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rul:1_ac'c.l''rs'r:rcrvtHl:IC 17..1983' Letters to: the Editor PYFUMOCOCCN'L PERITONITIS A:CSOCIATED WITH AN IUCD StR:-:1'serits++f1116qt:niicrosatll ax1 Ilirmin4ham Ilnspital who had pncummct7c:al haclrracn»aiduringthc ycars:I!9r4-82'includid i Icax sa+f poriion it is-2 in ipat icnt s'wit h ncphrnt ic s-vndrltmc (n nvcl I- krtmwnassfxiation);Ind rt hnk in nconn n x.f prcs•ious;etxtd health who had hcon fiuld with an intrawcrirn contr:lccptil•c device (I(JIi.D). ('.arc l.'-A' 32-vli uvm7an, u'as, admittcd' toi hospital in. (kyo(xr. 1978l af,cr •tid:Yvs ofa(alominal'pain and distcnsion. \cith ai tc•mperaturc of 38•5"C and clinicallsigns of peritonitis. Rectal .:.aminatian w'as normal. Abdon7inal X-rovs shotvatllntan_v fluid Irvcls with diucrrek+d small-(xfi loops: A correctly plbccd 1Q:CD ('Cerarigard') I was also notedi 'lllis had l kx'cn. frtted 18 months prcvioustv. A chest X-ray was normal. The'clininl diagnosis was invasive salmoncllosis;'shc'u'as'givcn linl ravcnous chloramphenico( and improvcd!, \a intestinal pathogens \cerc isolatcdl but blood culture cicldcd a purc growth of Srrrprxnrars prrrrononialc. On bcnn•lpenicillin shc conhinucdlto improvc: Aficr a aransirn7t fcvcr 2 wccks after admission a chest \-ra)• was:repcatedJ demonstrating right+lo\eer-lobc consolidation. She recovered eompletclh'e•ithout funhcr hrcatmem. 1lcr IL!'CD a'as, rcmovcd in Augusr, 1979; H•hon it : was described as "unremarkablT '. Cuar 2. -A 4&vcar-nltl M•oman'a^as admit tcd in uMarch,1981, after a 5'dsy history ofcontinuous abdominal painznd watcrn^diarrhoea: Hor temperature w•as: 38-2nC and she had clinical signs of: peritonitis., Vaginal cxaminatiixn rcvcaled a langc:tcnderutcrus. :1'bdomina6 X-rays showed mam• fluid Icvclsand a eorrcctlb,'placcd IL'CD'(Il.ippcs ldmp. fittod'in Octobert 1975). A chest X-ray was normal. I(igh v:!ginal s\.•abs rsw+calid pus cells and normal cnnlmcnsal llnrni Shc was given gcntamicin and mcrronidazolh but did not inlprnrc. :11icri 2 Jacs. Srrzp pnrwnnrnirn t\'aa'isnluted front hhxxll \,uhlur: IScn>rvll.rnicillin was given and thcrcarti:r, shc recovered qui+klc.'11hrJIPCI)'appr:ucJ nornlal when rcntatt•cd1? davs aftur adntis>inn,. (:arr .?:-:1 -16nxar-nllll anman \oith mild ntitral stcnosis \vas, aJrnittrd .cirh a i7 Jnt hi.urrr++l aE1 kmtinal irain:rnJ Jiirrrhuc:+. She was ht'Tprocnsicc \oith ilinic:d signs nf'peritnnitisf laparottslnc conlirmcd peritonitis hut did not reveal its cause. I lo\vcvur, Srr.p prriroranri.vr was latur gru+\•n ftom'huth pcritoncalllluid and blood!, r)rsl.itc antihintic truaran.nt acutc renal failurc and.ardiac failurc'. Jha•clol+cJ unJ chc JicJ H Javs attcr :Idmis!ciun. \ci ropsc rc\•allud a hiusvnuatl• tne.rus. In anr horn Ihcrc:\cas a'I)alknn'shirlJ IL"CD. .rd!Jecnl nva smaJl inlat.thJ I ibrt+id.-I-his 1lYa. a rod'leducent typc. had hcun linud af least .1 ccJrx prcniuush'': Although there was na nlieross,opic, rvndencl• ol cndnnwtrims: hilutcr:ll salpingitis was prc..cnl. •ftinrc.c ts nrtvriifimre nfl.ncunxmia. In,ltn iaxc +cas Sir:f pn: unanr.rc i 71aleJlfrnrm the gcnital tra:tl andlanh' in..a.r 21wasl'h.r,•cviJim.'cof mrtritis: Dcsritethic; i1',is Jillicuh to disuount the pra•scnae ut thc IL'(I:D. Unla' h4"t,oHirilish women agCJ 3(1+511 vsc an I l;(:IV1ll all tcomcn in i group arccyualli•:nriskt7lj+nnunxwtx Jlpuritnnitisthcpro(iahilitcoflall three cases in: our scrics hcing in womcn using an ll:'L:D is 0•(H1t1216'. Tiis indicates a highly signilicant:assoiiationbot+i IIL'CD usagc'and pnounx+aoccal pcritoniuis: \C'c, knu.rof anlc. 1prctsiousI caswrc{lorti ufpncunx?coc.al poritonllie in a tcontanusinp an Il!'l:D((I LiprrcAoopflitenl 2\'cars before the inflrrion),` but: of several cases of pneunxxc7ccal cndomctritis and pcritonitis during, prognanzV , and the pucrperium. " Thr pneunx+eoccus is often ffsund in the L7h..\s/•..J.I-,. It: + :.IIlrlbn IIL.\t.rr.n•c.l'1'xr:~.nrnriry.runw...,..Iln.nnmm,........r.J.nh.n I+:I:clt \r tn.n,nnr...:a ,l (i-:1r70. SS: Up-.r1 \u.~..1.1111. lldn,t:Ait rM:.rrnn,lnrw, n.rr:rJh:J..rrnt p,rtn.n..,'.nJqhrpw~rrsr.um .1. 7VI+.e., (i..:..f'InrY.,)S; t Itrndrn- hl. San.k \1.4. Ste..n M1..r J: Spr.a.7 Px.:-w•,ur mf,m:lw+a- C.rr.,t. r n.. +rul Jun,lwl,nn N~.rrprs I 1+4.•r 172: 55-n1 677 orophar4•nxt but Inot in the adult fcmalc gcnital Itract." An IL•CD or placcntal it issuacould'provide a sanetuaq• for pneumococei borne ;i n thc: blood from the oropharvnx; or,he lung, befbre invasionofthe pcrituncal cavity. 1'nuumococcal perilonitis ascociatcd with an ll''CD1is clcarl' v von• rarc: Failurctotrcat it promptlv cou1111howcccr,havctragicr4•sulvs: \1'c suggcsl that am• woman using an ILYCD who presents with pcriluniris a'iuhout an oM'ious'sause should hc given antibiotics with, actinil\' :rgainst Srr;p prrnu.hmiac (cg; a penicillin or ccl7halns(\orii7); lliis advice might appll•'particularle I'ur n•om.n over 30 \rltosi• Ill'CD had hcrn:fittldnx.nthsnr vcars carlier. t .p.nmrnr nu.kdwul \Lanh,..XY:.. ~taJn'+1 \MrJ. L' n rcer+n e, ni'. R', r m,nt h- HnnnngWmHl1S_1rJ. puhlr: 1 trAUh 1 ~Arur.- . l.. D. Glfl't.R' F...r.Rhrmunth'umlh..prtal I\..1:. (a+llt'Iwa1A,\t ntrut mcnr o nI'sr holdKn~: ESaRummphsmllropiutl C..W. El)K1iitUS' LUNG'CANCER A'ND PASSINE:'SAilOK1NGc CONCLUSION OF'GREEKSTiIIDY StR,-Thc notion that passive smoking;ma,v increase the risk of lung cancer has been supported be, the results of two c pidemiological studies specifially designed to explore'the issui while a third° revealed a positiive but not signifoant and!dose- u nrelated iassociation. Positive results have also beon reporsed'from Pennsy)vania lla' and'Gerrna ny; " but no associarion wu: found lin n study, in Hong Kong.ta' Tihe association has been considered credible, on empirical and theoretical grounds,1D' but a L.aAarr editoriall t'has summed up ithr,situation by saying ,thaCthe message of these swdics"isnot that cpidemiologists and uthers have proved an associat ion .,. . but ohangctn i ng;proof mao not be as difl icu(t as it ionce sccnxJ". \'lost of the eontroucrso was generated bv the simultaneous publication of thc Greek' and Japanesc" studics:,Both ha\•e been criticiscd. and Rirapama has responded for the study in Japan.ll'Is The Grcok sludr.\'ascriti¢is\rl(ba• ourscl+•cs ' and othcrs)bccausc of the small numbcr of subioets, hccausc sc+ural tumours, lacked histnlogi:al oort/irntatitm, and lx•:ausc controls and cus.•s were liom Jilllrcutt hu,srit:llc, The Greek sludc has now hen cs+nciudcJ (in r\" k~*s q7rtdi•sst+rial ths•sis: L'i7ilxr:aitn, ol :\I'hens). A(t hough doubt must rrnuin ahaut thc histnlocical e\'idrncc and hospital dilli,ronccs Ihcrc are notc twice as nuns• cass•s' and i(N'S• more conrrobsc tho results:rcmain suhsfunliitllc th.'samrr. I n"_.,.nn.,n w n h a liiul.6ncoo.u.ai hme'.: mror v licIil h~n aJi n...ve: nw.nu aBwll;.:+.un.nr.,....JhnnoJ ru Ow rlinc, lurunr c.lw•.t':anrmr :'.1:Iwn.:, .. r. mWr+~cw.Jticn..xn Soplrn,tvv. IH~:U and Ip.:o:nttir.1lv.F;. loicrh;r s.ah`il rl.an tla- llnsl,vulltiy l1nM,p.rcJ,cI)u.•rJ.rs.:\rhrm:.li..nr Ihcc»mr.aruin4:\thcnsa,th'c.cav.: l.~s:e ind . nr.,l. w.,, m:rr. w-,,cJ. hrnce an+c hhi.wun ..j„+.and.. 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. THELANCET,SEPrEMBER 1'7;1983 678', S•\t(eK7SG 11.1611rS OF IICS'B.ANDS nF \QN:SStOKIXG'W(7:\SF.\'wlTll Ut'\'C4_1 tiC,ER'.AYni(1F \'t?.-WaKt:4lt Q1VTROt. t('N:NE3: (:iparo;tre'psrd:rv(rurrcno .mnknrs) ', ( rnup \on~smn+ker Fs-.mnWrt. 1-In'111 ?tl 'I-Nt 11~` rntal 1 unC c~e't Ifi - ! 22 . ,. ¢ ~ _ n I ( mrrnl4' It79 15 Iri_i a(Y_ 1 , . q RR'• - _ I•ol t-9. I >:.t 1 l.-l • Rerrne. rn4'-rrm nf rnk ol auna.•.n.:r ,mnnR'.,,mcn'+-.MMe hu.n,nJi Nrlon7(. rn, a rynwwlw •rmtmR carRnr., rn rhw amnng -men +M.e- hlu,NnJ..+rr nnn..mn4en. ; i(rnur trrndl • n-:: p,ff-in:+hnur o+nl. The tabk, increases afie credibility, of the h3Tot'hesis implicating, passive',smoking as,a faetor iniung cancer. Given thrsmall siie'of the relative rnsk' and the many potential sources ofbim, rmsingle study, will be able to provideoonvincing cvidence for or against this's hypothesis; only the convergence ofresults from difTeront studies in diCFerent populations'will,perrnit,a reasonably sound'eonclusion: We mnsider'the Athensstudy'a step in this direction: This studywas supportcd principallc'by ahe'.Greck Jlinislry of. HeahA. thpenmenr mf HT{ienr end EpidemiologF. l'ni.miryer~Arhem• Athene 11SII7;Grette;, and ilkpenmem sf Epidemisbpy , Hlr.nd'Scainet inf Tublk Healtlh,.. Nmron,.anueMr.rers. CSA DIMITiR105 TRIQHDPODUOS' AN~\A XAtaTDIDI LACKAS~ SRA'R'RDS' GI:AStSOW'CO'MA' SCALE: TO SUPN OR' NOT TO SUM?' SIR,-The method for assessingpatients' with~ impaired consciousness that we described almost a1decade ago' has been uideh accepted, and in many'cemres the cye, verbal, and motor components aresummed.2 Totals'~up to 8'relate'to patients in~coma with no eye opening or verbal responses;,re/lccting changes in motor response; scores from'9'to~1'5 depend more upon eye opening and verbal responses: JanineJaggcr and her colleagues Quly, 9, p 97) doubt ifeye and verbal Iresponscs add predictive inftirmation. Thcyy studied the short-termoutcome in ihcad-injurcd patients assessed on admission only, Not surprisingly, t hey fbu nd t he motor'responscs'to be most,infovmative;,patients who, on admission,show cyc'opcning, and'comprehensib)evcrbaliresponscs ougtit'not to die. Death can be expected only amongst patients alncady in: coma due to sevcrcc est amlished brain damage. Such patient s'would ha(e no cyc opening and no comprehensible verbal responsesao that',their comsscorca would depend upon the molor response:. Changes in the c_ve and,verhal responses, and'thus higher overall scores, are useful in discriminating brnsr'on patients wilh less sceeMi mpai ,mon t of eonsciousness. All hou gh t hcsc pa t i e nt s wrou ld he expected to surn•ii;c, Ihis, nur be' with differing dlgrecs af disability- The Charlottesville group themselves found that increasing scores in the'9-1 i range (reflecting improving cve and I verbal performances) are associated with a doubling of the rate of c(xol recosmrv in survivors of head iniun•,t' Furahcrmorr;, eorrelations have been established across the+eh'olr rangc'ofthre eoma: score with cerebral n7etaholic rate for owgtin,' evoked potential studics,S and hrochemcal,indices of hrain damagc.h I l..+•';r Ivt4: Irnn,-u a.Wll,n¢.up,rR u8,em. c,,,•...I:a, \:~.i.v M•IV;v-j~,hunrlt: 11-1n , X-lXW. (,nrd.mA. 14rni It..1.nr,I.'1\(,.kr,r, n,:.d,m~ur,-,.••mCAr~nc rM, I,n~,..t yvc.lnum~,y Nnn nr.um. .\r.v+..•.•~•..19'1;. ,11: I11 r i 1 1 1.neein t'0-titnrrr(liT:1:(+Mnl'atl,Rru.cn.l.Limnn,rmunlt.\1•r,npr,r,h•~h, rulure snneJw~no+,,.nJm.n.ermenr~o(:'h-~wlirn,ur,(;L..1'rwn,,,.r Ivr:.2l: eIKWr...l•.rlinl. Kcnnre, 1- F'nIi. N1; lnne...i- T.rnJar (iT1 F.+•leJ pMCmuh ,.n<rr nr+•t'~i naM„ .nj rrlaron, rn oui<nm, 1.~'r..N. „ I teyr:9E- .\naM A+: .: aalar: RnE:,9rerd AE 1,' En,xmucehenw.:m +rrumend~ce.ebrwp,nalinuid m rrurNKrcJ,mun.: ),.\'n.o,.•(199;I;1ac.?7-17 Head-iniured patiems,may change rapidly a/ter admission, and thc'cs'c a nd ve rbal responses are uscfu l i n asscssi ng i mp rovcmcn t or deterioration to shosc svhcther aipatient is iis eoma and hou^long he romainseomatnsc:,Scores obtained during the first few daysaftcr admiss^on reveal much more about prognosis than do admission scores- Thr analysrs uscd by the Charlottesvillr,group is not'u'ell suited to comparing the relative predictive power of diRorent clinical fcotures and can exaggerate minor dilTerences- \tiorcosrr„thes' included inforntation a(iout pupil responses,and about a hacmatonu u,hichcould nothavc becn knotvmat the tinx'ofadmission.l-enthcti' have previously demonstrated correlations between higher coma scores and decreasing Jrequenty, of abnormal pupil responses and CT scan abnormalities in moderately injured patients. Because of this, the' inclusion ofltlicse features rmy have masked the' information provided by, the rs•c and verbal responses. Thcir anahysis should, have beea restricted to the three aspects of the coma scalt. They would then,have found= that knowledge of the eye and vcrbal~ responses in addition,to the motor response, does convev extra information, whether'tlie t'hrce,responses areconsidered separately or summed. Although we cannot accept the Charlottesville group's reservations about the value of the eyp'and verbal components there are limitations inherent in the surtvnation,of the theee'responses. This step assumes'an equal'weighting for the,three responses. 41ore importantly, the information conveyed,by'the coma score is less than that contained in the three responses separately:j'? This' is because the same score auy be,tnade up in differentways:,Indeed, in Glasgow'patients under treatmentare'always described byahe three separate responses and never,by the,total. Thetotal score is merely a convenient method for summarising data, especialls• for'a serics of patients: Therefore, while u7e do not'favourits use in day~to+dag clinical practice, we frnd no rcason to doubt'that,inu•ill continue to bc'used widely in the analvsis and reporting of a series of patiencs with head injur'i('s or other, forms of acute brain damagc:. 1 n, u r n~.• . d i.' c u n,h •b: al ISa v nc c,: . ,mlhrrn 6;cnerul H,~pmil. r'fF Gt(rtll:an't TE.%sD.nt.r BRVALV JF:V.ETT1.I11t:\:V \!l'KN:-tn~ G(nRDOVNlf'KR.'1A' CULT'URED EPIDERM'AL CELLS AMD'BUR(+iS' Silc,-\\-r,rrad the article br Dr Hefton and colleagues (tlug 20, p •i28).ciih interest becausc:fbnsome'time.ee'have'beon studying' both humanepidcrmal cell culture'and,methods for stimul4ting the rr-epithelialisation oflnon-tiealing ulcers. Before those caring for burns patients rush out to buvan epidermallcelltulturc kit a not'eof' caution should be sounded. It took' mant• vears before human epidermal cells couldl be cultivatcd regularly in vitro. TF7c techniques require considerabl'r sk'i1l and rxperiencr to have consistent success even with a feeder layer of rrwuse dcrived 3T3 culls;',togroYC crdls fiom cadaver skin (how long after death sce'are not told) sl'ithouta feeder lal•cr is psaise.oorthp• bucnot within the grasp of many other laboratories:. With the ss'stem used bv Flefion ea al, based on the studies of Eisinger et alja there docs mot appearto be an iincrease inthe number ufrpiddrmal'crlls. The total numberofcells in culture after 25 dhys is liss Qian the number ofcells secdedatday '0(see fig 2 in£isingcr ct al). This would imply that the sYstem' as a whole has Ihee disadvantage that an,area of cadas•erskin equal lin arra to the site to he' covered would be:required for grafting: On the other hand the 3?I13 6broblusr spstem~usrd by UConnor.et al° is capable of a considerable increase in'tho numbrr ofeclls in vitro. Unless Heflon : I.nu<uR.lYadnmKpn.,nJ.muKr,aticrhr.dm~urc /Nrn-C+l/Y'Kc.w./•oraldviviOi, IWi-hMr tl: Enrnrer \I„1.rr )S;,Ilihon l.\(;.Darcrn,r.ue.Z, ChiwJlr''.-de11>rrrn E.. Iluman rpdermd adl ;utturo' (rtanh and Jdrerrnrurwnm. rhe abxnct of'-0rrmd compon<na+ rn4 m<d,u+n ~ wpplrmenn. P.a Nad Arud Sn USA r974 71: Sfto-e~ 9. (Y'Connur NE,.VvlNtenJE• BsnY+-Schefel Si Kehlnde (')• Gretn H. GieBmrofbvrns -rthcutrvedrpnhrliumprep>rrd!6omuurologowepidermalerlh..Laero I9a1;,: 7s-7a.