632
known, however, that subclinical infection with rotavirus is in adult
of infected infants even in the presence of serum antibody.8 In 2 mothers, eight-fold and thirtytwo-fold rises in milk antibody titres during the post-partum period were accompanied by four-fold rises in serum fluorescent antibody9 titres. Animal studies indicate that ingestion of rotavirus antibody in milk protects the young.’o-iz A better understanding of the immune response to rotavirus may be important in the future control of infantile gastroenteritis. G. CUKOR N. BLACKLOW F. CAPOZZA University of Massachusetts Medical School, Z. PANJVANI and Memorial Hospital, F. BEDNAREK Worcester, Massachusetts 01605, U.S.A. common
contacts
MORE SEROTYPES OF HUMAN ROTAVIRUS
SIR,-We have reported the existence of two serotypes of human rotavirus and indicated the probability of a third.’ Zissis and Lambert2 also found two different serotypes of human rotavirus and have since described children in a day nursery infected with both serotypes at different times.3 Dr Rodriguez and colleagues (July 1, p. 37) described a child infected with one serotype at 12 weeks and a different serotype at 14 months of age. ROTAVIRUS SEROLOGY
These are smaller differences than we reported before, but based on more experiments by different workers.
are
Regional Virus Laboratory, East Birmingham Hospital, Birmingham B9 5ST
T. H. FLEWETT M. E. THOULESS J. N. PILFOLD A. S. BRYDEN
Department of Microbiology and Immunology, Institute of Medical Science, University of São Paulo, Brazil
J. A. N. CANDEIAS
HEPATOBILIARY SCANNING IN JAUNDICE
SIR--May we take issue with the statement in your editorial (Aug. 26, p. 457) referring to the inadequacy of radionuclide scanning with technetium-99m pyridoxylidene glutamate in jaundiced patients. A principal feature of this technique is that it can be applied in the presence of jaundice-indeed it can differentiate, in a high percentage of cases, between obstructive and non-obstructive jaundice. Our experience’ (correct in 31 out of 35 patients) confirms that of others.23 We believe that this simple, safe technique is an advance in the early assessment of jaundiced patients (as well as those with suspected acute cholecystitis) and will save many of these patients from more invasive investigations and even unnecessary laoarotomv. J. O. M. C. CRAIG Departments of Radiology and Surgery, St Mary’s Hospital, London W2 1NY
J. HINTON F. MURPHY G. GLAZER
ACTIVE CHRONIC HEPATITIS
SIR,—Your editorial (Sept. 2, p. 507) does 1975 i
The numbers represent the
reciprocal
of the
serum
dilution
giving
50% reduction in number of fluorescent foci. Sera 720, 146, and 285 were raised in rabbits against human viruses RH, RB, and MB, respectively. a
Serum 136 is a human convalescent virus 101 was obtained.
serum
from which
rota-
patient rota-
We have found another two serotypes, making a total of four. A third rabbit antiserum was raised against a Birmingham human rotavirus, which was neutralised by neither our type 1 nor type 2 rabbit antiserum. The fourth serum is an infant convalescent serum from Instituto da Crianca, H.C., Faculty of Medicine, University of Sao Paulo, Brazil. The rotavirus obtained from this child was not neutralised by types 1, 2, or 3 sera, but lamentably we do not have enough of this virus to raise a serum, although we had enough to do neutralisation tests. The table shows the average of six values obtained for the reciprocal of the serum dilution causing a 50% reduction in fluorescent foci. In each case the titre of the homologous virus and serum is four times the value with the heterologous virus. 8. Kim, H. W., Brandt, C. D., Kapikian, A. Z., Wyatt, R. G., Arrobio, Rodriguez, W. J., Chanock, R. M., Parrott, R. H. J. Am. med. Ass.
J. O., 1977,
238, 404. Blacklow, N. R., Echeverria, P., Smith,
D. H. Infect. Immun. 1976, 13, 1563. 10. Woode, G. N., Jones, J., Bridger, J. Vet. Rec. 1975, 97, 148. 11. Lecce, J. G., King, M. W., Dorsey, W. E. Science, 1978, 199, 777. 12. Snodgrass, D. R., Wells, P. W. Vet. Rec. 1978, 102, 146.
9.
1. 2. 3. 4.
Thouless, M. E., Bryden, A. S., Flewett, T. H. Lancet, 1978, i, 39. Zissis, G., Lambert, J. P. ibid. p. 39. Fonteyne, J., Zissis, G., Lambert, J. P. ibid. p. 983. Rodriguez, W. J., Kim, H. W., Brandt, C. D., Yolken, R. H., Arrobio, J. O., Kapikian, A. Z., Chanock, R. M., Parrott, R. H. ibid. ii, 37.
paper,^and
we
not
refer
to our
opportunity of reporting the patients treated with cyclophospha-
take this
longer term results in our mide and prednisolone. At that time three of the four patients showed complete clinical, biochemical, and histological recovery and the fourth showed considerable improvement in the biochemical evidence of the disease. In all four patients the diagnosis was confirmed by liver-function tests, serum antibodies, and liver biopsy. The first patient, now aged 72, started treatment in March, 1969. This was discontinued in April, 1974, and she has been symptom-free since. On April 17, 1978, serum bilirubin, alkaline phosphatase, thymol turbidity, aspartate aminotransferase (A.S.T., S.G.O.T.), alanine aminotransferase (A.L.T., S.G.P.T.), albumin, and globulin were all normal, and electrophoresis showed a normal pattern. The second patient, now aged 83, started treatment in May, 1969, and all treatment was stopped on May 1, 1975. Liverfunction tests were then normal but, although she was well on Aug. 2, 1976, her liver-function tests showed: bilirubin 9 µmol/l, alkaline phosphatase 51 i.u./l, (37°c), thymol turbidity 0-5 unit, A.S.T. 136 l.u./l A.L.T. 132 t.u./1, albumin 42 g/l, globulin 42 g/1. Electrophoresis: increased gamma-globulin. Treatment was restarted with cyclophosphamide 25 mg daily and prednisolone 2.5mg three times a day. Tests of liver function became normal by Oct. 4, 1976; treatment was stopped on Oct. 17, 1977. She has remained well since and on June 19, 1978 liver-function tests were normal. The third patient, now aged 58, started treatment in May, 1972. She was well on Oct. 8, 1974, with normal liver-function 1. 2.
Murphy, press).
F.
Hinton, J. Craig, J. O. M. C., Glazer, G. Br. J. Surg. (in the
Matolo, N. M., Stadalmk, R. C., Krohn, K. A., Jansholt, A.-L., DeNardo, G. L., Wolfman, E. F. Surgery, 1976, 80, 317. 3. Williams, J. A. R., Baker, R. J., Walsh, J. F., Marion, M. A. Surgery Gynec. Obstet 1977, 144, 525. 4. Pengelly, C. D. R., Jennings, R. C. Practitioner, 1975, 214, 233.
633 was discontinued. She has remained well and her liver-function tests on June 13, 1978, were normal. The fourth patient, now aged 48, started treatment in August, 1973. She is working as an assistant nurse and feels well, but tests of liver function remain abnormal. A liver biopsy on June 8, 1976, showed no abnormality. Treatment with cyclophosphamide 25 mg daily and prednisolone 10 mg daily is being continued, and when seen on July 18, 1978 her liverfunction tests showed: bilirubin 9 p.mol/1, alkaline phosphatase 194 i.u./l, thymol turbidity 1 unit, A.S.T. 55 LU./l, A.L.T. 87 t.u./1, albumin 32 g/1, globulin 29 g/l. Electrophoresis: slight reduction in albumin only. We believe that the combination of cyclophosphamide with adrenocorticosteroids is a valuable method of treatment for active chronic hepatitis and should still be considered as an alternative to therapy with azathioprine and adrenocorticosteroids. None of our patients showed any of the toxic effects of cyclophosphamide found by Gilmore et al. who used larger doses over a short trial period. C. D. R. PENGELLY St Anne’s Hospital,
tests, and treatment
Bowdon, Altrincham, Chesire WA 14 2AQ
R. C. JENNINGS
RESPECT FOR CLASSICS
SIR,-In your issue of July 15you speak of eicosapentaenoic and eicosatetraenoic acids. This spelling has the approval of the Merck Index, but to anyone with a classical background these are "congenital malformations". Twenty in Greek is eikosi ; the final "i" may change to "a" in front of a vowel. But twenty-four and twenty-five are eikositetra and eikosipenta, re-
spectively. The British approved name sulphasomidine (instead of sulphisomidine, as in U.S., German, French, Spanish, and other versions) is also wrong. There is no connection between this drug and soma (Greek for "body"). Sulphisomidine is the isomer of sulphadimidine. A useful analogy is sulphisoxazole which nobody would have dreamt calling sulphasoxazole. The word loci has entered English scientific and medical terminology via genetics and allergology. Locus means "place". In classical Latin its plural, however, is loca and not loci. The latter means "places in books" (e.g., references); sunt plerumque /oc!
scripitis but loca sunt regiones was drummed into the heads of our forebears. Even so, I am familiar with at least one classical quotation (Horace) where places in books, too, are referred to as loca ("loca iam recitata revolvere", "to repeat passages already declaimed"). Thus by using loca scientists may err on the safe side. By wrongly using loci they expose themselves to ridicule, at least in those countries where the classics are still "in" among the educated. When the Merck Index, the British Pharmacopoeia Commision, and medical authors display ignorance of the classical languages should not The Lancet stop them? :M
the lociinscriptis but locasuntregioneswas drummed into
Aachenstrasse 38,
S190 Stolberg, West
H. E. SCHABLIN
Germany
This letter has been shown to the secretary of the Nomenclature Committee, British Pharmacopoeia Commission, whose
reply follows.-ED.L. SIR,-In showing commendable concern for the apparent misappropriation of classical Greek grammar in scientific nomenclature, Mr Schablin has regrettably lost sight of the technical content of the examples he cites. The chemical names eicosatetraenoic and eicosapentaenoic acids have nothing whatever to do with the concept of "twenty-four" and "twenty-five". Both names derive from eicosane, 5.
Gilmore, I. T., Cowan, 1977, 18, A952.
R.
E., Axon, A. T. R., Thompson, R. P. H. Gut,
the International Union of Pure and the parent hydrocarbon substance conApplied Chemistry taining twenty, straight-chain carbon atoms, CH3(CH2)lSCH3. When unsaturated chemical bonds are introduced, the stem of the systematic name changes to -ene, and their number, if more than one, is indicated by the appropriate multiplier, for example tetraene, pentaene. Acids are named by changing -ane or -ene to -anoic or -enoic and adding the word acid. Putting these rules together, the name eicostetraenoic acid emerges and tells the chemist that the substance in question is a C-20 acid containing four double bonds. A vowel is then interposed between thesand t for added euphony and to preserve the identity of each syllable, and perhaps a was deliberately chosen rather thani to avoid the very misinterpretation your correspondent has made. The approved name sulphasomidine makes use of the officially recommended generic stem sulpha- which tells the prescribing physician that the substance in question is an antimicrobial agent of the sulphonamide group and that appropriate precautions should be exercised. No such warning signals are borne by the terms sulphi- or sulpho-, both of which are used in non-proprietary names for substances quite unrelated to the sulphonamides. The synonym sulphisomidine is therefore by way of an exception to the rule and is recognisable as a sulphonamide only by virtue of its overall similarity to the name
the
name
assigned by to
sulphadimidine. Nomenclature Committee, British Pharmacopœia Commission, London W1M 5FT
R. B. TRIGG
DRUG-INDUCED GASTROINTESTINAL BLEEDING
SiR,—The unwary reader might extrapolate Dr Jick and Jane Porter’s calculations of the risk of gastrointestinal bleed-
ing due to drugs (which they claim to be "reasonably accurate and useful") to ordinary individuals (July 8, p. 87). I think this would be a mistake. If, as Jick and Porter suggest, aspirin given alone induces bleeding in 0-3% of hospital medical patients without known predisposing illness, then some rough calculations can be made to determine the expected frequency of such events in ordinary people, if their figures did apply to them. Annual aspirin product rates in the U.K. have been thought to be of the order of 1500 tons per year, enough for nearly 100 tablets per year for everyone in England and Wales. 100 tablets at two tablets four times a day, the usual dosage, is roughly equivalent to a fortnight’s course per head. Jick and Porter do not tell us about the length of treatment on average before bleeding, but let us suppose a fortnight is enough. Assuming most patients with a major bleed are admitted to hospital, then we would expect 0.3% of 50 million annually (for the population of England and Wales) or 150 000. Hospital Activity Analysis data show that 5000 to 7000 people are admitted annually with acute upper gastrointestinal bleeding of uncertain cause. Even if all these events were aspirin induced, which is very unlikely, the figure is still a twentieth to a thirtieth of those derived from their calculations. National aspirin consumption figures (falling) and admissions for bleeding (rising) emphasise that aspirin intake is very1 unlikely to be a prime cause of bleeding of undetermined cause. I prefer to believe, on current evidence, that aspirin can cause major bleeding (but rarely) and look for support in this view, amongst other data, to that of Levy derived from an earlier Boston collaborative drug study on outpatients.2 Levy found that light aspirin use did not appear to predispose to acute bleeding whilst heavy regular use (four or more days per week) did so, but only slightly, the calculated rate attributable being 15 per 100 000 per year. The risk may be very much higher in hospital inpatients and 1. 2.
Langman, M. J. S. Aust. N.Z. Jl Med. 1976, 6, suppl. 1, p. 22. Levy, M. New Engl.J.Med. 1976, 290, 1158.
known, however, that subclinical infection with rotavirus is in adult
of infected infants even in the presence of serum antibody.8 In 2 mothers, eight-fold and thirtytwo-fold rises in milk antibody titres during the post-partum period were accompanied by four-fold rises in serum fluorescent antibody9 titres. Animal studies indicate that ingestion of rotavirus antibody in milk protects the young.’o-iz A better understanding of the immune response to rotavirus may be important in the future control of infantile gastroenteritis. G. CUKOR N. BLACKLOW F. CAPOZZA University of Massachusetts Medical School, Z. PANJVANI and Memorial Hospital, F. BEDNAREK Worcester, Massachusetts 01605, U.S.A. common
contacts
MORE SEROTYPES OF HUMAN ROTAVIRUS
SIR,-We have reported the existence of two serotypes of human rotavirus and indicated the probability of a third.’ Zissis and Lambert2 also found two different serotypes of human rotavirus and have since described children in a day nursery infected with both serotypes at different times.3 Dr Rodriguez and colleagues (July 1, p. 37) described a child infected with one serotype at 12 weeks and a different serotype at 14 months of age. ROTAVIRUS SEROLOGY
These are smaller differences than we reported before, but based on more experiments by different workers.
are
Regional Virus Laboratory, East Birmingham Hospital, Birmingham B9 5ST
T. H. FLEWETT M. E. THOULESS J. N. PILFOLD A. S. BRYDEN
Department of Microbiology and Immunology, Institute of Medical Science, University of São Paulo, Brazil
J. A. N. CANDEIAS
HEPATOBILIARY SCANNING IN JAUNDICE
SIR--May we take issue with the statement in your editorial (Aug. 26, p. 457) referring to the inadequacy of radionuclide scanning with technetium-99m pyridoxylidene glutamate in jaundiced patients. A principal feature of this technique is that it can be applied in the presence of jaundice-indeed it can differentiate, in a high percentage of cases, between obstructive and non-obstructive jaundice. Our experience’ (correct in 31 out of 35 patients) confirms that of others.23 We believe that this simple, safe technique is an advance in the early assessment of jaundiced patients (as well as those with suspected acute cholecystitis) and will save many of these patients from more invasive investigations and even unnecessary laoarotomv. J. O. M. C. CRAIG Departments of Radiology and Surgery, St Mary’s Hospital, London W2 1NY
J. HINTON F. MURPHY G. GLAZER
ACTIVE CHRONIC HEPATITIS
SIR,—Your editorial (Sept. 2, p. 507) does 1975 i
The numbers represent the
reciprocal
of the
serum
dilution
giving
50% reduction in number of fluorescent foci. Sera 720, 146, and 285 were raised in rabbits against human viruses RH, RB, and MB, respectively. a
Serum 136 is a human convalescent virus 101 was obtained.
serum
from which
rota-
patient rota-
We have found another two serotypes, making a total of four. A third rabbit antiserum was raised against a Birmingham human rotavirus, which was neutralised by neither our type 1 nor type 2 rabbit antiserum. The fourth serum is an infant convalescent serum from Instituto da Crianca, H.C., Faculty of Medicine, University of Sao Paulo, Brazil. The rotavirus obtained from this child was not neutralised by types 1, 2, or 3 sera, but lamentably we do not have enough of this virus to raise a serum, although we had enough to do neutralisation tests. The table shows the average of six values obtained for the reciprocal of the serum dilution causing a 50% reduction in fluorescent foci. In each case the titre of the homologous virus and serum is four times the value with the heterologous virus. 8. Kim, H. W., Brandt, C. D., Kapikian, A. Z., Wyatt, R. G., Arrobio, Rodriguez, W. J., Chanock, R. M., Parrott, R. H. J. Am. med. Ass.
J. O., 1977,
238, 404. Blacklow, N. R., Echeverria, P., Smith,
D. H. Infect. Immun. 1976, 13, 1563. 10. Woode, G. N., Jones, J., Bridger, J. Vet. Rec. 1975, 97, 148. 11. Lecce, J. G., King, M. W., Dorsey, W. E. Science, 1978, 199, 777. 12. Snodgrass, D. R., Wells, P. W. Vet. Rec. 1978, 102, 146.
9.
1. 2. 3. 4.
Thouless, M. E., Bryden, A. S., Flewett, T. H. Lancet, 1978, i, 39. Zissis, G., Lambert, J. P. ibid. p. 39. Fonteyne, J., Zissis, G., Lambert, J. P. ibid. p. 983. Rodriguez, W. J., Kim, H. W., Brandt, C. D., Yolken, R. H., Arrobio, J. O., Kapikian, A. Z., Chanock, R. M., Parrott, R. H. ibid. ii, 37.
paper,^and
we
not
refer
to our
opportunity of reporting the patients treated with cyclophospha-
take this
longer term results in our mide and prednisolone. At that time three of the four patients showed complete clinical, biochemical, and histological recovery and the fourth showed considerable improvement in the biochemical evidence of the disease. In all four patients the diagnosis was confirmed by liver-function tests, serum antibodies, and liver biopsy. The first patient, now aged 72, started treatment in March, 1969. This was discontinued in April, 1974, and she has been symptom-free since. On April 17, 1978, serum bilirubin, alkaline phosphatase, thymol turbidity, aspartate aminotransferase (A.S.T., S.G.O.T.), alanine aminotransferase (A.L.T., S.G.P.T.), albumin, and globulin were all normal, and electrophoresis showed a normal pattern. The second patient, now aged 83, started treatment in May, 1969, and all treatment was stopped on May 1, 1975. Liverfunction tests were then normal but, although she was well on Aug. 2, 1976, her liver-function tests showed: bilirubin 9 µmol/l, alkaline phosphatase 51 i.u./l, (37°c), thymol turbidity 0-5 unit, A.S.T. 136 l.u./l A.L.T. 132 t.u./1, albumin 42 g/l, globulin 42 g/1. Electrophoresis: increased gamma-globulin. Treatment was restarted with cyclophosphamide 25 mg daily and prednisolone 2.5mg three times a day. Tests of liver function became normal by Oct. 4, 1976; treatment was stopped on Oct. 17, 1977. She has remained well since and on June 19, 1978 liver-function tests were normal. The third patient, now aged 58, started treatment in May, 1972. She was well on Oct. 8, 1974, with normal liver-function 1. 2.
Murphy, press).
F.
Hinton, J. Craig, J. O. M. C., Glazer, G. Br. J. Surg. (in the
Matolo, N. M., Stadalmk, R. C., Krohn, K. A., Jansholt, A.-L., DeNardo, G. L., Wolfman, E. F. Surgery, 1976, 80, 317. 3. Williams, J. A. R., Baker, R. J., Walsh, J. F., Marion, M. A. Surgery Gynec. Obstet 1977, 144, 525. 4. Pengelly, C. D. R., Jennings, R. C. Practitioner, 1975, 214, 233.
633 was discontinued. She has remained well and her liver-function tests on June 13, 1978, were normal. The fourth patient, now aged 48, started treatment in August, 1973. She is working as an assistant nurse and feels well, but tests of liver function remain abnormal. A liver biopsy on June 8, 1976, showed no abnormality. Treatment with cyclophosphamide 25 mg daily and prednisolone 10 mg daily is being continued, and when seen on July 18, 1978 her liverfunction tests showed: bilirubin 9 p.mol/1, alkaline phosphatase 194 i.u./l, thymol turbidity 1 unit, A.S.T. 55 LU./l, A.L.T. 87 t.u./1, albumin 32 g/1, globulin 29 g/l. Electrophoresis: slight reduction in albumin only. We believe that the combination of cyclophosphamide with adrenocorticosteroids is a valuable method of treatment for active chronic hepatitis and should still be considered as an alternative to therapy with azathioprine and adrenocorticosteroids. None of our patients showed any of the toxic effects of cyclophosphamide found by Gilmore et al. who used larger doses over a short trial period. C. D. R. PENGELLY St Anne’s Hospital,
tests, and treatment
Bowdon, Altrincham, Chesire WA 14 2AQ
R. C. JENNINGS
RESPECT FOR CLASSICS
SIR,-In your issue of July 15you speak of eicosapentaenoic and eicosatetraenoic acids. This spelling has the approval of the Merck Index, but to anyone with a classical background these are "congenital malformations". Twenty in Greek is eikosi ; the final "i" may change to "a" in front of a vowel. But twenty-four and twenty-five are eikositetra and eikosipenta, re-
spectively. The British approved name sulphasomidine (instead of sulphisomidine, as in U.S., German, French, Spanish, and other versions) is also wrong. There is no connection between this drug and soma (Greek for "body"). Sulphisomidine is the isomer of sulphadimidine. A useful analogy is sulphisoxazole which nobody would have dreamt calling sulphasoxazole. The word loci has entered English scientific and medical terminology via genetics and allergology. Locus means "place". In classical Latin its plural, however, is loca and not loci. The latter means "places in books" (e.g., references); sunt plerumque /oc!
scripitis but loca sunt regiones was drummed into the heads of our forebears. Even so, I am familiar with at least one classical quotation (Horace) where places in books, too, are referred to as loca ("loca iam recitata revolvere", "to repeat passages already declaimed"). Thus by using loca scientists may err on the safe side. By wrongly using loci they expose themselves to ridicule, at least in those countries where the classics are still "in" among the educated. When the Merck Index, the British Pharmacopoeia Commision, and medical authors display ignorance of the classical languages should not The Lancet stop them? :M
the lociinscriptis but locasuntregioneswas drummed into
Aachenstrasse 38,
S190 Stolberg, West
H. E. SCHABLIN
Germany
This letter has been shown to the secretary of the Nomenclature Committee, British Pharmacopoeia Commission, whose
reply follows.-ED.L. SIR,-In showing commendable concern for the apparent misappropriation of classical Greek grammar in scientific nomenclature, Mr Schablin has regrettably lost sight of the technical content of the examples he cites. The chemical names eicosatetraenoic and eicosapentaenoic acids have nothing whatever to do with the concept of "twenty-four" and "twenty-five". Both names derive from eicosane, 5.
Gilmore, I. T., Cowan, 1977, 18, A952.
R.
E., Axon, A. T. R., Thompson, R. P. H. Gut,
the International Union of Pure and the parent hydrocarbon substance conApplied Chemistry taining twenty, straight-chain carbon atoms, CH3(CH2)lSCH3. When unsaturated chemical bonds are introduced, the stem of the systematic name changes to -ene, and their number, if more than one, is indicated by the appropriate multiplier, for example tetraene, pentaene. Acids are named by changing -ane or -ene to -anoic or -enoic and adding the word acid. Putting these rules together, the name eicostetraenoic acid emerges and tells the chemist that the substance in question is a C-20 acid containing four double bonds. A vowel is then interposed between thesand t for added euphony and to preserve the identity of each syllable, and perhaps a was deliberately chosen rather thani to avoid the very misinterpretation your correspondent has made. The approved name sulphasomidine makes use of the officially recommended generic stem sulpha- which tells the prescribing physician that the substance in question is an antimicrobial agent of the sulphonamide group and that appropriate precautions should be exercised. No such warning signals are borne by the terms sulphi- or sulpho-, both of which are used in non-proprietary names for substances quite unrelated to the sulphonamides. The synonym sulphisomidine is therefore by way of an exception to the rule and is recognisable as a sulphonamide only by virtue of its overall similarity to the name
the
name
assigned by to
sulphadimidine. Nomenclature Committee, British Pharmacopœia Commission, London W1M 5FT
R. B. TRIGG
DRUG-INDUCED GASTROINTESTINAL BLEEDING
SiR,—The unwary reader might extrapolate Dr Jick and Jane Porter’s calculations of the risk of gastrointestinal bleed-
ing due to drugs (which they claim to be "reasonably accurate and useful") to ordinary individuals (July 8, p. 87). I think this would be a mistake. If, as Jick and Porter suggest, aspirin given alone induces bleeding in 0-3% of hospital medical patients without known predisposing illness, then some rough calculations can be made to determine the expected frequency of such events in ordinary people, if their figures did apply to them. Annual aspirin product rates in the U.K. have been thought to be of the order of 1500 tons per year, enough for nearly 100 tablets per year for everyone in England and Wales. 100 tablets at two tablets four times a day, the usual dosage, is roughly equivalent to a fortnight’s course per head. Jick and Porter do not tell us about the length of treatment on average before bleeding, but let us suppose a fortnight is enough. Assuming most patients with a major bleed are admitted to hospital, then we would expect 0.3% of 50 million annually (for the population of England and Wales) or 150 000. Hospital Activity Analysis data show that 5000 to 7000 people are admitted annually with acute upper gastrointestinal bleeding of uncertain cause. Even if all these events were aspirin induced, which is very unlikely, the figure is still a twentieth to a thirtieth of those derived from their calculations. National aspirin consumption figures (falling) and admissions for bleeding (rising) emphasise that aspirin intake is very1 unlikely to be a prime cause of bleeding of undetermined cause. I prefer to believe, on current evidence, that aspirin can cause major bleeding (but rarely) and look for support in this view, amongst other data, to that of Levy derived from an earlier Boston collaborative drug study on outpatients.2 Levy found that light aspirin use did not appear to predispose to acute bleeding whilst heavy regular use (four or more days per week) did so, but only slightly, the calculated rate attributable being 15 per 100 000 per year. The risk may be very much higher in hospital inpatients and 1. 2.
Langman, M. J. S. Aust. N.Z. Jl Med. 1976, 6, suppl. 1, p. 22. Levy, M. New Engl.J.Med. 1976, 290, 1158.
