THE LANCET
378
Vincristine with aggressive plasma exchange is effective in TTP.’ Its mechanism of action is unknown but seems to result in a rapid increase in the platelet count and resolution of symptoms in TTP. We are conducting a randomised trial of plasma exchange with and without weekly vincristine.
JEANNA L. WELBORN Division of Hematology and Oncology, University of California at Davis, Sacramento, California 96817, USA
ROBERT O’DONNELL TIMOTHY HSIEH JANET EATHERTON KAREN ASPRY
JL, Emrick P, Acevedo M Rapid improvement thrombocytopenic purpura with vincristine and plasmapheresis
1 Welborn
of thrombotic Am J Hematol
1990, 35: 18-21.
Tissue pressure, posture, and ulceration
venous
SIR,—DR Scott and Dr Coleridge Smith (Dec 22/29, p 1585) raise several points about my hypothesis (Oct 27, p 1050) that need to be answered. I did not suggest that loss of normal postural reflexes caused venous ulceration-indeed I cited evidence that other mechanisms were involved. My own measurements were also done at the toe level. I suggested that in patients with oedema and deep venous disease there was a constant relation between total tissue pressure and intravascular pressure during postural changes, and that it was this constancy that accounted for the differences noted by other workers between patients and controls. Scott and Coleridge Smith ask "How does oedema result in ulceration?". Clearly it does not happen in the simple way that they envisage. The acute stretching that they describe in heart failure and skin expansion surgery, or even chronic oedema associated with lymphoedema, are mechanically different from that in venous disease. As well as chronicity there is associated venous hypertension. Mechanically these are totally different, and there are clear parallels in engineering.Griffiths’ pioneering work at the turn of the century and later that of Inglis has emphasised the importance of "stress concentration" in fracture mechanisms. The classic modem example is that of the Comet airliner where an y, inch rivet hole caused stress concentration sufficient for a whole aeroplane to disintegrate. The forces that I cite seem to Scott and Coleridge Smith insufficient to produce distraction; however, counter forces of similar scale applied daily via support stockings do seem sufficient to prevent and heal ulcers. Royal South Hants Hospital, Southampton SO9 4PE. UK 1. Gordon JE. The
new science
A. D. B. CHANT of strong materials London-
Penguin,
1976
Erythromycin for reflex ileus in Ogilvie’s syndrome SIR,—Erythromycin has been reported to be a stimulant of gastric and small bowel motor activity.1 This macrolide antibiotic coordinates cyclic motor activity in the gut2 by binding to the motilin receptor3in the proximal small intestine and colon.’ In normal subjects, erythromycin accelerates colonic transit and increases stool frequency.’ Although reflex ileus after acute spinal cord injury has not been thought to be part of Ogilvie’s syndrome,’ these conditions may be may result from interference with normal extrinsic mechanisms that control colonic motility. We report two patients who were successfully treated with erythromycin; one with reflex ileus and one with Ogilvie’s syndrome. Patient l-A 64-year-old male was shot in the back with a handgun. The bullet lodged anterior to the body of the L2 vertebra, and led to sensory and motor loss in the right leg with subsequent sensory and motor loss in the left leg. The bullet was removed from behind the left renal vein and a lumbar laminectomy completed from Lto L3. Residual paraplegia persisted after operation below T12 on the right and L2 on the left. On postoperative day 17, the patient complained of abdominal pain and was constipated. His abdomen was grossly distended, but was soft and non-tender.
related;6 both
revealed a normal small bowel pattern, a grossly dilated colon, and a 14 cm diameter caecum. Oral erythromycin (500 mg four times a day) was started and within 24 h the patient began passing flatus with rapid resolution of his abdominal distension. Further radiography showed a normal colonic gas pattern and a 6 cm caecum. Erythromycin was continued for 10 days with no recurrence. Patient 2-A 45-year-old male gave a 24-h history of acute lower back pain, sustained after bending at work. He had nausea, anorexia, and increasing abdominal distension. He could not pass flatus, urinate, or walk. Examination revealed an obese man with a distended tympanitic, and non-tender abdomen. Neurological examination was normal. Abdominal radiography showed gross colonic distention with a caecal diameter of 16 cm and a normal small bowel air pattern. A lumbar myelogram, computed tomography, and magnetic resonance imaging revealed no obvious abnormality, although transient compression of the cord by a lumbar disc was suspected. A bladder catheter was inserted and oral erythromycin (500 mg four times a day) started. Within 24 h he passed flatus and soon defaecated. Radiography showed a normal colonic gas pattern. Caecal diameter was 8 cm. Normal bladder function returned 9 days after his injury and there was no recurrence of his gastrointestinal symptoms. Erythromycin was stopped after
Radiography
10
days. Erythromycin has previously been reported as being effective for treatment of diabetic autonomic gastroparesis.7 Direct stimulation of gut motility with a motilin agonist such as erythromycin may have broad applicability to other gastrointestinal neurogenic motility disorders. Department of Surgery, Yale University School of Medicine, New Haven, Connecticut 06510, USA
DAVID N. ARMSTRONG GARTH H. BALLANTYNE IRVIN M. MODLIN
I, Satoh H, Maki Y, Hashimoto N, Itoh Z, Omura S An erythromycin derivative EM-523, induces motilin-like gastrointestinal motility in dogs J Pharmacol Exp Ther 1989, 251: 707-12 2. Itoh Z, Suzuki T, Nakaya M, Inoue M, Arai H, Wakabayashi K. Structure-activity relation among macrolide antibiotics in initiation of the interdigestive migrating contractions in the canine gastrointestinal tract Am J Physiol 1985, 248: G320-25 3 Peeters T, Matthijs G, Depoortere I, Cachet T, Hoogmartens J, Vantrappen G Erythromycin is a motilin antagonist. Am J Physiol 1989, 257: G470-74 4 Hasler W, Heldsinger A, Soudah H, Owyang C Erythromycin promotes colonic transit m humans mediation via motilin receptors Gastroenterology 1990, 98: A358 5. Vanek VW, Al-Salti M Acute pseudo-obstruction of the colon Ogilvie’s syndrome an analysis of 400 cases. Dis Colon Rectum 1986, 29: 203-10 6. Longo WE, Ballantyne GH, Modlin IM. The colon, anorectum, and spinal cord patient a review of the functional alterations of the denervated hindgut Dis Colon Rectum 1989; 32: 261-67 7 Janssens J, Peeters TL, Vantrappen G, et al Improvement of gastric emptying in diabetic gastroparesis by erythromycin preliminary studies N Engl J Med 1990, 322: 1028-31 1 Inatomi
Salami in publication SIR,—Probably no-one will ever get sick over adulterated etymology, even though it concerns a sausage, but I would like to point out that salami (also spelt salame, the original Italian word) had little to do with the city of Salamis (Dec 22/29 editorial). The origin is the medieval Latin salamert, from sal (salt) and -men ("things with the qualities of"—1e, "salted things". Mere salting was long considered the mechanism that preserved food such as sausages and fermentations were dependent on chance action of "wild" organism, not on the purposeful addition of starter cultures. You may get some consolation from the fact that one kind of sausage (mortadella) is called bologna in Italy, after the city from which it is said to have originated. I have often heard that name in English-speaking countries as well, often confused with "boloney" Might the confusion have stemmed from a contamination with Italian immigrants’ use of salame in its second meaning ("dumb")? There can be no medical explanation for that since this usage began well before we became aware of the relation between cerebral atherosclerosis and consumption of animal fat such as that contained in salami and bologna. via A Manzoni 19, 22054 Mandello del Lano,
Italy
ANTONIO ATTANASIO
378
Vincristine with aggressive plasma exchange is effective in TTP.’ Its mechanism of action is unknown but seems to result in a rapid increase in the platelet count and resolution of symptoms in TTP. We are conducting a randomised trial of plasma exchange with and without weekly vincristine.
JEANNA L. WELBORN Division of Hematology and Oncology, University of California at Davis, Sacramento, California 96817, USA
ROBERT O’DONNELL TIMOTHY HSIEH JANET EATHERTON KAREN ASPRY
JL, Emrick P, Acevedo M Rapid improvement thrombocytopenic purpura with vincristine and plasmapheresis
1 Welborn
of thrombotic Am J Hematol
1990, 35: 18-21.
Tissue pressure, posture, and ulceration
venous
SIR,—DR Scott and Dr Coleridge Smith (Dec 22/29, p 1585) raise several points about my hypothesis (Oct 27, p 1050) that need to be answered. I did not suggest that loss of normal postural reflexes caused venous ulceration-indeed I cited evidence that other mechanisms were involved. My own measurements were also done at the toe level. I suggested that in patients with oedema and deep venous disease there was a constant relation between total tissue pressure and intravascular pressure during postural changes, and that it was this constancy that accounted for the differences noted by other workers between patients and controls. Scott and Coleridge Smith ask "How does oedema result in ulceration?". Clearly it does not happen in the simple way that they envisage. The acute stretching that they describe in heart failure and skin expansion surgery, or even chronic oedema associated with lymphoedema, are mechanically different from that in venous disease. As well as chronicity there is associated venous hypertension. Mechanically these are totally different, and there are clear parallels in engineering.Griffiths’ pioneering work at the turn of the century and later that of Inglis has emphasised the importance of "stress concentration" in fracture mechanisms. The classic modem example is that of the Comet airliner where an y, inch rivet hole caused stress concentration sufficient for a whole aeroplane to disintegrate. The forces that I cite seem to Scott and Coleridge Smith insufficient to produce distraction; however, counter forces of similar scale applied daily via support stockings do seem sufficient to prevent and heal ulcers. Royal South Hants Hospital, Southampton SO9 4PE. UK 1. Gordon JE. The
new science
A. D. B. CHANT of strong materials London-
Penguin,
1976
Erythromycin for reflex ileus in Ogilvie’s syndrome SIR,—Erythromycin has been reported to be a stimulant of gastric and small bowel motor activity.1 This macrolide antibiotic coordinates cyclic motor activity in the gut2 by binding to the motilin receptor3in the proximal small intestine and colon.’ In normal subjects, erythromycin accelerates colonic transit and increases stool frequency.’ Although reflex ileus after acute spinal cord injury has not been thought to be part of Ogilvie’s syndrome,’ these conditions may be may result from interference with normal extrinsic mechanisms that control colonic motility. We report two patients who were successfully treated with erythromycin; one with reflex ileus and one with Ogilvie’s syndrome. Patient l-A 64-year-old male was shot in the back with a handgun. The bullet lodged anterior to the body of the L2 vertebra, and led to sensory and motor loss in the right leg with subsequent sensory and motor loss in the left leg. The bullet was removed from behind the left renal vein and a lumbar laminectomy completed from Lto L3. Residual paraplegia persisted after operation below T12 on the right and L2 on the left. On postoperative day 17, the patient complained of abdominal pain and was constipated. His abdomen was grossly distended, but was soft and non-tender.
related;6 both
revealed a normal small bowel pattern, a grossly dilated colon, and a 14 cm diameter caecum. Oral erythromycin (500 mg four times a day) was started and within 24 h the patient began passing flatus with rapid resolution of his abdominal distension. Further radiography showed a normal colonic gas pattern and a 6 cm caecum. Erythromycin was continued for 10 days with no recurrence. Patient 2-A 45-year-old male gave a 24-h history of acute lower back pain, sustained after bending at work. He had nausea, anorexia, and increasing abdominal distension. He could not pass flatus, urinate, or walk. Examination revealed an obese man with a distended tympanitic, and non-tender abdomen. Neurological examination was normal. Abdominal radiography showed gross colonic distention with a caecal diameter of 16 cm and a normal small bowel air pattern. A lumbar myelogram, computed tomography, and magnetic resonance imaging revealed no obvious abnormality, although transient compression of the cord by a lumbar disc was suspected. A bladder catheter was inserted and oral erythromycin (500 mg four times a day) started. Within 24 h he passed flatus and soon defaecated. Radiography showed a normal colonic gas pattern. Caecal diameter was 8 cm. Normal bladder function returned 9 days after his injury and there was no recurrence of his gastrointestinal symptoms. Erythromycin was stopped after
Radiography
10
days. Erythromycin has previously been reported as being effective for treatment of diabetic autonomic gastroparesis.7 Direct stimulation of gut motility with a motilin agonist such as erythromycin may have broad applicability to other gastrointestinal neurogenic motility disorders. Department of Surgery, Yale University School of Medicine, New Haven, Connecticut 06510, USA
DAVID N. ARMSTRONG GARTH H. BALLANTYNE IRVIN M. MODLIN
I, Satoh H, Maki Y, Hashimoto N, Itoh Z, Omura S An erythromycin derivative EM-523, induces motilin-like gastrointestinal motility in dogs J Pharmacol Exp Ther 1989, 251: 707-12 2. Itoh Z, Suzuki T, Nakaya M, Inoue M, Arai H, Wakabayashi K. Structure-activity relation among macrolide antibiotics in initiation of the interdigestive migrating contractions in the canine gastrointestinal tract Am J Physiol 1985, 248: G320-25 3 Peeters T, Matthijs G, Depoortere I, Cachet T, Hoogmartens J, Vantrappen G Erythromycin is a motilin antagonist. Am J Physiol 1989, 257: G470-74 4 Hasler W, Heldsinger A, Soudah H, Owyang C Erythromycin promotes colonic transit m humans mediation via motilin receptors Gastroenterology 1990, 98: A358 5. Vanek VW, Al-Salti M Acute pseudo-obstruction of the colon Ogilvie’s syndrome an analysis of 400 cases. Dis Colon Rectum 1986, 29: 203-10 6. Longo WE, Ballantyne GH, Modlin IM. The colon, anorectum, and spinal cord patient a review of the functional alterations of the denervated hindgut Dis Colon Rectum 1989; 32: 261-67 7 Janssens J, Peeters TL, Vantrappen G, et al Improvement of gastric emptying in diabetic gastroparesis by erythromycin preliminary studies N Engl J Med 1990, 322: 1028-31 1 Inatomi
Salami in publication SIR,—Probably no-one will ever get sick over adulterated etymology, even though it concerns a sausage, but I would like to point out that salami (also spelt salame, the original Italian word) had little to do with the city of Salamis (Dec 22/29 editorial). The origin is the medieval Latin salamert, from sal (salt) and -men ("things with the qualities of"—1e, "salted things". Mere salting was long considered the mechanism that preserved food such as sausages and fermentations were dependent on chance action of "wild" organism, not on the purposeful addition of starter cultures. You may get some consolation from the fact that one kind of sausage (mortadella) is called bologna in Italy, after the city from which it is said to have originated. I have often heard that name in English-speaking countries as well, often confused with "boloney" Might the confusion have stemmed from a contamination with Italian immigrants’ use of salame in its second meaning ("dumb")? There can be no medical explanation for that since this usage began well before we became aware of the relation between cerebral atherosclerosis and consumption of animal fat such as that contained in salami and bologna. via A Manzoni 19, 22054 Mandello del Lano,
Italy
ANTONIO ATTANASIO
