689 second intravenous injection of 0-4 mg naloxone was given approximately 10 min later he became fully awake. He gave a history of 12 h heavy drinking on the day of admission but claimed to have taken no other drugs. Blood-ethanol 3 h after admission was 84 mmol/1 but no other drugs were tested for. The patient’s high blood-alcohol on admission may readily explain his comatose state. The reversal of alcohol-induced coma by naloxone is worthy of further study. Department of Anæsthesiology,
Copenhagen Municipal Hospital, Copenhagen, Denmark
may be made. Department of Medicine, Division
of Hematology/Oncology,
and
Department of Pathology, University of Alabama, Birmingham, Alabama 35294, U.S.A., and V.A. Hospital, Birmingham
A. B. WEIR, III M.-C. POON E. I. MCGOWAN
SØREN CLAUS SØRENSEN KARLWILLY MATTISSON
PLASMA EXCHANGE FOR IDIOPATHIC THROMBOCYTOPENIC PURPURA
SIR,-Branda and colleagues’ reported successful treatment a young man with fulminant autoimmune thrombocytopenia with splenectomy, prednisone, vincristine, and plasma exchange. The plasma exchange may have been beneficial. Similar success has been reported in two other cases.2Our experience with plasma exchange in a patient with idiopathic thrombocytopenic purpura (I.T.P.) is less encouraging. A 54-year-old male was diagnosed as having I.T.P. in 1964. Splenectomy and prednisone were successful until 1973 when a fall in platelet-count required addition of cyclophosphamide, with improvement in platelet-count. After 6 months, cytotoxic therapy was discontinued and maintenance prednisone was continued until October, 1977, when platelets fell to 5000/1 with intermittent gastrointestinal bleeding. Evaluation revealed no accessory spleen. Therapy with cyclophosphamide and prednisone for 1 month was ineffective. Intravenous vinof
cristine was unsuccessful and transient motor weakness developed. In June, 1978, vinblastine-loaded platelets4 were infused twice without success. Because of the intermittent gastrointestinal bleeding plasma exchange was tried. Cyclophosphamide and prednisone were continued (prednisone dose lowered to 30 mg to control diabetes) and five plasma exchanges over 10 days were given via a Haemonetics model 30 blood processor with a 225 ml disposable bowl. During each exchange approxi60% of the patient’s plasma volume was exchanged. Plasma-protein fraction was used during the first three exchanges and fresh frozen plasma during the last two. The patient had one minor hypotensive episode during the first exchange, but there were no other complications. There was no significant rise in platelet-count, and 1 week after his last exchange he required transfusion for a gastrointestinal bleed and a platelet-count of 1000/µl. With the combination therapy given to Branda’s patient, it, is difficult to determine the contribution of plasmapheresis, but the transient rise in platelet-count produced by plasma exchange in his patient was not seen in ours. It may be that our patient’s disease was pathogenetically different. Our patient is older and has chronic severe thrombocytopenia refractory to all other treatment. Several case-reports of success with plasmapheresis in autoimmune diseases have been published, and there have been occasional negative reports.2 Classic chronic adult !.T.p. has not been reported to be helped by plasma exchange. Although this procedure may be effective for certain patients with immune thrombocytopenia, our experience indicates that it is not effective in all. Because of the risks and expense of this procedure, we feel that a controlled study in patients with immune thrombocytopenia should be done before plasmapheresis is accepted as proven therapy for these diseases. Such a trial
mately
1.
might identify those patients with characteristics which make plasma exchange useful, so that selective therapeutic decisions
Branda, R. F , Tate, D. V., McCullough, J. J., Jacob, H. S. Lancet, 1978, i, 688. 2 Branda, R F., Moldow, C. F., McCullough, J. J., Jacob, H. S. Transfusion, 1975, 15, 570. 3 Novak. R., Williams, J. J. Pediat. 1978, 92, 434. 4 Ahr, Y. S., Byrnes, J. J., Harrington, W. J., Cayer, M. L., Smith, D. S , Brunskill, D E., Paul, L. M. New Engl. J. Med. 1978, 298, 1101.
HYPERSENSITIVITY TO TABLET ADDITIVES IN TRANSPLANT RECIPIENTS ON PREDNISONE
SIR,-When tablets are made, additives are usually included binders, fillers, adhesives, and so on. Two plant substances, acacia and tragacanth, have been used as adhesives to serve as
for many years. We have observed hypersensitivity reactions to acacia and tragacanth in kidney transplant patients on longterm
prednisone.
Fifteen transplanted recipients had been treated for 10 months to 5 years with prednisone and azathioprine. The prednisone tablets were of local manufacture from two producers. One manufacturer used acacia and tragacanth and the other used methylcellulose as the adhesive. Three patients proved to be sensitive to the formulation containing the plant substances, the hypersensitivity manifesting as itching with rash and fever in one patient, itching with a rash in another, and itching with arthralgia in the third. The symptoms disappeared when the preparation containing acacia and tragacanth was withdrawn and did not return when the methylcellulose formulation was used instead. We decided to do scratch tests on fourteen of the transplant patients. Of the three who had had hypersensitivity reactions one showed a positive test for acacia, another reacted to tragacanth and the third refused to be tested. Of the remaining eleven patients, one reacted to tragacanth, yet did not show any clinical manifestations. The other ten were both symptomfree and negative on skin testing. Hypersensitivity to acacia has been reported previouslyl3 but hypersensitivity to tragacanth seems very rare.45 Three of our patients had clinical signs of hypersensitivity when exposed to these substances in tablets. The possibility that drug additives may be responsible for allergic reactions should be taken into consideration, even with tablets of prednisone. Nephrological Service, and Division of Pharmacy Services and Medical Supplies, Hadassah-Hebrew University Medical
Centre, Jerusalem, Israel
DVORA RUBINGER MICHAEL FRIEDLANDER EDWARD SUPERSTINE
MEDIBANK METAMORPHOSIS
SIR The first paragraph of "Medibank Dismantled" (Aug. 26, p. 466) is surprising. Health insurance was not automatic in Australia before the Aug. 15 budget-it was mandatory. And Medibank has not been dismantled, it has had to undergo a metamorphosis. The Hayden "free" health-insurance programme of July 1, 1975, continues to function on behalf of the poor, but now on a responsible financial basis. A rose by 1 Spielman, A. D., Baldwin, H. S. J. Am. med. Ass 1933, 101, 444. 2. Maytum, C.K., Magath, T. B. ibid 1932, 99, 2251. 3. Bohner, C. B., Sheldon,J M., Trenis, J. W J. Allergy, 1941, 12, 290 4. Remington’s Pharmaceutical Sciences, p. 1242 Easton, Pennsylvania, 1975. 5. Martindale the Extra Pharmacopœia, p 917. London, 1977
690 any other name ... Standard hospital care-free from charge - is to be available to all. Pensioners and the "socially disadvantaged" (euphemism for low-income earners?) are to have free medical care and those who have the means will have to pay 60% of their doctors’ bills and insure privately for special privileges and extra cover. As we say down under-give it a go. 6
Certain bore tube
whole-protein products do pass through the, -fineby continuous gravity drip and may, in most clinical situations, be more appropriate than elemental diets. Roussel Nutritional Division, Roussel Laboratories Ltd., Wembley Park, Middlesex HA9 0NF
J. C. CROW
Aubrey Road,
Northbridge,
New South Wales 2063
CATHERINE G. LEFEVRE
SIR The paper by Dr Metz and his’colleagues is a timely a technique which has been known and used for many years.’ The additional advantage of the current system is the flexible guide wire to position the tube. The push fit of a butterfly needle to join the tube to a flask of liquid feed is in our view clumsy. A male luer fitting should be part of the assembly attached to the proximal end of the narrow-gauge reminder of
NASOENTERIC FEEDING
SIR,—Dr Metz and his colleagues (Aug. 26, p. 454) describe a technique which is growing in clinical usage.’ However, their paper has led to some confusion, both in the U.K. and overseas, about the availability of the components. Although the tubes are manufactured by Portex Ltd. and the guide wires by Cambmac Instruments Ltd., Roussel Nutritional Division market the complete intubation set. The set consists of a guide wire with safety stop which ensures that the flexible distal tip cannot protrude through the open end; five polyvinyl-chloride radio-opaque 1 mm internal diameter tubes with luer fittings; and instructions. The intubation sets come in packs of five (i.e., 25 tubes). 1.
Fowell, E., Lee, H. A., Dickerson, J. W. T. in Nutrition in the Clinical Management of Disease (edited by J. W. T. Dickerson and H. A Lee), p. 341. London, 1978.
Commentary from Westminster From
our
Parliamentary Correspondent
Royal Commission and the Postponed Election THE Prime Minister’s decision to postpone a general election until 1979 may turn out to be embarrassing for The
the Conservatives. For it means that the report of the Royal Commission on the National Health Service could be published before an election, which would confront the Conservatives with the need for some awkward decisions. At the moment the party is avoiding committing itself on a number of sensitive issues on the justifiable grounds that it is awaiting the report of the Royal Commission. Labour’s attacks on Conservative ideas for introducing new health charges and extending private health insurance are parried by playing the Royal Commission card. Last month Mr Patrick Jenkin, Conservative spokesman on social services, answered a challenge from Mr David Ennals, Secretary of State for Social Services, by replying, "Answers to the detailed questions he has posed must await the report of the Royal Commission on the health service". But of course Mr Jenkin was speaking at a time when he confidently expected an October election. Now that this has been put off until the spring, summer, or autumn of next year, Mr Jenkin is faced with the possibility of actually having to answer some of Labour’s questions. The Royal Commission’s report is expected during the first half of 1979 and the earlier it comes the more likely it will be that Mr Jenkin will be forced to commit the Conservatives one way or the other on a number of issues. One of the more moderate members of Mrs
tubing. This fitting can easily be inserted into the tubing of a bladder irrigation set or intravenous infusion set connected to the flask of liquid feed. We recommend strongly that such female-to-male attachment should become standard for enteric feeding. Though inadvertent intravenous infusion of liquid feeds intended for enteric use is unlikely, this tragic complication has been encountered. The two systems--enteric and intravenous-should be obviously incompatible. Academic Surgical Unit, St Mary’s Hospital, London W2 1NY 1.
L. P. FIELDING H. A. F. DUDLEY
Dudley, H. A. F Principles of General Surgical Management. Edinburgh, 1958.
Thatcher’s shadow cabinet, Mr Jenkin has steered his party away from adopting an extreme stand on health policy. Despite Labour charges that the Conservatives are out to "smash the N.H.S.", Mr Jenkin has repeatedly made it clear that he has no wish to dismantle the service. He supports the concept of a national health service. Having conceded the errors of the 1974 reorganisation, he rejects another wholesale shake-up. He has also managed to preserve the N.H.S. from the public-expenditure cuts which a Conservative Government would embark on, although he has said there would be no possibility of extra money. In all these respects Mr Jenkin has won the argument inside the Conservative Party over the future of the N.H.S. Where party policy has been left deliberately vague is in the areas of alternative finance. There is little doubt that a Conservative Government would immediately increase prescription charges, a prospect which Labour M.p.s are quick to condemn, despite the fact that the present Government has increased optical and dental charges on more than one occasion. The question of new charges, such as a hospital bed or meal charge, has been examined by the Conservatives and turned down "for the moment". But with a number of Conservative Nt.P.s favouring new charges, the Royal Commission’s report is likely to reopen the argument. Likewise the introduction of an element of health insurance into the financing of the N.H.S. has been pushed to one side by the Conservatives to await a verdict from the Royal Commission. Although the party favours the idea as a long-term aim, its statements on the matter remain deliberately vague. Mr Jenkin has always moved cautiously on the issues of health charges and private insurance. He recognises their extreme political sensitivity and the fact that Labour ht.P.s can be expected to make the most of the issues in an election
Copenhagen Municipal Hospital, Copenhagen, Denmark
may be made. Department of Medicine, Division
of Hematology/Oncology,
and
Department of Pathology, University of Alabama, Birmingham, Alabama 35294, U.S.A., and V.A. Hospital, Birmingham
A. B. WEIR, III M.-C. POON E. I. MCGOWAN
SØREN CLAUS SØRENSEN KARLWILLY MATTISSON
PLASMA EXCHANGE FOR IDIOPATHIC THROMBOCYTOPENIC PURPURA
SIR,-Branda and colleagues’ reported successful treatment a young man with fulminant autoimmune thrombocytopenia with splenectomy, prednisone, vincristine, and plasma exchange. The plasma exchange may have been beneficial. Similar success has been reported in two other cases.2Our experience with plasma exchange in a patient with idiopathic thrombocytopenic purpura (I.T.P.) is less encouraging. A 54-year-old male was diagnosed as having I.T.P. in 1964. Splenectomy and prednisone were successful until 1973 when a fall in platelet-count required addition of cyclophosphamide, with improvement in platelet-count. After 6 months, cytotoxic therapy was discontinued and maintenance prednisone was continued until October, 1977, when platelets fell to 5000/1 with intermittent gastrointestinal bleeding. Evaluation revealed no accessory spleen. Therapy with cyclophosphamide and prednisone for 1 month was ineffective. Intravenous vinof
cristine was unsuccessful and transient motor weakness developed. In June, 1978, vinblastine-loaded platelets4 were infused twice without success. Because of the intermittent gastrointestinal bleeding plasma exchange was tried. Cyclophosphamide and prednisone were continued (prednisone dose lowered to 30 mg to control diabetes) and five plasma exchanges over 10 days were given via a Haemonetics model 30 blood processor with a 225 ml disposable bowl. During each exchange approxi60% of the patient’s plasma volume was exchanged. Plasma-protein fraction was used during the first three exchanges and fresh frozen plasma during the last two. The patient had one minor hypotensive episode during the first exchange, but there were no other complications. There was no significant rise in platelet-count, and 1 week after his last exchange he required transfusion for a gastrointestinal bleed and a platelet-count of 1000/µl. With the combination therapy given to Branda’s patient, it, is difficult to determine the contribution of plasmapheresis, but the transient rise in platelet-count produced by plasma exchange in his patient was not seen in ours. It may be that our patient’s disease was pathogenetically different. Our patient is older and has chronic severe thrombocytopenia refractory to all other treatment. Several case-reports of success with plasmapheresis in autoimmune diseases have been published, and there have been occasional negative reports.2 Classic chronic adult !.T.p. has not been reported to be helped by plasma exchange. Although this procedure may be effective for certain patients with immune thrombocytopenia, our experience indicates that it is not effective in all. Because of the risks and expense of this procedure, we feel that a controlled study in patients with immune thrombocytopenia should be done before plasmapheresis is accepted as proven therapy for these diseases. Such a trial
mately
1.
might identify those patients with characteristics which make plasma exchange useful, so that selective therapeutic decisions
Branda, R. F , Tate, D. V., McCullough, J. J., Jacob, H. S. Lancet, 1978, i, 688. 2 Branda, R F., Moldow, C. F., McCullough, J. J., Jacob, H. S. Transfusion, 1975, 15, 570. 3 Novak. R., Williams, J. J. Pediat. 1978, 92, 434. 4 Ahr, Y. S., Byrnes, J. J., Harrington, W. J., Cayer, M. L., Smith, D. S , Brunskill, D E., Paul, L. M. New Engl. J. Med. 1978, 298, 1101.
HYPERSENSITIVITY TO TABLET ADDITIVES IN TRANSPLANT RECIPIENTS ON PREDNISONE
SIR,-When tablets are made, additives are usually included binders, fillers, adhesives, and so on. Two plant substances, acacia and tragacanth, have been used as adhesives to serve as
for many years. We have observed hypersensitivity reactions to acacia and tragacanth in kidney transplant patients on longterm
prednisone.
Fifteen transplanted recipients had been treated for 10 months to 5 years with prednisone and azathioprine. The prednisone tablets were of local manufacture from two producers. One manufacturer used acacia and tragacanth and the other used methylcellulose as the adhesive. Three patients proved to be sensitive to the formulation containing the plant substances, the hypersensitivity manifesting as itching with rash and fever in one patient, itching with a rash in another, and itching with arthralgia in the third. The symptoms disappeared when the preparation containing acacia and tragacanth was withdrawn and did not return when the methylcellulose formulation was used instead. We decided to do scratch tests on fourteen of the transplant patients. Of the three who had had hypersensitivity reactions one showed a positive test for acacia, another reacted to tragacanth and the third refused to be tested. Of the remaining eleven patients, one reacted to tragacanth, yet did not show any clinical manifestations. The other ten were both symptomfree and negative on skin testing. Hypersensitivity to acacia has been reported previouslyl3 but hypersensitivity to tragacanth seems very rare.45 Three of our patients had clinical signs of hypersensitivity when exposed to these substances in tablets. The possibility that drug additives may be responsible for allergic reactions should be taken into consideration, even with tablets of prednisone. Nephrological Service, and Division of Pharmacy Services and Medical Supplies, Hadassah-Hebrew University Medical
Centre, Jerusalem, Israel
DVORA RUBINGER MICHAEL FRIEDLANDER EDWARD SUPERSTINE
MEDIBANK METAMORPHOSIS
SIR The first paragraph of "Medibank Dismantled" (Aug. 26, p. 466) is surprising. Health insurance was not automatic in Australia before the Aug. 15 budget-it was mandatory. And Medibank has not been dismantled, it has had to undergo a metamorphosis. The Hayden "free" health-insurance programme of July 1, 1975, continues to function on behalf of the poor, but now on a responsible financial basis. A rose by 1 Spielman, A. D., Baldwin, H. S. J. Am. med. Ass 1933, 101, 444. 2. Maytum, C.K., Magath, T. B. ibid 1932, 99, 2251. 3. Bohner, C. B., Sheldon,J M., Trenis, J. W J. Allergy, 1941, 12, 290 4. Remington’s Pharmaceutical Sciences, p. 1242 Easton, Pennsylvania, 1975. 5. Martindale the Extra Pharmacopœia, p 917. London, 1977
690 any other name ... Standard hospital care-free from charge - is to be available to all. Pensioners and the "socially disadvantaged" (euphemism for low-income earners?) are to have free medical care and those who have the means will have to pay 60% of their doctors’ bills and insure privately for special privileges and extra cover. As we say down under-give it a go. 6
Certain bore tube
whole-protein products do pass through the, -fineby continuous gravity drip and may, in most clinical situations, be more appropriate than elemental diets. Roussel Nutritional Division, Roussel Laboratories Ltd., Wembley Park, Middlesex HA9 0NF
J. C. CROW
Aubrey Road,
Northbridge,
New South Wales 2063
CATHERINE G. LEFEVRE
SIR The paper by Dr Metz and his’colleagues is a timely a technique which has been known and used for many years.’ The additional advantage of the current system is the flexible guide wire to position the tube. The push fit of a butterfly needle to join the tube to a flask of liquid feed is in our view clumsy. A male luer fitting should be part of the assembly attached to the proximal end of the narrow-gauge reminder of
NASOENTERIC FEEDING
SIR,—Dr Metz and his colleagues (Aug. 26, p. 454) describe a technique which is growing in clinical usage.’ However, their paper has led to some confusion, both in the U.K. and overseas, about the availability of the components. Although the tubes are manufactured by Portex Ltd. and the guide wires by Cambmac Instruments Ltd., Roussel Nutritional Division market the complete intubation set. The set consists of a guide wire with safety stop which ensures that the flexible distal tip cannot protrude through the open end; five polyvinyl-chloride radio-opaque 1 mm internal diameter tubes with luer fittings; and instructions. The intubation sets come in packs of five (i.e., 25 tubes). 1.
Fowell, E., Lee, H. A., Dickerson, J. W. T. in Nutrition in the Clinical Management of Disease (edited by J. W. T. Dickerson and H. A Lee), p. 341. London, 1978.
Commentary from Westminster From
our
Parliamentary Correspondent
Royal Commission and the Postponed Election THE Prime Minister’s decision to postpone a general election until 1979 may turn out to be embarrassing for The
the Conservatives. For it means that the report of the Royal Commission on the National Health Service could be published before an election, which would confront the Conservatives with the need for some awkward decisions. At the moment the party is avoiding committing itself on a number of sensitive issues on the justifiable grounds that it is awaiting the report of the Royal Commission. Labour’s attacks on Conservative ideas for introducing new health charges and extending private health insurance are parried by playing the Royal Commission card. Last month Mr Patrick Jenkin, Conservative spokesman on social services, answered a challenge from Mr David Ennals, Secretary of State for Social Services, by replying, "Answers to the detailed questions he has posed must await the report of the Royal Commission on the health service". But of course Mr Jenkin was speaking at a time when he confidently expected an October election. Now that this has been put off until the spring, summer, or autumn of next year, Mr Jenkin is faced with the possibility of actually having to answer some of Labour’s questions. The Royal Commission’s report is expected during the first half of 1979 and the earlier it comes the more likely it will be that Mr Jenkin will be forced to commit the Conservatives one way or the other on a number of issues. One of the more moderate members of Mrs
tubing. This fitting can easily be inserted into the tubing of a bladder irrigation set or intravenous infusion set connected to the flask of liquid feed. We recommend strongly that such female-to-male attachment should become standard for enteric feeding. Though inadvertent intravenous infusion of liquid feeds intended for enteric use is unlikely, this tragic complication has been encountered. The two systems--enteric and intravenous-should be obviously incompatible. Academic Surgical Unit, St Mary’s Hospital, London W2 1NY 1.
L. P. FIELDING H. A. F. DUDLEY
Dudley, H. A. F Principles of General Surgical Management. Edinburgh, 1958.
Thatcher’s shadow cabinet, Mr Jenkin has steered his party away from adopting an extreme stand on health policy. Despite Labour charges that the Conservatives are out to "smash the N.H.S.", Mr Jenkin has repeatedly made it clear that he has no wish to dismantle the service. He supports the concept of a national health service. Having conceded the errors of the 1974 reorganisation, he rejects another wholesale shake-up. He has also managed to preserve the N.H.S. from the public-expenditure cuts which a Conservative Government would embark on, although he has said there would be no possibility of extra money. In all these respects Mr Jenkin has won the argument inside the Conservative Party over the future of the N.H.S. Where party policy has been left deliberately vague is in the areas of alternative finance. There is little doubt that a Conservative Government would immediately increase prescription charges, a prospect which Labour M.p.s are quick to condemn, despite the fact that the present Government has increased optical and dental charges on more than one occasion. The question of new charges, such as a hospital bed or meal charge, has been examined by the Conservatives and turned down "for the moment". But with a number of Conservative Nt.P.s favouring new charges, the Royal Commission’s report is likely to reopen the argument. Likewise the introduction of an element of health insurance into the financing of the N.H.S. has been pushed to one side by the Conservatives to await a verdict from the Royal Commission. Although the party favours the idea as a long-term aim, its statements on the matter remain deliberately vague. Mr Jenkin has always moved cautiously on the issues of health charges and private insurance. He recognises their extreme political sensitivity and the fact that Labour ht.P.s can be expected to make the most of the issues in an election
