any benefit or reward prevents the free end of the big toe nail during his lifetime.' May we offer an opinion growing normally; the condition may -some- that Hans Holbein, the informant, appears to times be genetically 4jgetermined. I wonder, in have made his point on the underlying fact, whether this was the cause in the first "genetic impediment" of the King ? The of the cases reported by Mr- Bailie:-and Mr- artist's- comment is relevant. We hope that Dr-Hetherington will consider Evans.

BRITISH MEDICAL JOURNAL

1088

the possibility, notwithstanding the conjectural opinions reported by Scarisbrick, McLennan, and McNalty, that the fact of Henry Carey's survival to maturity at all postulates (on the face of the undoubted evidence relevant to the non-surviving births to the King) a further theory that he may actually have been the legitimate son of Sir William Carey and Mary Howard. MAX SKOBLO Department of Psychiatry, Wembley Hospital, Wembley, Middx

JACK LESLAU London NW6 I

Leslau, J, Ricardian, 1978, 4, 2.

Intraoperative management of phaeochromocytoma with sodium nitroprusside SIR,-We read with interest the article by Dr Peter Daggett and others (29 July, p 311) and would agree with their conclusion that sodium nitroprusside "is a useful hypotensive agent [in the operative management of] patients with a phaeochromocytoma." We would, however, be grateful for an explanation of the rationale behind their choice of 0 5 mg/kg as a maximum total dose of the drug, as they present no evidence in support of this figure. Our own studies,' based on data from over 300 patients and many animal experiments in which plasma and red cell cyanide were monitored, lead us to conclude that 1-5 mg/kg can safely be regarded as a maximum dose for short-term infusion. The apparent arbitrary establishment of such a low limiting dose as 0 5 mg/kg could possibly lead to a lack of realisation of the full potential of this drug. JOHN KRAPEZ PETER COLE Department of Anaesthesia, St Bartholomew's Hospital, London ECI

Cole, P V, Anaesthesia, 1978, 33, 473.

***We sent a copy of this letter to Dr Daggett and his colleagues, whose reply is printed below.-ED,

BM_J.

SIR,-The maximum dose of sodium nitroprusside (SNP) of 1-5 mg/kg recommended by Drs Krapez and Cole is the same as that suggested by Vesey et all and is applicable to situations where prolonged hypotension is required. In the very particular circumstance of arteriography or operation in cases of phaeochromocytoma, however, episodes of hypertension are usually short-lived. In a 70-kg man the upper limit advised by Drs Krapez and Cole would allow the infusion of 105 mg of SNP "short term." Most phaeochromocytomas are excluded from the circulation within 1-2 h of starting surgery, and at this point the need to infuse SNP ceases. Thus at the outside the infusion would last for 120 min, and in order to utilise the 105 mg computed above the infusion would have to deliver 875 .Lg/min for the whole of this time. Vesey and Cole2 have observed that the rate of infusion is probably a more important determinant of possible toxicity than the total dose infused, and rates in excess of 800 [±g/min are regarded as hazardous.3 -. The-.preparatory- a- and ,-Aadrenoceptor-

14 OCTOBER 1978

diflunisal to this regimen she became ill with involvement of skin, conjunctiva, and mucous membranes typical of severe Stevens-Johnson syndrome. The second patient, aged 54, was receiving 500 mg of diflusinal twice daily for pain related to cervical osteoarthrosis. In addition she had been taking Ferrograd C (ferrous sulphate and sodium ascorbate) for six months and lorazepam for one month. Two weeks after starting diflunisal she had an exactly similar presentation to the first patient, with conjunctiva, skin, and mucous membrane Department of Anaesthesia, Middlesex Hospital, involvement typical of severe Stevens-Johnson London Wl syndrome. In this patient there was also a I Vesey, C J, et al, British Journal of Anaesthesia, 1976, transient elevation of aspartate and alanine 48, 651. transaminases and creatine kinase. Both 2 Vesey, C J, and Cole, P V, British J7ournal of patients had a mild thrombocytopenia and a Anaesthesia, 1975, 47, 115. 3 Roche Pharmaceuticals, Nipride, p 24. Welwyn striking feature of both has been the persistence Garden City, Roche Products Ltd. of oral lesions. Further work is in progress to elucidate the relationship between diflunisal and StevensJohnson syndrome in these cases. Copper intrauterine devices in the abdomen JOHN A HUNTER A J DORWARD SIR,-Mr P J M Watney's paper (22 July, ROBIN KNILL-JoNEs p 255) prompts me to report an experience R T S GUNN with a Copper 7 intrauterine device which Gartnaval General Hospital, supports the belief that these devices, if in Glasgow the abdominal cavity, should be removed as RONA MACKIE soon as reasonably possible.

blocking regimen described in our paper makes it unnecessary to use doses of this magnitude. A dose of 0-5 mg/kg in our hypothetical 70-kg man is equivalent to 350 ml of a 0-01°%O solution, a volume which is seldom even approached in this situation. To recommend a larger dose would encourage administration at a potentially toxic rate and this could bring into disrepute a drug which we are agreed is invaluable. PETER DAGGETT IAN VERNER

University Department

The patient was referred when approximately 18 of Dermatology, weeks pregnant in her fourth pregnancy. Two Western Infirmary, Glasgow years previously she had had a Copper 7 intrauterine device inserted, and the insertion had been very painful. The pregnancy continued to term and ended in a normal delivery. The device was not fouiLd at the Changing advice on vaccination time of delivery, either with the placenta and membranes or in the uterus. A plain abdominal SIR,-As a poor bemused general practitioner x-ray showed the device to be lying above the struggling to keep abreast of medical progress, level of the umrbilicus. The patient had requested I am at a loss to know what recent advances laparoscopic sterilisation six weeks post partum in knowledge prompted the current changes in and this was undertaken, but the device could not vaccination procedures. be located with the laparoscope. In 1972 we were told that in view of recent Formal laparotomy was undertaken and after a prolonged search the device was located high in advances in immunological knowledge it was the small-bowel mesentery, penetrating the wall undesirable to immunise infants under 6 of the superior mesenteric artery as it emerged months old owing to the incomplete immunity under the body of the pancreas. It was removed conferred and the risks of side effects. This with great difficulty; after the removal the intima seemed logical and the revised schedule of the vessel was bulging into the cavity left by received general compliance. the device. The wall of the artery was repaired In 1978 we are told by the same experts with fine silk sutures and the patient made an that, following recent changes in knowledge uneventful recovery.

This case suggests that the peritoneal cavity's reaction to such a device is more violent than to a non-metal-containing device. In this case it could only have been a matter ofitime before erosion into the lumen of the superior mesenteric artery occurred with what could have been catastrophic consequences. R E ROBINSON Cambridge

Diflusinal and Stevens-Johnson syndrome SIR,-Cholestatic jaundice associated with diflunisal therapy has been reported by Dr Jonathan S Warren (9 September, p 736). We would like to add Stevens-Johnson syndrome as a further probable side effect of diflunisal therapy. The first patient was an amputee aged 25 treated for pain in her back and remaining knee with 250 mg of diflunisal twice daily. She had been taking Paramol 118 (paracetamol and dihydrocodeine tartrate) for at least three vmonths, and.1O-14 days after the addition of

and policy it is now desirable to immunise 3-month-old infants. By what criteria was it judged Athat the benefits of incomplete immunity conferred on a 3-month-old baby outweigh the risks of possible brain damage, which I would assume to be highest in this age group ? Is this new schedule a temporary measure brought in to combat the present pertussis panic and will the experts recommend a return to the old regimen next year ? Having weathered the recent wave of anxious mothers asking whether or not their 6-month-old babies should be "done" against whooping cough and having recommended vaccination, I do not relish the prospect of indefinitely immunising the younger age group. In addition, the Department of Health and Social Security now recommends, after 15 years or more of using oral polio vaccine, that we should discard the remnants of a vial after an immunising session. This raises two important points. Firstly, why has it taken all these years to publicise adequately something which should have been apparent in the early stages of any research programme? And secondly, if the remaining vaccine in a vial is so unreliable are the hundreds of babies and

Health of King Henry VIII.

BRITISH MEDICAL JOURNAL 14 OCTOBER 1978 Further investigation has shown that the incorrect Reflomat result may have resulted from inserting the Refl...
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