504
bilirubin 8 umol/1, and albumin 40 g/1. In January, 1990, his alanine transferase (ALT) was 759 IU/1 and AST 367 IU/1, and in February, 1990, ALT (341 IU/1) and AST (278 IU/1) were still raised. Ultrasonography of the liver and gallbladder was normal. He was first tested for antibody to HCV (Ortho Diagnostics, Raritan, New Jersey) on Dec 14, 1989, and was positive. He subsequently tested positive in January, February, and March, 1990. Positivity was confirmed by the Abbott anti-HCV ELISA assay. His girlfriend was anti-HCV negative. A liver biopsy on Dec 1,1989 showed expansion of the portal tracts, which were infiltrated by lymphoid cells and segmented leucocytes with lymphoid aggregates. There was mild periportal and focal necrosis, and Kupffer cell hypertrophy. Because of the continuing inflammatory activity seven months after the onset of hepatitis, he was thought to have early chronic active HCV infection, and treatment with Ct.-interferon was begun. We believe that this patient acquired chronic HCV infection through saliva, or possibly blood contamination of saliva, via a human bite. This route may therefore be one method of hidden parenteral and person-to-person spread of hepatitis C, and of community acquired infection. Experimental transmission of NANB hepatitis by saliva to chimpanzees has been reported.! The fact that HCV may be transmitted by saliva has implications for dental practice. G. M. DUSHEIKO Departments of Medicine and Pathology, M. SMITH Free Royal Hospital, London NW3 2QG, UK P. J. SCHEUER 1. Abe K, Kurata T,
Sugitani M, Oda T. Experimental transmission of non-A, non-B hepatitis by saliva. J Infect Dis 1987; 155: 1078-79.
Long-term
use
of copper intrauterine devices
SIR,-While agreeing with the substance of the statement from the Medical Advisory Committee of the Family Planning Association and the National Association of Family Planning Doctors (June 2, p 1322) that there is strong evidence that copper intrauterine devices (IDUs) have lifetimes of 5 or more years, some details in the statement provided by Professor Newton and Dr Tacchi may be incorrect and some information has been omitted. The stated licensed duration of use of devices in the USA is out of date. The copper T 380A was approved for 6 years of use by the US Food and Drug Administration (FDA) in July, 1989, and the T 200 is approved for 4 years. Dr I. Batar’s data are cited as evidence that the ’Multiload 375’ retains its efficacy for 8 years. Unfortunately Batar’s work is with multiple segments of use, and few or no individual devices were used for 8 years. "Multiple segments" means that devices were removed and replaced with new ones. To date there are no randomised clinical trials that confirm a 6-year duration of clinical efficacy for the T 380S (a device different from the T 380A), the ’Multiload 250’, the multiload 375, or the ’Nova T’. Hence the last column of table 11 for these devices is based not on clinical data but on extrapolation. The TCu 380A was first studied in the USA in 1971. Newton and Tacchi designate the device as "third generation", but the invention and the trials preceded by several years the "second generation" devices in their table. The 380A is, in this sense, not "newer" than the second generation devices. The T 220C mentioned, widely used in China and Mexico, has been shown to be effective for 6 years in published randomised trials. The Population Council, using data from the World Health Organisation’s comparative IUD studies, is in the process of submitting a request to the FDA for 8 years of use of the TCu 380A after a single insertion. Population Council, Center for Biomedical Research, New York, NY 10021, USA
IRVING SIVIN
Vigabatrin and behaviour disturbances SjR,—Vigabatrin is the latest anticonvulsant agent to be licensed in UK, and it is indicated for the treatment of patients with drug-resistant epilepsy. Sander and Hartl have urged caution in the use of vigabatrin to treat epileptic patients, especially those with a history of psychiatric problems, because of a range of behavioural disturbances that developed in 7 of 145 patients who received this drug. Similarly, Johnstonz reported 2 patients receiving vigabatrin in whom aggressive behaviour developed. We would draw attention to similar behavioural disturbances that developed in 9 of 119 patients with refractory epilepsy who received vigabatrin in our epilepsy unit. 6 male and 2 female patients became both physically and verbally aggressive. Initial complaints from family members were of increased irritability, agitation, and short temper, which began an average of 5 weeks after the start of treatment. 3 patients were taking vigabatrin 10, 2-0, and 3-0 g per day, respectively. Patients sometimes showed short outbursts of quite striking aggression-for example, 1 patient armed with a knife assaulted a caretaker, 1 persistently attacked his mother and on one occasion attempted to strangle her, and 1 smashed furniture in his mother’s house as if on a rampage. Although 7 of the 8 patients in this group had a history of aggression, and had varying degrees of organic brain damage, this behaviour was atypical and unexpected. In the remaining (ninth) patient a psychotic disorder developed. Vigabatrin was withdrawn in 8 patients, with resolution of the behavioural problems within a few weeks in 7. In the remaining patient, symptoms were controlled with haloperidol. In only 1 of the 9 patients had seizures been fully controlled at the onset of the behavioural disturbances. A psychosis developed in this patient and was slow to resolve despite withdrawal of vigabatrin; the patient responded to thioridazine. Vigabatrin might have heightened pre-existing aggressive behavioural traits in some of our patients, especially in those with organic brain damage. We therefore urge caution in the use of vigabatrin in such patients.
the
Epilepsy Unit, University of Wales College of Medicine, Heath Park, Cardiff CF4 4XN, UK
M. K. ROBINSON A. RICHENS R. OXLEY
Vigabatrin and behaviour disturbances. Lancet 1990; 335: 57. Johnston SJ. Vigabatrin and behaviour disturbances. Lancet 1990, 335: 606.
1. Sander J, Hart Y. 2.
Lack of association between anticardiolipin antibodies and heart valve disease in Chinese patients with systemic lupus
erythematosus SIR,-Dr Khamashta and colleagues (June 30, p 1541) show associations between antiphospholipid antibodies (anticardiolipin [ACA] and the lupus anticoagulant [LAC]) and both mitral valve regurgitation and vegetations. We have recorded that several cardiac abnormalities are more frequent in Hong Kong Chinese patients with systemic lupus erythematosus (SLE) than in age and sex matched Chinese controls.1,2 We now report the absence of any association between cardiac valvular regurgitation and ACA in these patients. We investigated fifty patients (mean age 30 years [SD 8], mean duration of disease 33 months [29]) fulfilling the American Rheumatism Association revised criteria for SLE3and fifty age and sex matched Chinese controls. Patients and controls underwent full echocardiographic and doppler studies as described earlier.2 Sera obtained from forty-seven patients at the time of echocardiography were stored at - 70°C for the measurement of ACA with an enzyme-linked immunosorbent assay (Medical Innovations, Labrador, Australia), which was calibrated with international reference samples. Results are reported as normal, low positive, moderate positive, and high positive. Regurgitation affecting the mitral, tricuspid, or pulmonary valves occurred more frequently in patients than in controls: 46% vs 10%, 68% vs 44%, and 56% vs 34%, respectively. Aortic regurgitation
bilirubin 8 umol/1, and albumin 40 g/1. In January, 1990, his alanine transferase (ALT) was 759 IU/1 and AST 367 IU/1, and in February, 1990, ALT (341 IU/1) and AST (278 IU/1) were still raised. Ultrasonography of the liver and gallbladder was normal. He was first tested for antibody to HCV (Ortho Diagnostics, Raritan, New Jersey) on Dec 14, 1989, and was positive. He subsequently tested positive in January, February, and March, 1990. Positivity was confirmed by the Abbott anti-HCV ELISA assay. His girlfriend was anti-HCV negative. A liver biopsy on Dec 1,1989 showed expansion of the portal tracts, which were infiltrated by lymphoid cells and segmented leucocytes with lymphoid aggregates. There was mild periportal and focal necrosis, and Kupffer cell hypertrophy. Because of the continuing inflammatory activity seven months after the onset of hepatitis, he was thought to have early chronic active HCV infection, and treatment with Ct.-interferon was begun. We believe that this patient acquired chronic HCV infection through saliva, or possibly blood contamination of saliva, via a human bite. This route may therefore be one method of hidden parenteral and person-to-person spread of hepatitis C, and of community acquired infection. Experimental transmission of NANB hepatitis by saliva to chimpanzees has been reported.! The fact that HCV may be transmitted by saliva has implications for dental practice. G. M. DUSHEIKO Departments of Medicine and Pathology, M. SMITH Free Royal Hospital, London NW3 2QG, UK P. J. SCHEUER 1. Abe K, Kurata T,
Sugitani M, Oda T. Experimental transmission of non-A, non-B hepatitis by saliva. J Infect Dis 1987; 155: 1078-79.
Long-term
use
of copper intrauterine devices
SIR,-While agreeing with the substance of the statement from the Medical Advisory Committee of the Family Planning Association and the National Association of Family Planning Doctors (June 2, p 1322) that there is strong evidence that copper intrauterine devices (IDUs) have lifetimes of 5 or more years, some details in the statement provided by Professor Newton and Dr Tacchi may be incorrect and some information has been omitted. The stated licensed duration of use of devices in the USA is out of date. The copper T 380A was approved for 6 years of use by the US Food and Drug Administration (FDA) in July, 1989, and the T 200 is approved for 4 years. Dr I. Batar’s data are cited as evidence that the ’Multiload 375’ retains its efficacy for 8 years. Unfortunately Batar’s work is with multiple segments of use, and few or no individual devices were used for 8 years. "Multiple segments" means that devices were removed and replaced with new ones. To date there are no randomised clinical trials that confirm a 6-year duration of clinical efficacy for the T 380S (a device different from the T 380A), the ’Multiload 250’, the multiload 375, or the ’Nova T’. Hence the last column of table 11 for these devices is based not on clinical data but on extrapolation. The TCu 380A was first studied in the USA in 1971. Newton and Tacchi designate the device as "third generation", but the invention and the trials preceded by several years the "second generation" devices in their table. The 380A is, in this sense, not "newer" than the second generation devices. The T 220C mentioned, widely used in China and Mexico, has been shown to be effective for 6 years in published randomised trials. The Population Council, using data from the World Health Organisation’s comparative IUD studies, is in the process of submitting a request to the FDA for 8 years of use of the TCu 380A after a single insertion. Population Council, Center for Biomedical Research, New York, NY 10021, USA
IRVING SIVIN
Vigabatrin and behaviour disturbances SjR,—Vigabatrin is the latest anticonvulsant agent to be licensed in UK, and it is indicated for the treatment of patients with drug-resistant epilepsy. Sander and Hartl have urged caution in the use of vigabatrin to treat epileptic patients, especially those with a history of psychiatric problems, because of a range of behavioural disturbances that developed in 7 of 145 patients who received this drug. Similarly, Johnstonz reported 2 patients receiving vigabatrin in whom aggressive behaviour developed. We would draw attention to similar behavioural disturbances that developed in 9 of 119 patients with refractory epilepsy who received vigabatrin in our epilepsy unit. 6 male and 2 female patients became both physically and verbally aggressive. Initial complaints from family members were of increased irritability, agitation, and short temper, which began an average of 5 weeks after the start of treatment. 3 patients were taking vigabatrin 10, 2-0, and 3-0 g per day, respectively. Patients sometimes showed short outbursts of quite striking aggression-for example, 1 patient armed with a knife assaulted a caretaker, 1 persistently attacked his mother and on one occasion attempted to strangle her, and 1 smashed furniture in his mother’s house as if on a rampage. Although 7 of the 8 patients in this group had a history of aggression, and had varying degrees of organic brain damage, this behaviour was atypical and unexpected. In the remaining (ninth) patient a psychotic disorder developed. Vigabatrin was withdrawn in 8 patients, with resolution of the behavioural problems within a few weeks in 7. In the remaining patient, symptoms were controlled with haloperidol. In only 1 of the 9 patients had seizures been fully controlled at the onset of the behavioural disturbances. A psychosis developed in this patient and was slow to resolve despite withdrawal of vigabatrin; the patient responded to thioridazine. Vigabatrin might have heightened pre-existing aggressive behavioural traits in some of our patients, especially in those with organic brain damage. We therefore urge caution in the use of vigabatrin in such patients.
the
Epilepsy Unit, University of Wales College of Medicine, Heath Park, Cardiff CF4 4XN, UK
M. K. ROBINSON A. RICHENS R. OXLEY
Vigabatrin and behaviour disturbances. Lancet 1990; 335: 57. Johnston SJ. Vigabatrin and behaviour disturbances. Lancet 1990, 335: 606.
1. Sander J, Hart Y. 2.
Lack of association between anticardiolipin antibodies and heart valve disease in Chinese patients with systemic lupus
erythematosus SIR,-Dr Khamashta and colleagues (June 30, p 1541) show associations between antiphospholipid antibodies (anticardiolipin [ACA] and the lupus anticoagulant [LAC]) and both mitral valve regurgitation and vegetations. We have recorded that several cardiac abnormalities are more frequent in Hong Kong Chinese patients with systemic lupus erythematosus (SLE) than in age and sex matched Chinese controls.1,2 We now report the absence of any association between cardiac valvular regurgitation and ACA in these patients. We investigated fifty patients (mean age 30 years [SD 8], mean duration of disease 33 months [29]) fulfilling the American Rheumatism Association revised criteria for SLE3and fifty age and sex matched Chinese controls. Patients and controls underwent full echocardiographic and doppler studies as described earlier.2 Sera obtained from forty-seven patients at the time of echocardiography were stored at - 70°C for the measurement of ACA with an enzyme-linked immunosorbent assay (Medical Innovations, Labrador, Australia), which was calibrated with international reference samples. Results are reported as normal, low positive, moderate positive, and high positive. Regurgitation affecting the mitral, tricuspid, or pulmonary valves occurred more frequently in patients than in controls: 46% vs 10%, 68% vs 44%, and 56% vs 34%, respectively. Aortic regurgitation
