1537
You did
not
emphasise
the
importance
of
paracentesis in
management of established severe OHSS. We admit patients with OHSS for intravenous fluid therapy (crystalloid solutions only) if they complain of nausea and vomiting, have tense ascites, or their packed cell volume is greater than 45%. Rehydration improves urine output and reverses haemoconcentration (thereby reducing the risk of thrombosis) but increases ascites. We now do paracentesis early, by the transvaginal route, with TV UDFA equipment. Our experience with more aggressive transvaginal paracentesis has been the same as that reported by Aboulghar et al:l it not only relieves symptoms of tense ascites immediately, but it also seems to be followed by diuresis and to accelerate disease resolution. Those at risk of an exaggerated response to hMG should be treated with the lowest possible dose, but they are not always identified in advance. Even with the most careful adjustment of hMG dosage some of these patients tend to respond in all or nothing fashion. It is essential to distinguish between ovulation induction cycles, in which follicles are allowed to rupture, and superovulation cycles, in which follicles are aspirated and oocytes collected. When many follicles grow, ovulation induction cycles should be cancelled, but superovulation cycles can be allowed to proceed provided that all follicles are aspirated and the other measures that we have outlined are taken.
JOHN WATERSTONE Assisted
Conception Unit, King’s College School of Medicine and Dentistry, London SE5 8RX, UK
STEPHEN BENNETT RODRIGO RIBEIRO RUTH CURSON JOHN PARSONS
MA, Mansour RT, Serour GI, Amin Y. Ultrasonically guided vaginal aspiration of ascites in the treatment of severe ovarian hyperstimulation syndrome. Fertil Steril 1990; 53: 933.
1. Aboulghar
Innsbruck coma scale SIR,-There is much confusion among intensive care physicians and nurses about the correlation between dilated pupils and brain death. In their article on predicting non-survival after trauma with the Innsbruck coma scale Dr Benzer and colleagues (Oct 19, p 977) attribute a score of 0 to completely dilated pupils and of 1 to dilated pupils. This should be reversed because completely dilated pupils (mydriasis) are evidence of preserved sympathetic outflow and/or third cranial nerve dysfunction, and are incompatible with a diagnosis of brain death. The pupils in brain death are in the mid-position (4-6 mm diameter) and unreactive to light. This concept2 is apparently not appreciated by many physicians and nurses,3 and this may lead to premature interruption of resuscitation attempts. Intensive Care Unit,
Ospedale Civico, CH 6900 Lugano, Switzerland
Attempts at resuscitation often include the administration of high doses of catecholamines. Because these drugs cause the pupils to dilate, this dilatation must be excluded as a diagnostic criterion. The abandonment of resuscitation attempts should therefore not be determined by pupil dilatation, but, when possible, by other, more reliable indices such as irreversible circulatory failure and
electroencephalographical findings. A. BENZER G. MITTERSCHIFFTHALER
University Clinic for Anaesthesia and Intensive Medicine, A-6020 Innsbruck, Austria
M. MAROSI G. LUEF F. PÜHRINGER K. DE LA RENOTIERE H. LEHNER E. SCHMUTZHARD
SIR,-Dr Benzer and colleagues emphasise the value of the Innsbruck coma scale, which accurately predicted non-survival in the first 21 days in the limited patient group with scores of 0 or 1 out of a total of 21. Of major importance, however, are patients with longer life expectancy. Moreover, patients in the state of general anaesthesia are not accessible for coma scale rating. The management of these patients requires early decisions about intensive care treatment and prognostic indices about the usefulness of long term neurorehabilitation. Modem imaging methods are mandatory, permitting direct morphological assessment of the extent, location, and nature of brain damage. Since the superiority of magnetic resonance imaging (MRI) in neurological applications is well established,’ we used it in the work-up of 150 patients with severe closed head injury. We found an excellent correlation between lesion pattern and neurological deficit. MRI proved to be more sensitive than computed tomography in the detection of parenchymal lesions in all stages of traumatic brain diseased The Innsbruck coma scale is of great value in mass accidents, when a preselection of trauma victims has to be made. In daily practice, however, individual therapeutic decisions cannot be based solely on clinical ratings. To improve the clinical (and economical) management of severe brain trauma, evaluation of sustained brain damage by MRI and improved clinical assessment by coma scales are
complementary.
Department of Magnetic Resonance Imaging and Spectroscopy, University Hospital, A-6020 Innsbruck, Austria
GÜNTHER BIRBAMER WERNER JUDMAIER STEPHAN FELBER WOLFGANG BUCHBERGER FRANZ AICHNER
1. Molyneux AJ. Computed tomography and radiation doses. Lancet 1991; 337: 1164. 2. Birbamer G, Aichner F, Kampfl A, Felber S, Luz G, Gerstenbrand F. MR-Imaging of inner cerebral trauma. Abstract: 8th Annual congress of the European Society for Magnetic Resonance in Medicine and Biology, Zurich, Apr 18-21; 1991.
F. DE’ CLARI
Indoor radon and childhood 1. Smith MC, Bleck TP. Techniques for determining brain death. J Crit Illness 1989; 4: 67-73. 2. Plum F, Posner JB. The diagnosis of stupor and coma. 3rd edition. Philadelphia: FA Davis, 1980: 317. 3. Bleck TP. Dilated pupils and brain death. Ann Intern Med 1990; 112: 632.
*** This letter has been shown to Dr Benzer and colleagues, whose
reply follows.-ED. L. SIR,-Dr de’Clari’s comments are representative of a wide body of opinion among clinicians. A coma scale, by definition, can never by used to determine death; it measures the degree of coma and can be used only on the living. de’Clari’s arugment includes a basic misinterpretation if he equates completely dilated pupils (0 points) in the Innsbruck coma scale with the diagnosis of brain death. The purpose of our study was not the determination of brain death with a clinical scale but an evaluation of the scale as it related to the survival of trauma victims within 21 days of injury. We agree that dilated pupils alone are no reason to abandon resuscitation.
cancer
SIR,-Henshaw and colleagues have reported a significant correlation between mean indoor radon concentrations and the international incidence of all childhood cancers.1 However, the National Radiological Protection Board (NRPB) has demonstrated wide variation in indoor radon concentrations in different parts of the UK and even from house to neighbouring housed so average national levels are meaningless when considering radon in the aetiology of cancer. We have done a case-control study measuring indoor radon concentrations over the same 3-month period in the bedroom and living room of children in the Wessex health region. The cases comprised children with cancer diagnosed within the preceding 3 years, 45 % of whom had acute lymphoblastic leukaemia. Controls were matched for age and area of residence. Cases who had moved house since one year prior to diagnosis and controls who had moved house within the last year were not recruited. Radon detectors were supplied and processed by NRPB and readings were seasonally adjusted. The measurements for the two
1538
and 3 males, aged 60-89) had scores of 86 to 103 at the time of lumbar puncture. 13 of the 15 demented patients had a histopathological diagnosis3 of AD; 1 had progressive supranuclear palsy; and 1 had normal pressure hydrocephalus. The anomalous molecular form of AChE was found in the CSF taken during life in 11 patients with AD but not in any of the controls, even when the amount of CSF applied to the gel contained 5 nmol/min AChE activity (twice that used for the demented patients):
*By isoelectric focusing, as described’ except that amount of CSF applied to gel was that containing 2-5 nmol/min AChE activity at 30.C.
Although we do not have histopathological findings for the control group these interim results do suggest that demonstration of the anomalous form of AChE in CSF might be useful in the diagnosis of AD in life.
Departments of Pharmacology, Clinical Neurology, and Neuropathology, University of Oxford, Oxford OX1 3QT, UK
A. D. SMITH K. A. JOBST D. S. NAVARATNAM Z. X. SHEN J. D. PRIDDLE B. MCDONALD E. KING M. M. ESIRI
DS, Priddle JD, McDonald B, Esiri MM, Robinson JR, Smith AD. Anomalous molecular form of acetylcholinesterase in cerebrospinal fluid in histologically diagnosed Alzheimer’s disease. Lancet 1991; 337: 447-50. 2. Roth M, Huppert FA, Tym E, Mountjoy CQ. CAMDEX: the Cambndge examination for mental disorders of the elderly. Cambridge: Cambridge University Press, 1988. 3. Khachaturian ZS. Diagnosis of Alzheimer’s disease. Arch Neurol 1985; 42: 1097-105. 1. Navaratnam
household areas were averaged to give a mean radon concentration for each dwelling. Only one house in the study had a radon concentration exceeding the national action limit of 200 Bq/m3 (figure). There was no significant difference between the mean values for cases and controls. These results confirm observations from random surveys that radon concentrations in Wessex are low.3 It seems unlikely that radon is a major causative factor in the aetiology of childhood cancer in Wessex. Although a geographical correlation has been shown between childhood leukaemia and radon concentrations’* this does not prove a cause and effect, and other confounding factors may be involved.5 Larger case-control epidemiological studies are planned and may cast more light on the aetiology of childhood cancer. Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton SO9 4XY, UK
M. WAKEFIELD
J. A. KOHLER
1. Henshaw DL, Eatough HP, Richardson RB. Radon as a causative factor in induction in myeloid leukaemia and other cancers. Lancet 1990; 335: 1008-12. 2. Bowie C, Bowie SHU. Radon and health. Lancet 1991; 337: 409-13. 3. National Radiological Protection Board. Natural radiation exposure in UK dwellings: (R190). London: HM Stationery Office, 1988. 4. Cartwright RA, Alexander FE, McKinney PA, Rickets TJ. Leukaemia and lymphoma: an atlas of distribution within areas of England and Wales 1984-88. 5. Wolff SP. Radon and socioeconomic indicators. Lancet 1991; 337: 1476.
Anomalous acetylcholinesterase in lumbar CSF in Alzheimer’s disease SIR,-We have taken lumbar cerebrospinal fluid (CSF) periodically from more than 150 patients, referred with memory problems, in a prospective study of the pathogenesis of Alzheimer’s disease (AD). We use isoelectric focusing to look for the anomalous molecular form of acetylcholinesterase (AChE) that we found in CSF obtained at necropsy from patients with AD We here report fmdings on 15 demented patients for whom a histopathological diagnosis at necropsy is now available, together with results from 10 non-demented individuals of comparable age who are still alive. The patients with clinical dementia (9 females and 6 males, aged 63-92) had scores in the CAMCOG section ofCAMDEX2 ranging from 0 to 78 (cut-off for dementia 80), while the controls (7 females
Long-term follow-up of lead poisoning in an infant SIR,-We report 93 years of follow-up of a case of acute lead poisoning in a baby reported in your columns on Dec 3, 1898.1 The medical practitioner had attended the birth of a healthy baby 10,1898, but four weeks later the child was taken ill and had a fit. "I found the patient evidently in considerable pain, screaming violently, and with the legs flexed upon the abdomen. My first and most natural conclusion was that these symptoms indicated colic due to imperfectly digested food, but on examining the tongue I noticed an unmistakable blue line on the gums. This with a history of constipation was quite sufficient to confirm my diagnosis that lead was the cause of the trouble. The child had never taken milk from the breast, but the feeding bottles were, I found, above suspicion, as well as the water supply and general surroundings. Finally I discovered that the nurse, considered an experienced woman, had been freely dusting the child with powder, procured by herself quite innocently from a local chemist, and which was shown to be in a packet bearing the label "Powdered White Lead". This had been liberally dusted about the neck and behind the ears, and consequently would as such times be freely inhaled... I am pleased to be able to add that under the usual treatment, modified to suit the age, the child is making a good recovery." The patient subsequently thrived and became a highly respected teacher. She has had in recent years lapses of short-term memory, but at the time of writing remains well. We are happy to report therefore that this unusual case has had a successful long-term on Oct
outcome. 73 Cadogan Terrace, London E9 5HP, UK
1.
SIMON FRASER ALAN HAWARTH
Stephenson FWM. Lead poisoning in an infant four weeks old. Lancet 1898; ii:
1473.
You did
not
emphasise
the
importance
of
paracentesis in
management of established severe OHSS. We admit patients with OHSS for intravenous fluid therapy (crystalloid solutions only) if they complain of nausea and vomiting, have tense ascites, or their packed cell volume is greater than 45%. Rehydration improves urine output and reverses haemoconcentration (thereby reducing the risk of thrombosis) but increases ascites. We now do paracentesis early, by the transvaginal route, with TV UDFA equipment. Our experience with more aggressive transvaginal paracentesis has been the same as that reported by Aboulghar et al:l it not only relieves symptoms of tense ascites immediately, but it also seems to be followed by diuresis and to accelerate disease resolution. Those at risk of an exaggerated response to hMG should be treated with the lowest possible dose, but they are not always identified in advance. Even with the most careful adjustment of hMG dosage some of these patients tend to respond in all or nothing fashion. It is essential to distinguish between ovulation induction cycles, in which follicles are allowed to rupture, and superovulation cycles, in which follicles are aspirated and oocytes collected. When many follicles grow, ovulation induction cycles should be cancelled, but superovulation cycles can be allowed to proceed provided that all follicles are aspirated and the other measures that we have outlined are taken.
JOHN WATERSTONE Assisted
Conception Unit, King’s College School of Medicine and Dentistry, London SE5 8RX, UK
STEPHEN BENNETT RODRIGO RIBEIRO RUTH CURSON JOHN PARSONS
MA, Mansour RT, Serour GI, Amin Y. Ultrasonically guided vaginal aspiration of ascites in the treatment of severe ovarian hyperstimulation syndrome. Fertil Steril 1990; 53: 933.
1. Aboulghar
Innsbruck coma scale SIR,-There is much confusion among intensive care physicians and nurses about the correlation between dilated pupils and brain death. In their article on predicting non-survival after trauma with the Innsbruck coma scale Dr Benzer and colleagues (Oct 19, p 977) attribute a score of 0 to completely dilated pupils and of 1 to dilated pupils. This should be reversed because completely dilated pupils (mydriasis) are evidence of preserved sympathetic outflow and/or third cranial nerve dysfunction, and are incompatible with a diagnosis of brain death. The pupils in brain death are in the mid-position (4-6 mm diameter) and unreactive to light. This concept2 is apparently not appreciated by many physicians and nurses,3 and this may lead to premature interruption of resuscitation attempts. Intensive Care Unit,
Ospedale Civico, CH 6900 Lugano, Switzerland
Attempts at resuscitation often include the administration of high doses of catecholamines. Because these drugs cause the pupils to dilate, this dilatation must be excluded as a diagnostic criterion. The abandonment of resuscitation attempts should therefore not be determined by pupil dilatation, but, when possible, by other, more reliable indices such as irreversible circulatory failure and
electroencephalographical findings. A. BENZER G. MITTERSCHIFFTHALER
University Clinic for Anaesthesia and Intensive Medicine, A-6020 Innsbruck, Austria
M. MAROSI G. LUEF F. PÜHRINGER K. DE LA RENOTIERE H. LEHNER E. SCHMUTZHARD
SIR,-Dr Benzer and colleagues emphasise the value of the Innsbruck coma scale, which accurately predicted non-survival in the first 21 days in the limited patient group with scores of 0 or 1 out of a total of 21. Of major importance, however, are patients with longer life expectancy. Moreover, patients in the state of general anaesthesia are not accessible for coma scale rating. The management of these patients requires early decisions about intensive care treatment and prognostic indices about the usefulness of long term neurorehabilitation. Modem imaging methods are mandatory, permitting direct morphological assessment of the extent, location, and nature of brain damage. Since the superiority of magnetic resonance imaging (MRI) in neurological applications is well established,’ we used it in the work-up of 150 patients with severe closed head injury. We found an excellent correlation between lesion pattern and neurological deficit. MRI proved to be more sensitive than computed tomography in the detection of parenchymal lesions in all stages of traumatic brain diseased The Innsbruck coma scale is of great value in mass accidents, when a preselection of trauma victims has to be made. In daily practice, however, individual therapeutic decisions cannot be based solely on clinical ratings. To improve the clinical (and economical) management of severe brain trauma, evaluation of sustained brain damage by MRI and improved clinical assessment by coma scales are
complementary.
Department of Magnetic Resonance Imaging and Spectroscopy, University Hospital, A-6020 Innsbruck, Austria
GÜNTHER BIRBAMER WERNER JUDMAIER STEPHAN FELBER WOLFGANG BUCHBERGER FRANZ AICHNER
1. Molyneux AJ. Computed tomography and radiation doses. Lancet 1991; 337: 1164. 2. Birbamer G, Aichner F, Kampfl A, Felber S, Luz G, Gerstenbrand F. MR-Imaging of inner cerebral trauma. Abstract: 8th Annual congress of the European Society for Magnetic Resonance in Medicine and Biology, Zurich, Apr 18-21; 1991.
F. DE’ CLARI
Indoor radon and childhood 1. Smith MC, Bleck TP. Techniques for determining brain death. J Crit Illness 1989; 4: 67-73. 2. Plum F, Posner JB. The diagnosis of stupor and coma. 3rd edition. Philadelphia: FA Davis, 1980: 317. 3. Bleck TP. Dilated pupils and brain death. Ann Intern Med 1990; 112: 632.
*** This letter has been shown to Dr Benzer and colleagues, whose
reply follows.-ED. L. SIR,-Dr de’Clari’s comments are representative of a wide body of opinion among clinicians. A coma scale, by definition, can never by used to determine death; it measures the degree of coma and can be used only on the living. de’Clari’s arugment includes a basic misinterpretation if he equates completely dilated pupils (0 points) in the Innsbruck coma scale with the diagnosis of brain death. The purpose of our study was not the determination of brain death with a clinical scale but an evaluation of the scale as it related to the survival of trauma victims within 21 days of injury. We agree that dilated pupils alone are no reason to abandon resuscitation.
cancer
SIR,-Henshaw and colleagues have reported a significant correlation between mean indoor radon concentrations and the international incidence of all childhood cancers.1 However, the National Radiological Protection Board (NRPB) has demonstrated wide variation in indoor radon concentrations in different parts of the UK and even from house to neighbouring housed so average national levels are meaningless when considering radon in the aetiology of cancer. We have done a case-control study measuring indoor radon concentrations over the same 3-month period in the bedroom and living room of children in the Wessex health region. The cases comprised children with cancer diagnosed within the preceding 3 years, 45 % of whom had acute lymphoblastic leukaemia. Controls were matched for age and area of residence. Cases who had moved house since one year prior to diagnosis and controls who had moved house within the last year were not recruited. Radon detectors were supplied and processed by NRPB and readings were seasonally adjusted. The measurements for the two
1538
and 3 males, aged 60-89) had scores of 86 to 103 at the time of lumbar puncture. 13 of the 15 demented patients had a histopathological diagnosis3 of AD; 1 had progressive supranuclear palsy; and 1 had normal pressure hydrocephalus. The anomalous molecular form of AChE was found in the CSF taken during life in 11 patients with AD but not in any of the controls, even when the amount of CSF applied to the gel contained 5 nmol/min AChE activity (twice that used for the demented patients):
*By isoelectric focusing, as described’ except that amount of CSF applied to gel was that containing 2-5 nmol/min AChE activity at 30.C.
Although we do not have histopathological findings for the control group these interim results do suggest that demonstration of the anomalous form of AChE in CSF might be useful in the diagnosis of AD in life.
Departments of Pharmacology, Clinical Neurology, and Neuropathology, University of Oxford, Oxford OX1 3QT, UK
A. D. SMITH K. A. JOBST D. S. NAVARATNAM Z. X. SHEN J. D. PRIDDLE B. MCDONALD E. KING M. M. ESIRI
DS, Priddle JD, McDonald B, Esiri MM, Robinson JR, Smith AD. Anomalous molecular form of acetylcholinesterase in cerebrospinal fluid in histologically diagnosed Alzheimer’s disease. Lancet 1991; 337: 447-50. 2. Roth M, Huppert FA, Tym E, Mountjoy CQ. CAMDEX: the Cambndge examination for mental disorders of the elderly. Cambridge: Cambridge University Press, 1988. 3. Khachaturian ZS. Diagnosis of Alzheimer’s disease. Arch Neurol 1985; 42: 1097-105. 1. Navaratnam
household areas were averaged to give a mean radon concentration for each dwelling. Only one house in the study had a radon concentration exceeding the national action limit of 200 Bq/m3 (figure). There was no significant difference between the mean values for cases and controls. These results confirm observations from random surveys that radon concentrations in Wessex are low.3 It seems unlikely that radon is a major causative factor in the aetiology of childhood cancer in Wessex. Although a geographical correlation has been shown between childhood leukaemia and radon concentrations’* this does not prove a cause and effect, and other confounding factors may be involved.5 Larger case-control epidemiological studies are planned and may cast more light on the aetiology of childhood cancer. Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton SO9 4XY, UK
M. WAKEFIELD
J. A. KOHLER
1. Henshaw DL, Eatough HP, Richardson RB. Radon as a causative factor in induction in myeloid leukaemia and other cancers. Lancet 1990; 335: 1008-12. 2. Bowie C, Bowie SHU. Radon and health. Lancet 1991; 337: 409-13. 3. National Radiological Protection Board. Natural radiation exposure in UK dwellings: (R190). London: HM Stationery Office, 1988. 4. Cartwright RA, Alexander FE, McKinney PA, Rickets TJ. Leukaemia and lymphoma: an atlas of distribution within areas of England and Wales 1984-88. 5. Wolff SP. Radon and socioeconomic indicators. Lancet 1991; 337: 1476.
Anomalous acetylcholinesterase in lumbar CSF in Alzheimer’s disease SIR,-We have taken lumbar cerebrospinal fluid (CSF) periodically from more than 150 patients, referred with memory problems, in a prospective study of the pathogenesis of Alzheimer’s disease (AD). We use isoelectric focusing to look for the anomalous molecular form of acetylcholinesterase (AChE) that we found in CSF obtained at necropsy from patients with AD We here report fmdings on 15 demented patients for whom a histopathological diagnosis at necropsy is now available, together with results from 10 non-demented individuals of comparable age who are still alive. The patients with clinical dementia (9 females and 6 males, aged 63-92) had scores in the CAMCOG section ofCAMDEX2 ranging from 0 to 78 (cut-off for dementia 80), while the controls (7 females
Long-term follow-up of lead poisoning in an infant SIR,-We report 93 years of follow-up of a case of acute lead poisoning in a baby reported in your columns on Dec 3, 1898.1 The medical practitioner had attended the birth of a healthy baby 10,1898, but four weeks later the child was taken ill and had a fit. "I found the patient evidently in considerable pain, screaming violently, and with the legs flexed upon the abdomen. My first and most natural conclusion was that these symptoms indicated colic due to imperfectly digested food, but on examining the tongue I noticed an unmistakable blue line on the gums. This with a history of constipation was quite sufficient to confirm my diagnosis that lead was the cause of the trouble. The child had never taken milk from the breast, but the feeding bottles were, I found, above suspicion, as well as the water supply and general surroundings. Finally I discovered that the nurse, considered an experienced woman, had been freely dusting the child with powder, procured by herself quite innocently from a local chemist, and which was shown to be in a packet bearing the label "Powdered White Lead". This had been liberally dusted about the neck and behind the ears, and consequently would as such times be freely inhaled... I am pleased to be able to add that under the usual treatment, modified to suit the age, the child is making a good recovery." The patient subsequently thrived and became a highly respected teacher. She has had in recent years lapses of short-term memory, but at the time of writing remains well. We are happy to report therefore that this unusual case has had a successful long-term on Oct
outcome. 73 Cadogan Terrace, London E9 5HP, UK
1.
SIMON FRASER ALAN HAWARTH
Stephenson FWM. Lead poisoning in an infant four weeks old. Lancet 1898; ii:
1473.
