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such a programme for one year, we want to re-emphasise our call for international effort to continue to stop the further spread of bloodbome diseases among children in Romania. an

University Children’s Hospital, University of Basel,

CH. RUDIN

CH-4058 Basel, Switzerland

P. W. NARS

AIDS in

Nicaragua

SIR,-Dr Summerfield (April 20, p 967) reports on the ending of the "Contra" war and the AIDS situation in Nicaragua, and we welcome the attention given to this issue. The source of this item seems to be a report that we wrote for the Nicaragua Health Fund newsletter.1 Since then information on HIV infection amongst returnees from Honduras has revealed a different situation. Summerfield suggests that the return of Contra troops and refugees from Honduras has had a significant impact on the small number of Nicaraguans identified as seropositive. In an earlier letter to The Lancec2 we showed that this concern was largely unfounded. Only 1 Contra and 4 refugees, out of more than 12 000 people tested, were HIV antibody positive, the apparent explanation being that Nicaraguans who lived in Honduras during the war stayed in the border region with little contact with urban areas in the centre and north of the country where two-thirds of the people with AIDS in Honduras have been identified. Whilst it is true that 47 people had been identified as HIV seropositive (up to Sept 30,1990), only 26 are Nicaraguan and the remainder have left the country. Injecting of illegal drugs is not a problem in Nicaragua, as implied by Summerfield, but the frequency of intramuscular injections of antibiotics and vitamins bought over the counter would be a potential route of transmission if the availability of sterile needles and syringes cannot be guaranteed. Social dislocation and poverty due to war are thought to be factors facilitating the spread of sexually transmitted diseases. Low intensity wars leading to destabilisation, especially in rural areas, are also seen as creating conditions for HIV transmission in countries such as Mozambique.3 The paradoxical situation of Nicaragua derives from the observation that ten years of this type of warfare seem to have protected the country from AIDS by limiting contact with the aggressor. The Fundación Nimehuatzin is a European Community Task Force on AIDS funded project, which was founded in collaboration with a group of gay health educators (CEP-SIDA) who instigated AIDS prevention in 1986. Its objectives are not confined to epidemiological surveillance of HIV but aim to develop a culturally appropriate programme of education and condom promotion to reduce the incidence of sexually transmitted diseases and population risk of AIDS in Nicaragua. RITA ARAUZ NICOLA LOW ANNA GORTER GEORGE DAVEY SMITH

Fundación Nimehuatzin, Casa 68,

Managua, Nicaragua 1. Low N. Is AIDS

a problem in Nicaragua? Nicaragua Health Fund Newsl 1990 (autumn). 2. Low N, Davey Smith G, Gorter A, Arauz R AIDS and migrant populations m Nicaragua. Lancet 1990; 336: 1593-94. 3. Baldo M, Cabral AJ. Low intensity wars and social determination of the HIV transmission: the search for a new paradigm to guide research and control of the HIV-AIDS pandemic. In: Proceedings of Maputo Conference on Health in Transition in Southern Africa (April 9-16, 1990). New York: CHISA, 1990.

Control of

bleeding

in advanced

cancer

SIR,-Mrs McElligot and her colleagues (Feb 16, p 431) and Dr Regnard (April 20, p 974) describe the use of topical medication, including tranexamic acid, alum, and sucralfate, for haemorrhage in patients with locally advanced malignant tumours. Although these approaches are of interest, their place in the management of haemorrhage in such patients remains unclear. In most patients, definitive palliative local treatment with radiotherapy will provide effective control of bleeding for the lifespan of the patient without the need for continued medication. Published data show that haemoptysis,l rectal bleeding,2 and

haematuria3are controlled after only short palliative courses of irradiation in most patients. We have reviewed our experience of palliative irradiation in the treatment of relapsed ovarian cancer after chemotherapy. In a consecutive series of 54 patients, 8 were treated for vaginal haemorrhage from pelvic tumour invading the vaginal vault. Complete resolution of bleeding was seen in all 8 patients after a short course of irradiation; our standard dose in this situation was only 2 doses of 4 Gy on consecutive days. Such treatment is accompanied by few if any side-effects and causes minimum disruption to the patient; it may also be given after previous irradiation. At present topical therapy should be reserved for those few patients in whom local irradiation is not effective or feasible and preferably should be given in the context of a clinical trial to evaluate its true efficacy. Department of Radiotherapy and Oncology, Royal Marsden Hospital,

P. J. HOSKIN

London SW3 6JJ, UK

P. R. BLAKE

1. Collins

TM, Ash DV, Close HJ, Thorogood J. An evaluation of the palliative role of in inoperable carcinoma of the bronchus. Clin Radiol 1989; 39:

radiotherapy 284-86.

Kerr GR, Amott SJ. External beam radiotherapy for rectal adenocarcinoma. Br J Surg 1987; 74: 455-59. 3. Green M, George FW. Radiotherapy of advanced localised bladder cancer. J Urol 1974; 111: 611-12. 2.

Taylor RE,

Man-to-man transmission of melioidosis SIR,-Melioidosis, a highly fatal infectious disease of South-East Asia, is caused by Pseudomonaspseudomallei, a free-living bacterium widely found in soil and surface water in endemic areas.’ The disease is most common during the rainy seasonMost cases arise through soil contact or occupations such as farming. However, laboratory accidents have been reported,3,4 as has contamination of fluids or equipment.s We are aware of only one report of man-to-man transmission, this being from a man with chronic prostatitis whose wife had a raised haemagglutination titre.1 In June, 1990, a Thai man, aged 45, was referred from southern Thailand to this hospital in Bangkok. He had been a tin miner and he cleaned soil by high-pressure hosing. 10 years previously he began to experience periodic pain in his left shoulder, ascribed to physical effort. In May, 1990, he was referred for physiotherapy but after a few days of deep-heat therapy, the pain increased and fever developed. Incision at the left shoulder joint yielded purulent discharge. Amoxycillin/clavulanic acid and aztreonam had little effect and the patient was referred to Ramathibodi Hospital, Bangkok. He had arthritis of left elbow, knees, right ankle, and left shoulder, and an X-ray of the shoulder revealed bony destruction with

a

dense sclerotic border

at

the humeral head. A chest

radiograph showed bilateral diffuse patchy infiltration, reflecting bloodbome pneumonia. The diagnosis of disseminated septicaemic melioidosis was confirmed by the presence of P pseudomallei on culture of blood, discharge, and aspirates. Ceftazidime and co-trimoxazole were given. When sensitivity tests indicated resistance to co-trimoxazole, only ceftazidime was maintained. The patient recovered after 6 weeks. While he was in hospital, previously undetected diabetes mellitus was found. A 53-year-old woman, the patient’s sister, lived in north-eastern Thailand. In June, 1990, she visited her sick brother and nursed him devotedly, staying in hospital with her brother’s wife. 10 days later, she had pain in the right inguinal canal that was referred to the right hip. No bone or joint abnormalities were demonstrated by X-ray. She had hepatosplenomegaly and abdominal tenderness. Appendiceal abscess was diagnosed but at laparotomy the appendix was normal. Appendectomy was done. Because of worsening fever and pain she was referred here. She had a history of diabetes with irregular follow-up. Examination revealed tachypnea, crackles in the right lower lung, and swelling and tenderness of the right groin. No evidence of any abscess was found by ultrasonography. Groin aspiration yielded only a small amount of blood from which no organism could be isolated. Chest films showed interstitial and patchy infiltration. Blood cultures grew P pseudomallei. After

1291

antibiotic

treatment,

her

fever, pneumonitis, and groin

inflammation gradually subsided.

By biochemical reactions and on antibiotic sensitivity the two isolates resembled P pseudomallei reference strain NCTC 4845. A sonicated extract of bacilli was analysed by sodium dodecyl sulphate/polyacrylamide gel electrophoresis (SDS-PAGE). The SDS-PAGE patterns were compatible with type I, the common type among the six found in clinical isolates in Thailand.7 The man and the woman came from north-eastern Thailand, an area endemic for melioidosis, but the brother had been in southern Thailand for many years. They could have acquired the organism in childhood, these episodes merely reflecting reactivation of a latent infection; nevertheless, the family’s occupation was trading, not farming. Southern Thailand is also endemic for melioidosis,and it is very possible that the brother acquired the infection there. The radiological findings indicated chronicity of the left humerus lesion aggravation of the infection and overwhelming septicaemia may have followed manipulation of a localised focus during physiotherapy.l,8 The acute symptoms in his sister developed after prolonged close contact with the patient who had an infectious wound and pneumonia. Transmission may have been via the respiratory route since she had no pre-existing skin abrasion. A coincident relapse of pre-existing infection seems most improbable. Both patients had untreated diabetes that will have been an important predisposing factor.8,9 The man’s wife, who was not

diabetic, also had close contact with him but has remained free of the disease. We thank the microbiology staff in the Faculty of Medicine, Chulalongkom University, and especially Dr Somjai Rientprayoon and Mrs Sudalak Chantarachada for assistance in sonicated extract analyses; Dr Boonchuey Sathaphatayavongs for interpreting the bone X-ray; and Piriyapom Chongtrakool for helping with the biochemical reaction analysis and antibiotic sensitivity testing.

Departments of Pathology and Medicine, Faculty of Medicine, Ramathiobodi Hospital, Mahidol University, Bangkok 10400, Thailand

MONGKOL KUNAKORN PANIDA JAYANETRA DEJA TANPHAICHITRA

1. Thomas AD, Forbes-Faulker JC. Persistence of Pseudomonas pseudomallei in soil. Aust Vet J 1981; 57: 535-36. 2. Leelarasamee A, Bovornkitti S. Melioidosis: review and update. Rev Infect Dis 1989; 11: 413-25. 3. Green RN, Tuffnell PG. Laboratory acquired melioidsis. Am J Med 1968; 44: 599-605. 4 Schlech WA, Turchik JB, Westlake RE, Klein GC, Band JD, Weaver RE. Laboratory-acquired infection with Pseudomonas pseudomallei (melioidosis). N Engl J Med 1981; 305: 1133-35. 5. Ashdown LR Nosocomial infection due to Pseudomonas pseudomallei: two cases and an epidemiologic study. Rev Infect Dis 1979; 1: 891-94. 6. McCormick JB, Sexton DJ, McMurray JG, Carey E, Hayes P, Feldman RA. Human to human transmission of Pseudomonas pseudomallei. Ann Intern Med 1975; 183: 512-13. 7. Sudaluck C. The patterns of sonic extract of Pseudomonas pseudomallei from clincial isolates: thesis Bangkok: Chulalongkorn University, 1988. 8. Chaowagul W, White NJ, Dance DA, et al. Melioidosis: a major cause of community-acquired septicemia in northeastern Thailand. J Infect Dis 1989; 159: 890-99. 9 Chayasirisobhon S, Indtraprasit S, Jayanetra P, Punyagupta S. Acute septicemia melioidosis J Med Assoc Thai 1976; 59: 375-79.

In-vitro fertilisation or tubal surgery SIR,-In view of the development of in-vitro fertilisation (IVF), you question (April 13, p 888) the justification for tubal surgery, especially salpingostomy. Although the success rate for IVF is higher, salpingostomy will continue to be offered to National Health Service patients, partly because IVF is not widely available in the NHS and partly because of the high cost in private IVF clinics. IVF is delayed by unsuccessful surgery, especially if ectopic pregnancy has occurred. In this unit, IVF is offered to patients with blocked fallopian tubes caused by salpingitis. Ours is one of the few such units in a non-academic NHS department in the UK. Walsgrave Hospital is a large district general hospital with a catchment area of 800 000. Finance for the IVF unit has been provided by charitable donation. Embryological support was given initially through the biological sciences department at the University of Warwick. A full-time clinical embryologist has now been appointed because of the

increased number of IVF cycles, the University maintaining its links with respect to a research programme. Patients are charged 300 per treatment cycle if they achieve embryo transfer, otherwise the fee is waived. Drugs are supplied either on NHS prescription by the general practitioner, or the patient buys the drugs from the hospital pharmacy at an average cost of L350 per treatment cycle. Superovulation is achieved with buserelin and ’Pergonal’ (menotropin). Follicular growth is monitored with vaginal ultrasonography and by serial assessment of serum oestradiol. We began IVF treatment in October, 1990, and 37 treatment cycles have been done in 34 women (mean age 32 years, range 26-39). Indications for IVF were tubal disease (21 women) unexplained infertility (7), oligospermia (4), endometriosis (1), and cervical mucus hostility factor (1). Embryo transfer was achieved in 31 cases. In the remaining 6 embryo transfer failed because of inaccessible ovaries in 1, poor response to ovarian stimulation in 3, hyperstimulation in 1, and failure to recover oocytes in 1. There have been six pregnancies (gestational age at present 10-30 weeks)—a rate per embryo transfer of 19-4%. There are four singleton, one twin, and one triplet pregnancy, and none have been

ectopic. Although patients are charged for IVF, the cost is substantially less than that in private clinics. We have demonstrated that a cost-effective IVF service can be established within an NHS unit without a high financial burden for the patient. Moreover, NHS managers might be persuaded to provide financial resources for IVF if savings on inpatient treatment can be demonstrated.

Department of Obstetrics and Gynaecology, Walsgrave Hospital, Coventry CV2 2DX, UK

RICHARD KENNEDY PAUL BYRNE MARCELLA VLAD TRUDI CLARKE

SiR,—Your April 13 editorial suggests that with increasing effectiveness of assisted reproduction, salpingostomy may become obsolete and tubal surgery per se might not be justified on the basis of pregnancy rates. Whereas we agree with many of your sentiments with respect to IVF and open microsurgery, you dismiss the role of laparoscopic surgery in one brief sentence. Yet there is increasing evidence, not only in infertility, that minimally invasive techniques will play an important part in routine medical practice. What are the facts in terms of efficacy, cost, and convenience?

Laparoscopic surgery for infertility has been developing since the late 1970s, and ovariolysis, salpingolysis, ovario-salpingolysis, fimbrioplasty, and salpingostomy have become well established procedures. The early intrauterine pregnancy rate after laparoscopic salpingostomy was 44%, with a 90% postoperative tubal patency rate for at least one tube and no extrauterine pregnancies; in contrast, only 27% achieved viable pregnancies after microsurgical salpingostomy. Most of the recent and large series still achieve pregnancy rates of 26-28-5% after conventional laparoscopic salpingostomy, and 20-25%* if laser is used. With less tubal damage, the results of laparoscopy are even better. Fimbrioplasty produces pregnancy rates of 31-61%, and salpingo-ovariolysis 58-78 %.2,4 There is an increased risk of ectopic pregnancy after any form of tubal surgery, but the approach is immaterial since extrauterine pregnancy rates are 2-18 % after tubal microsurgery and 5-16% after laparoscopy. In contrast, postoperative adhesion formation is less when the abdomen is not opened.6 Laparoscopic techniques can also be used to treat other major causes of infertility such as severe endometriosis and clomiphene-resistant polycystic ovarian syndrome, with pregnancy rates of 67-2-80%. There can be no argument that day-case laparoscopic surgery is cheaper than conventional microsurgery, other advantages including faster recovery, reduced discomfort, and less disfigurement. We also argue that the several attempts at IVF that are needed by most couples make this a more expensive and less convenient alternative to laparoscopic surgery. There is a place for both IVF and other assisted-conception techniques and laparoscopic tubal surgery. We suggest that women with proximal tubal disease or distal disease associated with mucosal damage shown by salpingoscopy9 should be treated by IVF,