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r Jk I THE LAsCET.sEPrEAtBER 17.1983 Letters to the MtO'r PNEUMOCOCCAL T'ERITOTITIS ASSOCIATED WITH IN JUCD SIn,-A aeria of 116 patients in Eat!Blrminiham Hospital who bad pneumocottal bactcraemia during the yars 1974-82 included S csa of paitonitls-2 in palents with nephrotac svndrottx (a ti•cll• RilowTi aasociation)arxd three in women of prerious good health who had been fined with an intrauterinc cotnracoprive drvitc ()UCD) Cau 1.-A 32•yar-olloftaaian was adnutted to hospital in Ociober,1938, after 4 ds%,s of abdominal pain and distension, wnh a ttmpaaturt of 38•5'C and di,t»al tcipn of peritonnis. Renal aalainaaion was nortml. Abdominal X•rals a)ww•ed mam° fluid hs.ds.aiib dlstended la>tiU•boY.el'ioops. A mrreclll plfced IUCD ('6xnLgard'J~ wx also Dt>tet! This had' been fitted 18 months prrriouslY. A dsatX-rn• was rsormal. The dinlal dugnosis w•as invaivc salrnorsellosis; -hcw•a given imrn•enous diloramphenicol and improeed. No imestinal patho=ens were isolated but blood euhure yieldcd a pure growth of Srnpmusresu prnr,rw7ur On btrlzylpenuilhn she eontinued to improve. After a transient fever 2 weeks after adinission a diat X•rar was repeated, demonurating ri,Sht-krwer•lobe consoLdation. She recovered completely without furthv treatment. Her IUCD vssretwved in August, 1979, w•hen it wss described as "unreasarkable". Cosr 2.-A 46yeartrld v,•oenan was admined in March,1981, after, a S da%' history of eontmuous abdommal'pun and wnerydiarrhoes. Her temperature was 38•21C and she had clinical signs of peritonitis Vaginal esaminaaion revealed s large tender uterus. Abdonwsal X•ra)•s showed trsana• fluid levels and a cvrrtcth~ placed IL'CD(Lippes loop, fsned in October, 1975). A chesrX•ray w•as aormal. High vaginal swabs rerealed~ pus alls and tsormall tomrrxnsalifiora She was pven Sentamiisn and mesronidazok but did not improve. Afttr 2 dars,Strep psrsnnorlimr was isolnedftom blood culture. Benzylpcnicillin was given and thereaftcr the reeovered quickly. The 1L'CD appeared noraul when rerwved 12 ds%-s after admission. Cau J:-A 46-rarold wolnan with mild mitral stenosis was admitted with a 7 da% history of abdominal pain and diarrhoea. She was hypotensive with: clinical signs of peritonitis Lparotomi confirmed peritoninis but did rswrtval its cause. However, Srrep psreumoniar was lata grown from both peritoneal fluid and bloodi Despite antibiotic treatment acvte renal failure and cardiac failure dl:vt:loped and she died 8 ds+i af'ter adm sston. Necropsy revealed a bicornuatt uterus. In one Aonn there was a'Dalkon' ahield IUCD adiaecnttoataaallinfarRedGbrad ThfslL•CD,aradlolucenttype, had beerl fnted at Ieist 4 years prn-kously. Although there was no microscopic evidencc of mdometritis, bilateral salpingitis was present. Therc was no evidence of pneumonia. In no case was Strep psrrwloniar isolated from the =enital tract, and only in csse 2 was there evidence of ttmtritis. Despite this, it n diffuuh to discoum thrpraena oftbc 1L'CD. Only 6% of British women aged 30-50 use an ]UCD.1'Iif all women in this age group we equalh• at risk of pneualococal peritonitis thrprobabilit•v of all three wes in our tsria being in women esint an lUCD is 0•000216. This indiates abi`hly aipsificw aaooatioa between IUCD usage and ptxuatoeoceal peritonitis. We brow of only I previous enrrepon of paessmococnl pcnoctitis in a wmlan using an EUCD (a 1Sppes loop fined 2 years blfOre the irlftlRiorl),2 but of /eYera) caSS of p0lliIIlOcioCtf1 eadometritis and peritonitis during pregilancy and the pverptimas•` The pneumococcns as ofter fowwd in the 1. Caaml6u,-ol tfrl;ee L'w Si an,aeF~ by or and rW as r.on-w NH Sr 7ud, IMD. Nk M 2. NerYen T], A{wrrr, -T nenww+t r.nrssml -erw... O.or A at ttr-,.erur mntepwe dewce 1r ) SrR 1914, H: a1-02 7 AI[GnM %? EwMwrrw. r•/ rrrM vwu Mw n SuAwr,v'wrwr O-rn OwrW 1-M, q: 4171-40) C -:.<1MC NN, Nen* AT M,srot rat.n~ dtY Fuy6 rnn W wrn. w*eeWIW M,rn4 peprin rW the Pner*nww .h 1 06.- Grrl'Ie1L i: Sr-fr f.Ifiarlti10. rrreMA, tAewn-M,ed iprwf ddrwrrw,ltiw.rrr r. i.Jw.! CA..re. M. A.+Nw.e 1111.r7+• 1AyoD.r lers, iat: ss-*1 677 omopharyr'lss but not in the aduh femalc =enital trnT.a An IUCD or placenul tissue could provide a sinctuarq• for pneumococci borne in the blood from the aopbaryni, or the hta& before iaraim of'the ptntonnl iavity;, Pneumococcal peritonitis assoaated with an lU'CD is deuly.ery rare. Failurototrat if promptl)•,could, dow•cver,havc trugicraults a'c suggest that any woman using an IUCD who presents with peritonitis withoul an obvious ouse should be pvrn antibiotics with activity against Snep pnrualolrlor (q, a penicillin or cephalosporin). This advice might apply pwcularll• for women over 30 whose IUCD had been finod taotlshs or years eulier. Dey.remcm .(s4Ln1 At,e6riia,., Ated-) 6rtieo1. V- of Is"ranatiltain` s.ra.p..,B1s1T] L D. Gtetru N•IK NpW1rA tJIM.IN.M, Lrlarrar{f1.s~Ne~y..i L E. COt].rMC.NAMDeparrwenl of -nhoiss,. i.•, au.ag,ew N..yrtai C. W. EDSAws LUNG CANCER AND PASS11rE SMOKING: COTiCLUS1OT OF fs1tEEX STUDY Stw,-Thc notion that passive smokinS may iaertasc the risk of lung cancer has been supported by the resuhs of twro epidemiological studies specifiolly desisned to explore thcssur," wrhile a tLird! rrveled a positive but not a4tifiattt and dou• unrelated association Positivc resuhs have also been reported from Pennsyh•anuito and Germany,l l but no asaoosrion was found ia a study in Hong Kors`.1j The assoaation has been aonsidned aediblc, on empirical and tLeoretial Smutsds," but a l:ancwn sdnarial t r Eas aummcd up the aituaam by anv>i that tbc mesa4c of these studies "is not that epidcmiologists and abcrs have proved an association ... but that gertiaS proofmay nac be aa difficub aa it once aeemed•"Most of.tlie eontro+rersy was generated by the simuhaneous publiotion of the Greek'i and Japaneses studia. Both have been aitidsed; and Hsragama has raponded for the study in Jrpan 1"• The Greek ssudy was euia><ed (by ourad ves' and others) bsaur of the amall number of aubjecu, because aeveral rumours Lcked •wolo6lal'confirmnan, and because cvmuols and osa were from 49Te'rcm hospltah. The Greek study has now been eondiaded (in A K's professorial thesu„L`niversitv ofAthens): Ahhouyh 4sobt aara H+++a,rs dwut the 6istokii;ial evidcncc and bpual Jilluet>as t8ae are now rw•xe as mwy usa And 5Or3'. more anuaia; the sasul4 serie aalbssaautUy the sfine 1tL'.ee+en wit4 a fwl diapwal. dhm4 caacer esher th.n.denoornamao or trrminaltitonthlal ornnoen.,adimmdtothe t6roedrtm et+nt uncer-nprtats in AtMm, were aalerrlewed trtiecn SepPember. 1976, and Dammtin, 1}9=:to{ett+ernt6251 eartroY tnthe Hawpual for Onbopedic Duorden. Aitirm, frwo the umc area ofAlhem a the cs>.n Ca.etand eonnoW were imerrew:d In- the nmc pliru:rn 77 o.nand 22S eenlrob were rwn-flno-'ers, atdtEeu drmograyA,e and aocwecnnamuc proflks rerv.enstaular Hu.ti.ndr wLo bad stopped anw/1n6 5-20lean bsftre the imenx,. .•crr ebadieda m-onotcn;,tso.c who bad stopped smottnR within S wn of sNr muraev; were comldered at currcnt anoken aed tMre w!0 6adxop!ped mdtia6, more than 20 fnn prenoutl+tere clYUfird a eon aswLen ieur< ann omed, a iindoa, as a dwenxe was cooudersda eqisniknf no morrW to. smsNw-a aeao ta-votdcer, Arptndm6 on the pOOn elrped naes sYe cvem. • Tr,r IN. Cwdr O. aaa.ai- IA r'yrl5o. arty..taara,awn AIIwCAM Pwr 1e7C a1: 957-61 7. T+sMOwlw D-i,-Wr, A.6a.na L MrWtr a Lra rn.r aaiiiiin. Iisift h)Clrn IN1:t7: 1-4 It Niq.rrn. T -:.niwr/rt.ww.f aar" rien bw. he. eA d-air aa.r a nrl hsta,l.wr is•Merl tasl:fo. us-ss S. Grdr4i L Taor tn.ik a Yue a.nt tlndnr am.%raYe. rd ..ae • V=-w w.-wK J Aa fiirw /wIN1,M: 106 1-M 30 MJMc Tlthsrt.rr..w..p-.wstaduK lA..r.tlha:al:s-t• It.Krn A. Isetf. N. 6cluuth iL.nnrearn Y t,wWwu.rwwawtf. hn I:ieMrwrefnuMa AMl/:rMa IM3.RI:Se-S~ 12 CYn w.en Ue,rle Lai* - N..a; K.n at... M1/ trui. 1111163.1111: 16 11 EAn.rl t'rr.eaw.ku{ lOREST,GASran/frwl-lw. sM-N 14NrtnnrT /rner.lwwlWitern,.l•MNI,INI.an: I391-94 IS, Nr.vrln 7 lKw,:r+...~ll~ r,w dtr.r Irns trn. a~,er rr.ll..e t,•cs+:1•. aMJlIM1;aO: 016-17 N N.n>am. T rZw,ra..-,y:w..Rr.r ~.am ar.e..-rfrr..-rrl+e ee.m , l•. wrl ssal.aat: IMrrw

678 aMnttnai NASI?s nf NI'sa...DS nf r:nti t,MOKIKG TOMEN WITH lt`I:( iCG>:CTR. Ak D nf tinr: fMn1:IK(i cM.'7•R(H : ttnMEN . GKattnn pn da,. (eurremrnolers) Gnur tiarwndn.l F.a-mw~n. 1-1n1 11-r ]1-'b !31• Taal l.oAe rrrlce 24 ls 21 2. 7 7 77 CeeMYoh 109 35 16 40 ! 17 225 RR• /•p. liN 2•4 !•1 •Rel.rw ..1. rw .t rl d 1wK t~e rrrne ..wrn iur ErINM. 4NrK a. 0~ ruw r~.a aaeas.., n Mu ~rwr...n, .fw. trW,/i an .w,rMa ~~ R.. 1Mm.reM1~e 7, r0a.+atl.A.n 0-Ol The table increases the credibillte of the hypothesis implicating ptusrve amoli,ng as a factor in lunC oncer. Given the ana11 aize of tbe relatis+c ruk and the manr potential souren of bus, no single arudyr ill be able to proeide convincing e.ndence for or against this bypot hats, only thY eonvetgence of results from dl fierent studies in dilferent populations will permii a reasonably sound conclusion. R'e eonwder the Athens etudy a step tn thn direction,. Ttw uud, .as wpponed twnrlp1l.a• de Greet: M•l4aan of. Health Der.*+~, .f Nnn.- a.d E0.onwMe.... V._nm af~A1Mw. AIMnw~17S3;. Grrrr.:. d~ Drp.n- .f Epi•wrl. +~ l DLNlTRIPS TRICHnfnCLOs ~ NsnrsmSrtwnl.fImllw NuuL, A1CNA KA1.A1:D1DIM~ ll..r.lirru. VsA. jAt•I:Af SrAtiAOs GLASGOR' OOMA S(".Al.E: TO SUM OR NOT TO SUM? StR,-Thr method for atsesung patients with impaired eisnsciousness that we described .ltrmst,a decade agol bas been vidclv accepted, and m msm antres the eyc„verbal, tmd motor components are wmmed 2 Toials up to 8 relate to patients in corna vith no eye opening or verbal resportses, rdle+cung ehangrs in motor response, scores from 9 to 15 depend more upon,eye opening and .erbal: responsa. Janine Jagger and ber colleagues (July 9, p 97) doubt if eyrand verbal responses add predictive informRtion, They audied'the sbon-term outcomc m hesd-inlured patients assessed on admission only, hlot surprisingli•,, thcy found tbe Itroaor rtsponsa to be most informati.c; patients w•ho, nn admiasion, sho+ eye opening and tompreheasibk verbal resporre ought,na to dle. Death can be esyected only an+ongst p.nents already in tomR due to fevere en abhshed brain danage 5uch pta ients wnuld hsve no evK opening and no comprehensible verbal'.responses so that their coma scvre would depend upon the motor response.. Changes in the eve and verbal rapanses, and thus higher o.etall aeores, are useful in durrimmating betwven pRtients With less severe impairment of corucibusness. Although theu patients would be atpected to survivc, this mRe be with differing deire.n of disabibty. The CJi,arlottesville group tLeaselves found that incrcasing scorea in the 9-1i range (reflecting msprw ing eye and verbal perform.nees)'are aasociated with a doubling of'the rate of good rerovery in turvivors of 6ead iaiury:1 ' L'urtllermore, tarelarioes have been tstabliahed aeraas the w^Bole ranr of the coma acore .ith cerebral metabolic rare for eryten, evoked potential studia ", asxw biochemical iadicss of brain darasge.a L Tnm&4 G.yr.an a A'rrr.f' af Iisa. aa ~r.N F~rwra l.~n 1974. r RI-M t TM-AI4:G, Mr..w G. Ts.ev 1./rr,, n AY-M..t•ra.Giy- err an.. M, ItrS. t• npNr 1 f-1• ! Ka~rl aw . Grbw, R- a-aJr . 1.r. )A Yyrr.~. Ir/ r.c" eompf+.y. Ne tlrul yrarw+.f lrre W-11 A. t~raf uTt . Ge.nea,~T A.OI+.~ w'D. M.a DA.ii..n... RARyuw A. Ih ear.e w tl. dwrrr. w rKrrae*+. r Rp/ irr. CA. A'ww..q IM:: tr: l15-7a S. LaN... KtL.C.rYrA.l. Kr..w, l..M. J. aMMrs A.. 7..r4 GM E..Ge pw.rrh ....en. tsa0 rw.> ArMS re rW.+, . r.ae~ . j A..wr Ai..r.q, Prwir - . I M 1: M: Par-R0. A..Yer RAL.. e..aAE 1, lfaq.x. ell.p . var...t..r..Or.a bd r V1rdPW11%As1.,.1.n. y AwM.q ,Mr.r: Z7-s7 THE1.A7:CET.SEFTLMBER 17,1983 Head-miured patients tnay, cchange rapidly after admisslon, and the eye and verbal responaes arc useful iul assessing improvetne nl or de!terioration to shou w•bether a patient is in comaand how long he remains consslose Scores obuined'during the first few dws.fter admission reveal much morr aboW prognoais than do admusion acores. Tbe anahsit wed bc the Charlottesville group u not aell wited to ecmparing the relaiiYe predictive power of differentt clinical features atd an esaggcratc minor differences. Moreover, thea included informat ron Rbou t pupil responscs and about a haernat oma w•bich could not have been krwwtf ar the umeofadrniuion Y•et the} have previously demonstrnad wrrclations betvesn higher mma t/c'orts and dscrcasing frequency of abnormal pupil responses and CT Rcan abnormalities in tnodertnely in'ryred paients Beauu of this, the inchnian of t6ese fesrures tr>•y, have t>sRSked the inforttauon pros^ided b} the eve and verbal responses. Their atulysis should have been restricted to the three aspects of the emr salc. The, would then have found7 that krrowledge of the eye and verbal responses in addition to the motor response, does convey extra infor•mation+.•hether the three responses ue eonsiderad Reparatelr a wmmed Although we cannot aecept the Charlottesville poup's raervauons Rbou t the .ylue of the eye and vt rb.l conrponerns there are limitations inherent in the wtmaation of the three responses. This step assurnn an equal .reighttng for the three responses More it7tportamh•, the mformstlon conveyed b.- the eotna score is kss than that contained in the three responses tepararrlh.= ; This is because the same scae tnay betn.de up in different w•ays. Indeed. in Glksgow patxnts under treatment ue ahswlY described by the three separate raponses and axv'er by the total! The total score u nereh• a convenient Inethod for sutarnaraun; data, apeciallj for a series of pauents. Therefore„whilt we do not favour its use in dav-todac clinical practice, wc find no reason to doubt that it will continue to be used w-idelc in the Rnahsis artd reporting of a uries of'pauents with had mtunes or othez forms of acute brain damage Seuilr,nC..rr.l Nry.ul, . GWaw GiluTf. GRANAm TE.SSDRLE. BRSAXJE"-LTT L]LIA~, Ml'Rxk1, GORDO% ).'h'KR11 CULTURED la'1DERJMAL M J3 AND SURNS Stn,-a'e read the aniclo b.' Dr H'efion and collogues (Aug 20, p{28) with interest because for eomt time wK have been studying brrh human.epidermal cell culture and methods for stimulating the rstplthe/ulisatian of aon balmg ulcers. Before those aring for burns pat tenrs rusA out to bu,v at epiderttul cell culc urs kit a trw e of caution sbould be aounded' h too/k manc ynean bcfore human ~ epidermal alis could be cultivated regulal.• ia risro. The techniques require eonsider.bie sl(il1 and acperience to has•e consistent success even with a feeder lNe of mouse derrved 3T3 ce11s: ro po* cslb from eads.n akin (bow• Img after death we are .a told) witLout a feeder, laver is prai><.orsDy but not vithm the grasp of many aher l.boraoria. 19'ah the sysrem used b~ liehoa a tl,,bsed an the studies of Eiaii><er et at,R tAerc does oa appar to Ik an increaae in the nurnber ~ of epidcrmeJ alb. The total numbcr of eetls in wlture tfier 25 ds% in bs tban the nutnDer of csl4 teeded at dn• 0(ree fi5 2 ia Essinger n /dl. Thif would impTy that the Rruem u a whole has the disadvantage ttial an area ofodsverslin equal in area to the ate to be twered wtwld be required fa pafiing. On the other hand the 3T3 fibroblast system used by O'Ccetnor at ale iR opablb of a eonsiderablt Inaeasc in the number.ofeelh in vitro. Unless Hefion 7/.r.eo 1 Dsfi..~ Fm. ~.qe d1n v rn. ) aw edVM..nr LwJ 1 *70.1r /r.-too a L1..Rrr M. 1- li. 14Aw~ I.AS. D.rr.a..,e L Gfr Iw . lN.E N+wu.. a0.d~l all aWWrw.. Gew~4 aY rlCrle.rmrw .. J. ab~t f Irr. a~.r.. W r4YeF- Auui .ArISn itSA N;e. ta ~SK~M 0. (1Y~..r A'E. r~Milrrw /!1. nrJ.fAe(.I a. KeA.Vr D. Gwew N G*.hqK nf Rr-- .r.\[r/ivde'YteL~.Mqi/~Irti~wY~rr/er~tl«11. 4~'n lec., 71-7i