BRITISH MEDICAL JOURNAL
19 FEBRUARY 1977
SIR,-We read with interest the letter from Drs N G Kounis and A W Howel Evans (29 January, p 291) describing a patient given multiple courses of ancrod (Arvin) therapy without anaphylactic reactions. In eight years' experience of ancrod treatment of venous thrombosis and peripheral arterial disease in almost 100 patients we have seen no local or general features of hypersensitivity, even in several patients treated for three weeks. Although resistance to defibrination, occurring in most cases after 4-6 weeks and thought to be due to antibody formation, has been described,' it seems at present that these antibodies rarely produce adverse reactions during a single course of treatment. We have given a second course of ancrod to one patient with therapeutic effect and no evidence of allergic reaction. A 65-year-old man with longstanding peripheral arterial disease and recent rest pain without overt gangrene was treated for 21 days with intermittent subcutaneous injections of ancrod (1 U/kg body weight/day), maintaining the plasma fibrinogen level between 0 5 and 1-5 g/l. During treatment rest pain disappeared and the claudication distance increased from 25 to 120 yards (23 to 110 m). Twelve months later the patienc was again referred to us complaining of recurrent rest pain occurring every night for six months; again no overt gangrene was present. Ancrod was given intravenously as an initial infusion of 4 U/kg over 24 h followed by 2 U/kg daily by bolus injection for 10 days. Plasma fibrinogen fell from 3 0 to 0 5 g/l in 6 h and was maintained below 0 5 g/l during treatment. Rest paini again disappeared within 48 h; no allergic features were noted even though no corticosteroid or antihistamine cover was given.
Although further experience of multiple courses of ancrod therapy is required, it appears that such treatment is practicable with
conventional doses provided several months have elapsed to allow the antibody level to fall. If repeated defibrination is required within a shorter time the use of other defibrinating agents, such as Defibrase, may be possible.2 Patients who may benefit from repeated defibrination include those with pregangrenous ischaemic rest pain (for whom controlled clinical trials are required3) as well as patients with recurrent venous thromboembolism resistant to conventional anticoagulants, such as the patient described by Drs Kounis and Evans. GORDON LOWE CHARLES D FORBES C R M PRENTICE Uniiversity Department of Medicine, Royal Infirmary, Glasgow Vinazzer, H, Thrombosis et Diathesis Haemorrhagica, 1973, 29, 339. 2 Vinazzer, H, Thrombosis Research, 1976, 8, 243. 3 Wolf, G K, European 3rournal of Clinical Pharmacology, 1976, 9, 387.
509
sents a fair sample of all pregnancies in our district, and "normal multiparae" (Dr Gillian Matthews, 1 January, p 48) were of course included in our study population. The way in which we identified our "lowrisk" population deliberately excluded all patients in whom a fetal or maternal emergency could be predicted on either epidemiological or clinical grounds. (Patients with prolonged labour were excluded.) The different categories of fetal emergency listed in our results were mutually exclusive. In the table "infants in poor condition at birth" referred to those which had not shown any signs of fetal distress during labour. We are taken to task by Dr K A Harden (15 January, p 168) for quoting from out-ofdate articles which had shown that relatively few general practitioners actually attended their own patients in labour when provided with the opportunity to do so. However, we also referred to the more recent paper of Wilkes et all in order to infer that this situation did not appear to have changed more recently. We are accused by Dr H R Chapman (1 January, p 48) of "forcing ... low-risk patients unnecessarily into the strange and sometimes impersonal environment of a hospital obstetric unit." We believe that having a baby in a modern obstetric unit and compassionate care are not mutually exclusive and that the presence of the husband during labour and delivery does much to offset the strange environment. Our argument was based on the fact that 700 of even "low-risk" patients develop unpredictable emergencies in labour. These are very often diagnosed by the midwife, whose role is essentially that of "specialist in primary maternity care." In a modern hospital unit members of the "obstetric team" are likely to be more easy to get hold of and better able to provide the "secondary" care of such emergencies than the independent general practitioner. It was not our intention to decry the work of GP obstetric units in those parts of the country where distance precludes hospital
delivery. PETER CURZEN URSULA MOUNTROSE Obstetric Unit,
Westminster Medical School,
Queen Mary's Hospital, Roehampton, London SW15
Wilkes, E, Dickson, R A, and Knowelden, J, British Medical _ournal, 1975, 4, 687.
The reprint game
My reason for requesting reprints is as follows. In order to keep up with developments in antibiotics alone I must read articles which are likely to appear in chemical, pharmacological, pharmaceutical, biochemical, microbiological, and general and specialist medical journals. One has immediate and free access to a handful of "core" journals, subscribed to by oneself or one's colleagues. These journals are perused and photocopies taken as required. In order to cover other sources one is compelled to use an index-publishing service such as Current Contents. Reading this weekly enables one to list additional articles of interest. Probably only a small proportion of these articles will be found in the library: for instance, the last 40 requests I made came from 35 different journals, only 11 of which are taken by our (very comprehensive) library. Obtaining these articles from the British Library can be expensive and is timeconsuming for library staff. Photocopying on the premises is also expensive (3p per sheet) and time-consuming. An airmail postcard, on the other hand, costs only 7-lOp, the response is encouraging, and any delay usually of no great importance. Very few papers turn out to be so vital that one cannot afford to wait six weeks for them. Some of this waiting period is in fact compensated for by the fact that indexes often appear in Current Contents before the actual journal involved has reached the UK. It would be interesting to know if my "reprint philosophy," as outlined above, is typical. It may be that microbiologists respond more kindly to requests for reprints than do members of other disciplines. J M T HAMILTON-MILLER Department of Medical Microbiology, Royal Free Hospital, London NW3
SIR,-From time to time an activity, often referred to as the reprint industry, has been the subject of correspondence in your columns. Readers of your journal, particularly readers outside the United Kingdom, may be interested to know of a recent development in the industry which has not been publicised. In at least one part of the country moneys are no longer available from National Health Service funds for the purchase or postage of reprints. Wouldbe exporters, therefore, have the choice of meeting the costs out of their own pockets or mutely declining the requests for records of their opus. Human nature and financial considerations being what they are, it seems likely that the ranks of the exporters will diminish. Whatever the merits or demerits of this new development it will at least lend new life to the controversy about the industry.
SIR,-The letter from Dr J W Todd and your reply (22 January, p 231) raise some important points and deserve a full answer, as maximum exchange of information is the essence of modern scientific medicine. My General practitioner's role in J F ADAMS own experience is, happily, that most of my management of labour requests for reprints do not "go straight into Southern General Hospital, basket." For the past five Glasgow SIR,-We are writing to answer some of the the wastepaper a record of the reprints I have kept I have years points raised in your correspondence columns (on specially printed postcards, SIR,-Many of the people who send for reprints following our article (11 December, p 1433). requested have never seen the article requested. At best Ours is the only NHS maternity depart- written in my own handwriting). they have seen the title in Current Contents, ment in our health district and we accept any but even the duty of scanning lists of titles pregnant woman from this district for delivery. Received Requested Year or key words may have been delegated to a During the period of our study less than 20% 235 (78-1) 301 1972 secretary or a computer. of all pregnant women in our district had home 261 (727°) 359 1973 209 (78°%) As a whimsical counter-move in the reprint 268 1974 confinements. In addition, we accept some 223 (76 1 °') 293 1975 game Nature in 1970 published two letters, patients from outside our district and these 164 (74-6)* 220 1976 one entitled "'Evolution'-'Development'account for about 25 of all our deliveries. Anatomical and Cerebral Features and the We therefore believe that our practice repre- *To date.
19 FEBRUARY 1977
SIR,-We read with interest the letter from Drs N G Kounis and A W Howel Evans (29 January, p 291) describing a patient given multiple courses of ancrod (Arvin) therapy without anaphylactic reactions. In eight years' experience of ancrod treatment of venous thrombosis and peripheral arterial disease in almost 100 patients we have seen no local or general features of hypersensitivity, even in several patients treated for three weeks. Although resistance to defibrination, occurring in most cases after 4-6 weeks and thought to be due to antibody formation, has been described,' it seems at present that these antibodies rarely produce adverse reactions during a single course of treatment. We have given a second course of ancrod to one patient with therapeutic effect and no evidence of allergic reaction. A 65-year-old man with longstanding peripheral arterial disease and recent rest pain without overt gangrene was treated for 21 days with intermittent subcutaneous injections of ancrod (1 U/kg body weight/day), maintaining the plasma fibrinogen level between 0 5 and 1-5 g/l. During treatment rest pain disappeared and the claudication distance increased from 25 to 120 yards (23 to 110 m). Twelve months later the patienc was again referred to us complaining of recurrent rest pain occurring every night for six months; again no overt gangrene was present. Ancrod was given intravenously as an initial infusion of 4 U/kg over 24 h followed by 2 U/kg daily by bolus injection for 10 days. Plasma fibrinogen fell from 3 0 to 0 5 g/l in 6 h and was maintained below 0 5 g/l during treatment. Rest paini again disappeared within 48 h; no allergic features were noted even though no corticosteroid or antihistamine cover was given.
Although further experience of multiple courses of ancrod therapy is required, it appears that such treatment is practicable with
conventional doses provided several months have elapsed to allow the antibody level to fall. If repeated defibrination is required within a shorter time the use of other defibrinating agents, such as Defibrase, may be possible.2 Patients who may benefit from repeated defibrination include those with pregangrenous ischaemic rest pain (for whom controlled clinical trials are required3) as well as patients with recurrent venous thromboembolism resistant to conventional anticoagulants, such as the patient described by Drs Kounis and Evans. GORDON LOWE CHARLES D FORBES C R M PRENTICE Uniiversity Department of Medicine, Royal Infirmary, Glasgow Vinazzer, H, Thrombosis et Diathesis Haemorrhagica, 1973, 29, 339. 2 Vinazzer, H, Thrombosis Research, 1976, 8, 243. 3 Wolf, G K, European 3rournal of Clinical Pharmacology, 1976, 9, 387.
509
sents a fair sample of all pregnancies in our district, and "normal multiparae" (Dr Gillian Matthews, 1 January, p 48) were of course included in our study population. The way in which we identified our "lowrisk" population deliberately excluded all patients in whom a fetal or maternal emergency could be predicted on either epidemiological or clinical grounds. (Patients with prolonged labour were excluded.) The different categories of fetal emergency listed in our results were mutually exclusive. In the table "infants in poor condition at birth" referred to those which had not shown any signs of fetal distress during labour. We are taken to task by Dr K A Harden (15 January, p 168) for quoting from out-ofdate articles which had shown that relatively few general practitioners actually attended their own patients in labour when provided with the opportunity to do so. However, we also referred to the more recent paper of Wilkes et all in order to infer that this situation did not appear to have changed more recently. We are accused by Dr H R Chapman (1 January, p 48) of "forcing ... low-risk patients unnecessarily into the strange and sometimes impersonal environment of a hospital obstetric unit." We believe that having a baby in a modern obstetric unit and compassionate care are not mutually exclusive and that the presence of the husband during labour and delivery does much to offset the strange environment. Our argument was based on the fact that 700 of even "low-risk" patients develop unpredictable emergencies in labour. These are very often diagnosed by the midwife, whose role is essentially that of "specialist in primary maternity care." In a modern hospital unit members of the "obstetric team" are likely to be more easy to get hold of and better able to provide the "secondary" care of such emergencies than the independent general practitioner. It was not our intention to decry the work of GP obstetric units in those parts of the country where distance precludes hospital
delivery. PETER CURZEN URSULA MOUNTROSE Obstetric Unit,
Westminster Medical School,
Queen Mary's Hospital, Roehampton, London SW15
Wilkes, E, Dickson, R A, and Knowelden, J, British Medical _ournal, 1975, 4, 687.
The reprint game
My reason for requesting reprints is as follows. In order to keep up with developments in antibiotics alone I must read articles which are likely to appear in chemical, pharmacological, pharmaceutical, biochemical, microbiological, and general and specialist medical journals. One has immediate and free access to a handful of "core" journals, subscribed to by oneself or one's colleagues. These journals are perused and photocopies taken as required. In order to cover other sources one is compelled to use an index-publishing service such as Current Contents. Reading this weekly enables one to list additional articles of interest. Probably only a small proportion of these articles will be found in the library: for instance, the last 40 requests I made came from 35 different journals, only 11 of which are taken by our (very comprehensive) library. Obtaining these articles from the British Library can be expensive and is timeconsuming for library staff. Photocopying on the premises is also expensive (3p per sheet) and time-consuming. An airmail postcard, on the other hand, costs only 7-lOp, the response is encouraging, and any delay usually of no great importance. Very few papers turn out to be so vital that one cannot afford to wait six weeks for them. Some of this waiting period is in fact compensated for by the fact that indexes often appear in Current Contents before the actual journal involved has reached the UK. It would be interesting to know if my "reprint philosophy," as outlined above, is typical. It may be that microbiologists respond more kindly to requests for reprints than do members of other disciplines. J M T HAMILTON-MILLER Department of Medical Microbiology, Royal Free Hospital, London NW3
SIR,-From time to time an activity, often referred to as the reprint industry, has been the subject of correspondence in your columns. Readers of your journal, particularly readers outside the United Kingdom, may be interested to know of a recent development in the industry which has not been publicised. In at least one part of the country moneys are no longer available from National Health Service funds for the purchase or postage of reprints. Wouldbe exporters, therefore, have the choice of meeting the costs out of their own pockets or mutely declining the requests for records of their opus. Human nature and financial considerations being what they are, it seems likely that the ranks of the exporters will diminish. Whatever the merits or demerits of this new development it will at least lend new life to the controversy about the industry.
SIR,-The letter from Dr J W Todd and your reply (22 January, p 231) raise some important points and deserve a full answer, as maximum exchange of information is the essence of modern scientific medicine. My General practitioner's role in J F ADAMS own experience is, happily, that most of my management of labour requests for reprints do not "go straight into Southern General Hospital, basket." For the past five Glasgow SIR,-We are writing to answer some of the the wastepaper a record of the reprints I have kept I have years points raised in your correspondence columns (on specially printed postcards, SIR,-Many of the people who send for reprints following our article (11 December, p 1433). requested have never seen the article requested. At best Ours is the only NHS maternity depart- written in my own handwriting). they have seen the title in Current Contents, ment in our health district and we accept any but even the duty of scanning lists of titles pregnant woman from this district for delivery. Received Requested Year or key words may have been delegated to a During the period of our study less than 20% 235 (78-1) 301 1972 secretary or a computer. of all pregnant women in our district had home 261 (727°) 359 1973 209 (78°%) As a whimsical counter-move in the reprint 268 1974 confinements. In addition, we accept some 223 (76 1 °') 293 1975 game Nature in 1970 published two letters, patients from outside our district and these 164 (74-6)* 220 1976 one entitled "'Evolution'-'Development'account for about 25 of all our deliveries. Anatomical and Cerebral Features and the We therefore believe that our practice repre- *To date.
