1419
Letters
to
the Editor
SHORT-COURSE CHEMOTHERAPY IN TUBERCULOSIS
SiR,—The successful preliminary results of the national trial organised by the British Thoracic and Tuberculosis Associationare welcomed by all who have to treat this disease. Longer follow-up of these patients may well establish that it is possible to treat tuberculosis successfully by using rifampicin and isoniazid in combination for 9 or 12 months, with a third drug for only the first 2 months of the course. With the authority of the B.T.T.A. behind this cooperative research, the medical profession may gain the impression that this is the best way to treat tuberculosis, or even that it is the officially correct way to treat it. Shortening the course of chemotherapy was a very desirable objective when P.A.S. was one of the three first-line drugs, but its place has been taken by ethambutol, a drug which carries no unpleasant side-effects and virtually no toxic effects in the standard dose of 15 mg. per kg. per day. This drug is entirely acceptable to all patients when combined with isoniazid in one tablet and taken as a single dose of three tablets after breakfast. The principles on which the modern treatment of tuberculosis are based have evolved during the 20-year era when the three first-line drugs were streptomycin, isoniazid, and P.A.S. Then, as now, all three drugs were used for the first 2 months of treatment, and the most toxic of the three was stopped once it was established that no resistant organisms were involved. Thereafter the course of 18 months to 2 years was completed with the less powerful combination of P.A.s. and isoniazid, which was nevertheless 100% effective in patients able to tolerate the unpleasant side-effects of P.A.S. These principles still hold good with the new trio, of which rifampicin is, at the same time, the most potent and the most toxic. The fact that it is also the most expensive makes a shorter course mandatory if it is to be used throughout. I submit, Sir, that patients who take three innocuous tablets each day after breakfast are quite unconcerned about an extra 3 or even 6 months of such hardship, provided they can be sure that their treatment is both safe and effective. Department of Medicine, Farnborough Hospital, Orpington, Kent BR6 8ND.
E. W. STREET.
TALC CONTAMINATION OF SURGICAL GLOVES SIR,-It has long been recognised that talc used as a surgical-glove powder has caused some cases of postoperative peritoneal adhesions as well as granulomata at the site of operation. For the past two decades, therefore, starch powder has been used in place of talc, but numerous reports suggest that this material can also produce a similar granulomatous reaction. We have now shown, however, that samples of surgeons’ gloves manufactured during the past two years have been contaminated with talc.
Using an extraction-replication technique followed by electronmicroscope microanalysis using an EMMA-4 (AEI, U.K.), particulate material on samples of surgeons’ gloves manufactured in the United
Kingdom, Austria, and the U.S.A. has been Furthermore, particulate material in histological sections of tissue classified as " starch " or " foreign body " granulomata has also been analysed by the same technique, which allows identification of individual particles down to a size of 200A in diameter.
analysed.
1. British Thoracic and Tuberculosis
Association, Lancet, 1975, i,
119.
20 pairs of supposedly talc-free gloves from British manufacturers were found to be contaminated with this material (see figure). Analysis of these particles showed the typical 3/1 silicon/magnesium ratio of talc. In the area of the glove surface analysed there were approximately 10,000 particles per sq. mm., although values did vary from sample to sample. For instance, four pairs of gloves manufactured in America were heavily contaminated with talc, whereas none could be found on the Austrian gloves. Although light microscopy of tissue classified as starch granulomata showed the classical rounded starch particles
Particles recovered from the surface of
a surgeon’s glove by the extraction-replication technique. (Reduced by a third from x 7500.) ,
X-ray per 20 seconds from the four show the typical 3/1 Si/Mg ratio of talc: counts
particles numbered
with Maltese-cross birefringence, ultramicroanalysis indicated that many of the tissues contained talc, some with up to 29,800 particles per sq. mm. Five tissue sections identified after microscopical examination as " foreign body " granulomata, not specifically implicating starch or any other particle, were all found to contain talc. It seems, therefore, that the manufacturing processes concerned with the production of surgeons’ gloves were unable to prevent the access of these extremely small particles. Normal procedures for checking contamination may not have the resolution or analytical capacity of EMMA-4. However, after being advised of these findings, the principal British manufacturer has located and eliminated the source of contamination. Talc cannot be definitely incriminated as the cause of these granulomatous lesions, since there is good clinical and laboratory evidence that adhesions within the peritoneal cavity as well as granulomata can result as a reaction to starch powder. But it seems that talc, as a contaminant of surgeons’ gloves, must still be considered in relation to the aetiology of postoperative granulomata. Tenovus Institute for Cancer
Research, Welsh National School of
Medicine, Heath, Cardiff. Department of Pathology, University Hospital of Wales, Heath, Cardiff.
W. J. HENDERSON C. MELVILLE-JONES K. GRIFFITHS. W. T. BARR.
Letters
to
the Editor
SHORT-COURSE CHEMOTHERAPY IN TUBERCULOSIS
SiR,—The successful preliminary results of the national trial organised by the British Thoracic and Tuberculosis Associationare welcomed by all who have to treat this disease. Longer follow-up of these patients may well establish that it is possible to treat tuberculosis successfully by using rifampicin and isoniazid in combination for 9 or 12 months, with a third drug for only the first 2 months of the course. With the authority of the B.T.T.A. behind this cooperative research, the medical profession may gain the impression that this is the best way to treat tuberculosis, or even that it is the officially correct way to treat it. Shortening the course of chemotherapy was a very desirable objective when P.A.S. was one of the three first-line drugs, but its place has been taken by ethambutol, a drug which carries no unpleasant side-effects and virtually no toxic effects in the standard dose of 15 mg. per kg. per day. This drug is entirely acceptable to all patients when combined with isoniazid in one tablet and taken as a single dose of three tablets after breakfast. The principles on which the modern treatment of tuberculosis are based have evolved during the 20-year era when the three first-line drugs were streptomycin, isoniazid, and P.A.S. Then, as now, all three drugs were used for the first 2 months of treatment, and the most toxic of the three was stopped once it was established that no resistant organisms were involved. Thereafter the course of 18 months to 2 years was completed with the less powerful combination of P.A.s. and isoniazid, which was nevertheless 100% effective in patients able to tolerate the unpleasant side-effects of P.A.S. These principles still hold good with the new trio, of which rifampicin is, at the same time, the most potent and the most toxic. The fact that it is also the most expensive makes a shorter course mandatory if it is to be used throughout. I submit, Sir, that patients who take three innocuous tablets each day after breakfast are quite unconcerned about an extra 3 or even 6 months of such hardship, provided they can be sure that their treatment is both safe and effective. Department of Medicine, Farnborough Hospital, Orpington, Kent BR6 8ND.
E. W. STREET.
TALC CONTAMINATION OF SURGICAL GLOVES SIR,-It has long been recognised that talc used as a surgical-glove powder has caused some cases of postoperative peritoneal adhesions as well as granulomata at the site of operation. For the past two decades, therefore, starch powder has been used in place of talc, but numerous reports suggest that this material can also produce a similar granulomatous reaction. We have now shown, however, that samples of surgeons’ gloves manufactured during the past two years have been contaminated with talc.
Using an extraction-replication technique followed by electronmicroscope microanalysis using an EMMA-4 (AEI, U.K.), particulate material on samples of surgeons’ gloves manufactured in the United
Kingdom, Austria, and the U.S.A. has been Furthermore, particulate material in histological sections of tissue classified as " starch " or " foreign body " granulomata has also been analysed by the same technique, which allows identification of individual particles down to a size of 200A in diameter.
analysed.
1. British Thoracic and Tuberculosis
Association, Lancet, 1975, i,
119.
20 pairs of supposedly talc-free gloves from British manufacturers were found to be contaminated with this material (see figure). Analysis of these particles showed the typical 3/1 silicon/magnesium ratio of talc. In the area of the glove surface analysed there were approximately 10,000 particles per sq. mm., although values did vary from sample to sample. For instance, four pairs of gloves manufactured in America were heavily contaminated with talc, whereas none could be found on the Austrian gloves. Although light microscopy of tissue classified as starch granulomata showed the classical rounded starch particles
Particles recovered from the surface of
a surgeon’s glove by the extraction-replication technique. (Reduced by a third from x 7500.) ,
X-ray per 20 seconds from the four show the typical 3/1 Si/Mg ratio of talc: counts
particles numbered
with Maltese-cross birefringence, ultramicroanalysis indicated that many of the tissues contained talc, some with up to 29,800 particles per sq. mm. Five tissue sections identified after microscopical examination as " foreign body " granulomata, not specifically implicating starch or any other particle, were all found to contain talc. It seems, therefore, that the manufacturing processes concerned with the production of surgeons’ gloves were unable to prevent the access of these extremely small particles. Normal procedures for checking contamination may not have the resolution or analytical capacity of EMMA-4. However, after being advised of these findings, the principal British manufacturer has located and eliminated the source of contamination. Talc cannot be definitely incriminated as the cause of these granulomatous lesions, since there is good clinical and laboratory evidence that adhesions within the peritoneal cavity as well as granulomata can result as a reaction to starch powder. But it seems that talc, as a contaminant of surgeons’ gloves, must still be considered in relation to the aetiology of postoperative granulomata. Tenovus Institute for Cancer
Research, Welsh National School of
Medicine, Heath, Cardiff. Department of Pathology, University Hospital of Wales, Heath, Cardiff.
W. J. HENDERSON C. MELVILLE-JONES K. GRIFFITHS. W. T. BARR.
