1482

the terminal hepatic venules, which leads then to diffuse thrombi formation, with subsequent congestion, ischaemia, and acute damage to the hepatocytes.1 Thus, there is a good rationale for the use of r-tPA: conceptually, it should be started early, as Laporte et al have done, but in our patient as well as in another reported by Baglin et al2 efficacy was maintained despite delayed use (21 and 7 days, respectively). The use of r-tPA should be studied prospectively in VOD, especially in patients, such as ours, with high-risk features.3,4

Institute of Hematology "L. e A. St Orsola University Hospital, 40138 Bologna, Italy

Seràgnoli",

GIANANTONIO ROSTI GIUSEPPE BANDINI ANNARITA BELARDINELLI ELEONORA CALORI SANTE TURA FILIPPO GHERLINZONI CRISTINA MIGGIANO

HM, Gown AM, Nugent DJ. Hepatic veno-occlusive disease after bone transplantation: immunohistochemical identification of the material within occluded venules. Am J Pathol 1987; 127: 549-58. 2. Baglin TP, Harper P, Marcus RE. Veno-occlusive disease of the liver complicating 1. Shulman

marrow

successfully treated with recombinant tissue plasminogen activator (r-TPA). Bone Marrow Transplant 1990; 5: 439-41. 3. McDonald GB, Sharma P, Matthews DE, Shulman HM, Thomas ED. The clinical course of 53 patients with veno-occlusive disease of the liver after marrow transplantation. transplantation 1987; 39: 603-08. 4. Jones RJ, Kamthom SKL, Beshomer WE, et al. Veno-occlusive disease of the liver following bone marrow transplantation. Transplantation 1987; 44: 778-83. ABMT

Outpatient cervical cerclage SIR,-We report a review of 39 patients who underwent cervical cerclage as day cases between June, 1990, and September, 1991. Two of the four consultants at this hospital opted for this outpatient approach but no other patient selection was made. Under outpatient general anaesthesia the McDonald cerclage method was used. After the operation the patients rested in hospital for 2-4 h, when they were discharged with advice to take things easy for 48 h. Patients were followed up in the same way as those who had had the inpatient procedure. We recognised that a proper trial is now required but our early experience is very encouraging. We compared outcome for inpatient cerclage in 1988-91. The indications for cerclage have not changed and the consultants were the same; so was the frequency of cervical cerclage (15-8 per 1000 deliveries in 1990-91 when both approaches were used and 16-55 and 17-44 per 1000 deliveries in 1988 and 1989, respectively, when all cerclage procedures were done on an inpatient basis). Our cervical cerclage rate is high but rates do vary from hospital to hospital and ours serves a poor area of London. There were 4 miscarriages after the 39 outpatient cerclages, 1 at 2 weeks, 2 at 4 weeks, and 1 at 6 weeks (table). The pre-term (28-33 weeks) delivery rate was similar to rates after inpatient procedures, as was the term delivery rate. We still follow the postoperative regimen described by McDonald in 1957.1 He found the most common complication of the method was failure because of myometrial stimulation soon after the stitch was inserted. Most failures happened in the first week, and cases where the suture held for more than 5 weeks were usually INPATIENT AND OUTPATIENT CERVICAL CERCLAGE COMPARED I

successful. Most deliveries are premature, the average gestation being 35 weeks in successful cases. Smith and Scragg2 supported McDonalds view; they found that in 8 of 10 failures the pregnancy ended within 3 weeks of cerclage (and 6 within a week). McDonald suggested that patients should remain in hospital for at least 5 days, ambulation being permitted for several days before discharge. The Trendelenburg position has been suggested for a few days after cerclage while another recommendation is that patients be kept in bed for 5-7 days and thereafter treated as for threatened abortion. McDonald also suggested postoperative morphine sulphate to clamp down uterine contractions, and other forms of uterine muscle relaxant have been suggested, including progesterone, ephedrine, papaverine and barbiturate, isoxsuprine, and beta-sympathetic drugs. Furthermore intravaginal or oral antibiotics have been suggested to improve the general hygiene of the vagina, promote healing, and prevent amnionitis. We question all these practices: rest in hospital, the Trendelenberg position, narcotics, uterine relaxants, and antibiotics were not used in our series yet our miscarriage, preterm delivery, and term delivery rates of 10%, 5%, and 72%, respectively, compare well with figures in the MRC/RCOG Working Party on Cervical Cerclage report3 (1988) figures of 8%, 13%, 65%. Moreover outcome after outpatient and inpatient procedures compares very well with that after our inpatient procedures. A. K. TREHAN A. KENNEY I. L. C. FERGUSSON

Department of Obstetrics and Gynaecology, St Thomas’ Hospital, London SE1 7EH, UK 1. McDonald IA. Suture of the cervix for inevitable

miscarriage.J Obstet Gynaecol Br Emp 1957; 63: 346-52. 2. Smith SG, Scragg WH. Premature cervical dilatation and the McDonald cerclage. Obstet Gynecol 1969; 33: 535-39. 3. MRC/RCOG Working Party on Cervical Cerclage. Interim report of Medical Research Council/Royal College of Obstetricians and Gynaecologist multicentre randomised trial of cervical cerclage. Br J Obstet Gynaecol 1988; 95: 437-45.

Cancer of breast among

men

in electrical

occupations SiR,—There have been several reports of excess mortality from of the male breast among electrical and telephone workers.’3 These findings are of interest because, although breast cancer is cancer

rare in men, it is similar in some ways to cancer of the female breast.4 I have done a case-control study using death registration data from the 24 states in USA which, beginning in 1985, have reported occupational data from death certificates. The cases were men over 19 years old who died of cancer of the breast (ICD-9 175) between 1985 and 1988, the last year for which data are available. The controls were randomly selected men in the same age range who died of any other cause; 10 controls were matched to each case by year of death. Occupational data were obtained from the death record, and electrical occupations were classified as previously.5 Ratios of observed to expected cases were estimated by odds ratios

very

(OR). During the 4 years there were about 923 000 deaths among eligible men, 250 from cancer of the breast. 4 cases (essentially the number expected, OR 0-9) had electrical occupations listed on their death certificates. 3 were less than 65 years old at death; this was more than twice the number of cases expected among this age group (OR 2-2 [95% CI 0-6-7-8]). These 3 men had had different specific occupations (electric power worker, 0-78 cases expected; electrical and electronic engineer/technician, 0-22; and telephone worker, 011). For telephone workers, the single observed case was 9 times the expected number, but the 95% CI was very broad (0-9-88-7). In this age group, there were no breast cancer deaths among men who had worked in any other electrical occupation. In addition, there was a substantial deficit of breast cancer deaths among men aged 65 or older who had been electrical workers (OR 0-4 [95% CI

0-05-2-4]). These data provide little support for the proposition that fatal of the male breast are associated with electrical occupations, in general. However, the results are consistent with earlier reports of excess breast cancer among younger men, particularly those who have worked in electrical trades and telephone-related cancers

*Total deliveries

in

four years 1988 to 1991

respectively tJune, 1990, to September, 1991

were

3201, 3383, 3465, and 3139,