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, 678 THE Ut?:CET. SEYTFJMB LR T 7• 1983 fl• I LG1fiKINt; HA11TS17F Nt'taA\DSOF NON tMOK/NG trOMFN t'ITH LVK(iCUNCER AND Or NM:'S.N(nKIN(i CtINTr((tli a(1MEN. •Ralwrw rW .[ rrl' ot IweK .awee uwauE .w.,rn.fiwr Kr.Aa.O. sasn` ,e . *.nrrln 1m/as cweqa, to IAn a*wnr ..wen .fw Yr>•aua ort n.n- rrln. I et.rsr ards" 7. r U..uan a.w, 0 01 ! M/em 1192..Geerc... , IDIMTTTtIiOSTRICHraK1l't.OS aN Derrnns, .f Epf4t.+iK•. leansne Scleol oft'.ubt,r Mw,a. ANNA KALAND1Dl ti.ua Mawrfurn.: tYA LDL•KAS SrAllROs DePv,.e.e.f Hnwr r F.pleu,asn. Uanrnrr.f ~Au/wn.:.. T3e table inereaxs the aedibilfty of the hypothesis implieating passrve smoking as a factor in bng oncer. Given the urull tue of tbe relativc risk and the many potential sources of bias, no single txudy will be able to provide connnnnget•'rdance for oragainst~thrs Dypothesis, only the convergence of results from different studies in different populauons will permit a reasanably sound eoncluaion, a•c oonrider the Athens stud% • a step in thu direction. Tlu.raud,was supponrd prertp.ll:t>AWr Grect lbltntunof Health GLASGOW OOAlA SCAIE TO SUM OR NOT TO SUM? StR,-The method for assessing parients with itttpaired consoousness tha; we described almost a decadi•e ago! has been wtidel+• accepred, and in manx' centres the n'e, verbal, and trwtor eomponents are swnmcd 2 Totali. up to 8 rclate to patients in coma with no eye opening or verbal rtsporses, reflecting changes in motor response, scores from 9 to 1Sdepend more upon eye opening and ve.rrbal responses. Janine Jagger and ber ooUeagues (July, 9, p 97) doubt ifeye and verbal responses add predictive information. They studied the shon-term outcome in hnd•inlured patients assessed on admission only. Not surprisingly, they found the motor responses to be most inftxmative; patients who, ooadmiuion, thom eye openi.ng and compreheaaibk verbal responses ought not to die. Death can be arpened only att7ongst, patrertts a/readc in eo>aa due to aevere establiched brain darnage Sudi pat itnts would have r7o eye opening and no comprehensiblt• verbal responses so that their, oorna ucore would depend upon the motor response. Changes in the evc and verbal responses, std thus higher orerall scores, are useful' in: disatminating betw'etn ~ patients with kss sercrc impairment ofcortsciousness. Although these patients would be acprcted to wrsi.'c, this mry: be a-itb differing de8rees of disability. The Charltrrtesvilk patp themcelves found that: ibernsing acores in the 9-15 range (reflecting improving eve and erti.I pcrfxmances) ~arc .aocined wirh a doubling of the rate of good recovery in survivon of Sad iniury., Furthermore, eorrelations have been established aeroas the wholc r.nr of the coma reore with arebral taetabolic tste for erygcn, evoked potential studles,s and bochemiol indices of brain datna=e.• r. Toobk G. Jorm n n A..n.t•ra af iamrawi rpuwl ewmo.raer L4an In7.... r al-M T Tn.bk G. Mvn.. G. Tartrr L:-14sn ) AMre.R.ta. Giyw eamo. K+.e. M+a N_r*W• 1919.31111 . (.rpPl l i 1 h/• 7 Rn.t Kl. Ge6.n, a. a.nAJT. p.e lA. M.Arnr.l`r1 0uun. "mpinry Hr e/wu I yrnrvn .f lr„n tr.r.u N...w-qn. 1910. f t': tN-1 ] 4. [a,nTt.Gnr+r11~T~A.O~r.,a'DJ.rreDA.Lrr.rnR.~ Ae.4.anl.tYr hwn r Jr dW,r.. . w..~e*, r An1 .rv. (J.. A'ww..,r ,M:. D: !S)-70 l.Ia1..• KTL.. C~4n1.. Kere. 1. Fn1. Mitrn A. Tndar GM E.+6M Rwnrrl..w..rw+. Isad ..rr,AaJ..w .tlrdr- r arrommor J. A...r, A'/r.w..j hvirn. 1081.44 : 70&-a0. a. babot,RAL. `MAE lr. td.arr.r,. dir.9. a orINI a.t s.iqq.rt rYd . ~rr..l~uol ,wws: J /A....r4 IM1 Y: :7-7) Had-rn)uted patients may change npidly, after dianstor:, and the eyc and verb.l responses ac useful in assessing improvement or deterioratton to thovu whether a panem is in corna and how long he t•ettuins comatou Scores obtained during the first ftrw"da.•s after admusion reveal much more about prognosis than do admuslon acorn. The ana))sis used tn the CTiarlonest'illb group is not well isu ited to comparing the rrlYtivc predictive power of differcnt cllnlcal': features and on esaggertte minor, dttferrnces. Moreover, the y included informst lon about pupil responses and about a hseraar orrv whleh could not:has been known at the time ofadiniuion Yet the.. have previously dettwnat»ted oornlations between higher coma tcores and decreasing frequency of abnormal pupil responses and CT ttan nbnormalities in moderately injured patients Beousc of this, the iaclusion of thee fotstres trssy have mnYed the iaformatuon provided by the eve and verbal responses. Their analysii should hatY been t'estrined'to the three aspens of the coma scalc. Thc%•' would then havc foundI that k'now•ledge of the eye and verbali responses in adduton to the motor response, does convn extra ' information, whether the three responses are eonsidered sepuatcl.% a summed. Although we eannot acttpt the Clsulottes.-i11c poup's reservations about the value of the eye and verbal components there are lrmtuuons tnhercnt in the wmrnation of the three responses. This step assumes an equal weighting for the threr raponses Morc ianpartYntly, the snforas.uon conveyed bc the coma score is less than that contained in the three responses separareh.= ' This is because the tamc seore may be made up in drtkrent wa.s.lndecd. in Glasgow pattenu undcr treatment arealw'ays described by the three separate responses and nmr by the total. The total trore is merely a con.enientmethod for sunimarlung data, especially for a series of psttents. Therefore, whilc we do not fsvour its use in dac-todav clinical practice, we find noaeason to doubtthaun will conunue to be used widely in the analysis and teponing of a series of patients with had rnturres or other forms of acute brain damage GRAHW Tf I~SDSLE Ir,uw" d \N,Wer,n:scrt.i.. BRt .t\ ~ENNETr 5wu~rrn Cwrrud Nap,uL LLIAN /~Si'RRUGby.-GSIVTF GORDON . AStRRI1 CULTURED F?IDERMAL MI 15 AND' BUR.``S Srn; a'e resd the article by Dr, Hefton and colleagues (Aug 20„ p 428) with interest because for aortx time we have been stud% •!ng both listman.epidermal ccll ieuhun and tneibods fox.aitnulat Ing thr rt-epnhelulitation ofnon-healing u)cers Before those nring for bums pattems rush out to buy an epidermal cell cuhurekn a notc of oution, should be tounded lt took many years before human epidermal a)ls could be euhivsred regularly in vitro. The techniques require considerable tkill and ezperienec to have consistent auccess even with a feeder Ik+'er ofmouse derived 3T3 alls: ro g7nw calls fiom cadaver akin (Aoa /cng din death we are mot told) without a feeder 1.-vo is prt:.ewortby but aa wIthtn the grasp of tnarrc other laboratotia. Wnh:the eystem used b:%' Hefton at tl; based on the studies of EiKinger,et a),a thesc doa na appcar to bc an invcatt in thrnumbcr ef epidermal a11s: The total number of eells in culture aft er 25 days is lew than the numberofetdl ls needed se d.c D(xe fig 2 in Ewnger, er al). This would itnph.• that the system s a whole has the disadvantage that an na of end.ver tkin equal in area to the site to be covered would' be required for graftrng On the other hand the 3T3 fibobJatst system used by O'Connor et al' is capable of a considerable increase in the number of erJb in .itro- Unless Hcfton 7 J.rra! DdiruKMVar.qea/4.hd..,w. IRnWli+.wL..f'to:v.rf rr,-xr+ a 6rqrr M. t.• jS. /lrfi.nlW n.rr.ara.n L Care It. IkNwwn E H+w..• dLu.nG.wi! rd hlknx+,w..n . , sa+ .brnc.nf.h- ~..up..er. W Ww.c ~srv.h.N.r/ Ad'Sn US4 . IP7i 76 1.Mr-N • O'Crr NL. MuFUrn 13 . n.J.&1d.1 S. Kefadr O. G-- HA..h,nr. ora\[r/rrd rr+slr/•~ .P.e>ro.dIrr.r,d.pr eMft•w. ~H. W.n Ic•. n-7. ~C123512605

r r . T 1 THE lA.''CET,SETTE.MBEA 17;19B3 Lttttrs to the Editor P1tMUMOCOCCAL PEJtITO*-1T1S ASSOCIATED WITH AXfUCD Sta,-A,neries of 116 patlems n East B)rmingham Hospitalw-ho liad pneumococcal b.neraerrus during the years 1974-82 included S cases of per itonit)s-2 in pat rcnts wnh nephrot tc syndrornc (a w•ell- kisowTS aasocistion)and threc irt w•oaxn ofpre.iotu pod health who bad been frned with an intrautcrane contraceptive devloe (IUCD). Cott 1.-A 32-year-olPw.vman was adtTUncd to hospital in October, 1978, after 4 dnys ofabdommal painind dlstension, wttha teaspaaturt of 38•S'C and clinical aittts of peritonitis. Rectal ptsminirion was normal. Abdotnirsal X-rals showed many fluid leveis witb distended taulhbor•c1 loops. A correctly placed Il1CD ('Eanatard'l was atso s7aed This had been fitted 18 tnonths preriously. A r3ltst X-tn- was normal. The clinical diagnosts w-as invasive wlinonellosis; shc was given intravcnous chloramphenicol and' improved. No intestinal pathogens were isolated but blbod euhure l•ieldcd a pure growth of Sr.rpraocctel pnrsrnte~ewr. On benzylpemeillin she continued to improve. After a transientfever 2' wveks after admission a chest X-rn• was repeated,,dcmonurating ri=ltt-loM-er-lobc consolidation. She recovered completely without further trrstment. Her IUCD was ranoved in August, 1979, when it w=s descTibed as "unremarkable". feu2-A 46vcsr•old wnman w-ss admined in March, 1981, afier a S dav 5iston• of continuous abdonunal pain and.catery,durrhoea. Hen tanperaturc wis 38•2°C and She had clinical siQts of perttonitis C'*nal examination revealed _a large tender uterus. Abdominal X ra}•s showed tnanv Ouid level's and a cvrrecth- placed' IL'CD (Lippes loop, fitted in ChZober, 1975). A chest X~ray w-as aormal. High vagtnal sw•abs revealed pus cclls and normal commensal flora She was given =entamian and ttsetronidazolc but did noi improve. After 2 days, Strep ynrv+nonrar was isolned from biood culture. Benrrlpenicillin was given and thereafter she recovered qulckly; The IL'CD appeared normal when ratsoved 12 da+s after admtssion, CC.QU 3.-A 46-vearold' woman with mild mitrzl stclosis was admitted with a 7 day history ofabdominallpaun and diarrhoea. She was hypoiensivc w-ith, clinical sips of peritonitis Laparotomc confirmed peritonitis butdid not reveal its cause. However, Strep 'ann.umicr was later grown from both peritoneal fluid and blood. Despite antibiotic treatment scute renal failure and ordoac failure developed and she died B dkys after adm:sston. Necropsyrevaletl a bcomuatc uterus. In onr horn there was a'Dalkon'shield IVCD adjacent to a small infartted fibrotd. ThIS IL'CD, a rsdlolucsnt type, had been fitted at,lean 4 years previously. Although there was no microscopic evidence of mdometritis„ bilatesal! ulpingitis was present. There wu no eridence of pneumonik.. In no ease was Strep pnnnnonlor isolated from tbe genital tran, and on1v . in casc 2 wastlrere evidence of tnetritis. Despite this, it is difficuh to discount the presence of tbe IUCD: Only. 6Sb of Bntish women ated 30-50 use an IUCD.! If all women in this tlte poup are equally n risk ofpncumococcsl peritonitis tbc probability ofall tbrec cases irt our .aia being in women using an IUCD is 0•000216. This ittdiates a hiahlc siFtificant tuaocistion baween IUCD usage and pneutttoeoccal peritonitis. R'c know of only I p7evious tase-repon of poeuntocoeeat peritonhis in a wvman using an IUCD (a Li.ppes loop fined 2 yeus before the infenion),7 bur of .everal ases of poeumomceal endometriti.s and peritonitis during pregnancy and the puerperiuma•• The ptxurssoroecus is often found in the t. t,.estnl Lnrrol Uniee t.'.r a onran}i,.a ar.qr W r.at ara r.o=rn. 1976 yr Tw.h 1N°, N: 99 2. Herbn ~Tl, M.nunr,,rP Recvnre+ pnmi.neol i,.r.ww.arnrd .'N an _...mln.eamnerpwt dn,n ,.,.S.q tf74.a1: Wl-t122 s AtrCarth.+ VT F•n6ewetrn,. W ranna .yu, Wr r. Swar.orm ywr.r Cl6.en G..roJ 1979,93: 475-91 4 . NJCt.ol. MH, HmK AT h~l wfen- .f tar arnul ~u.n w..a.rnw npes,all, a,nr( p.0.- ,..,a tr psp.,,rn: w. ) oenn G}:.d1.)t, sa: 7a2-VS S. Mendlel JO. S.aw LLS, S- FM, n.1 ~ apad .f .L..p.a.., A~ riwJ,es 1 Carrrae.ne .nd /snAn- . d tne J l%fw Dv. IIPS. eR: SSiI 677 oropharynxS but not in the aduh fcmalb genital trsn.a An IIJCD or placental tissue could provide a sanaruar) for pneumococci borne in the blood from the oropharyru, or the hu>;, bcforr invriaal of the peruonesl oviry. Pneurnococnl!peritonitis associsted with an JUCD is clearly very tarc. Failure to t reat tt promptly couldi bow-cwer, Aavc tragic results. {L'e suggest thauanl woman using an IUCD who praems with peritonitis without an obvious ouse should be given antibiotics with activity against Strep ywnnnow+ar (eq, a penicillin or eephalosporin)- This advice might apply psrticvlarly for wnmcn over 30 w•hose IUCD bad been fitted laonths or ynrs earlier. t?ep.mn.m. «r Mtdwl iA4atl4.loa.. Mvdra scmot. Nt«.r..n,, r.n..a.iiia, ..e.a.atnasnl L. D. Ottra P.ll,c HrahA Lbornnn. Lw.ar'raasttureWo.pual IC E. CoUJxGHArH Dea.nnnn .f Paae/es, . . i.a. tu0sdwte tiwyn.t C. V. EDt'AttDS LUNG CANCER AND PASSIVE SMOIQNG:: CONCLUSION OF GREEX STUDY Sut; Tbe notion that passive smoking may increase the risk of lung cancer has been aupported by , the results of tw•o epidemioloynl srudia sperifiollydesiped to esplort tbe issttc,Ta while a thirds revealed a positive but not ugnifinnt and dose- ttnrelkted assocution Positive resuhs have also been reported itom Pennsyhwnis10'aad Cnrmsny,ll but no assoastion was found in a study in Hont Kong:12 The at:aoeiation bas been nonsidtred oedible, on empiriol and tho°retiol Braunds,ts but a Laaar sdutaisl l r tis suarmed up the tsitttation by ssyiag tbtt the ttoessa=c of these studies "is not that epidemiologists and others bavc proved an assoeiation ... but that getting proofrmy tstx be as difficultas it once tleemed". Most of the controversy was generated by the nitnultsneous publication of the Greek7 and japanesea ttudla. Both bsvc been aitidaed, and Htrsyama has responded for the srudy in Jtpan.l+l6 TJte Greek uudyww attiaxd'(bc ouradires7 and otLers) because of ttbc staall asumber of' subjccts, because several i rumours lacked •wtdoEleal confirmatlors, and becausc mntrols snd oses were ftrom 4Wettnt bospitals. The Greek study has now been eonduded Un A. K:'s professorial thesis, L'niversity of Athens). Although leubt aarst aematn about the distologid evidencc aod Aospual 4iQ"sreami abtre are aow' twice a6 many eases and 50'S'. more asouuoi4; the ttuuha eesuaie aatstantrlly the sime. 102 .rom+en with a fseul diagnoua af lutq nrrv a Aer then adenoearc7ewtna o rcrmunl bronchul ornnoma, admuted'IOnAe tErer laraesl etieu unces bwpnab N, AttKlL, rett mtervlrwed brrertn. Seplembc:r„ 1976. and Decentticr. 19[2. hsorttier w-ItE 251 eonrro4 in the Hospital Jor Orts°paed,c Drorders. Atbens, from the aame arrs of Athens as the eaaes (uses and controls wsrr internrw:d In tlir a.rnr plirswur.. 77 osn and 22S eontroL were non,tatw6rra andttxly demographucandaocrarronosnrr profikswere .err smuhr 1lus6ands wbo !ad nopprd smok,n6 5-20 7e.n before the iatmur wrn elaladird'as a-onoken, those who had aopped'amaklnj wnLln S wn of Ih mtervtea were comldcred a current anwlrn: and those wko bad ptlppcd smokma tnorr tbae 20 yean pncrouskwtrs cl..+ficd as non- tlt.olers- 111" axrer ta.mcd: a ader., a a drmcsr was emudrred as prynskat to taamaar to a eoaamobt ax an eaimokcr, dependiog on the Vsn eLpsed susee the exnt. • T.buw IN. frWnn,CS. a aAepse lA Vaana Owm a.r.¢e..wt[ .~m Mi,. CJn. A.r l0rfa,at:: 957-61 7. Tr.M/.rls O, F:aYtld,, A. Sm rw L 4.d4.W I Lr{ s•nt W a.a,.t w..a,K l.r)f1..• 1M)117: HJlHn.~m.T r:.n.wdwe.n...(a.nraitnYrw.YNret.t.fY.Ks.n,.a .~da.am/aqe J•M.[JIMI,~t: la!-(S' ~. 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