439
Immunoblotting patterns in experiments designed to detect CSL antibodies in CSF of patients with various neurological diseases. (a) Amido-black protein stain of partly purified CSL as antigen. Bands at 31 5,33, and 45 kD are
characteristic.
(b) Staining obtained by omitting CSF as first antibody and using labelled goat anti-human antibodies as second antibody. (c) Pattern obtained with CSF patients with meningeal haemorrhage due to mechanical trauma; note background staining with no defined bands. (d) and (g) Immunodetection of CSL bands using CSF of patients with multiple selerosis as source of CSL antibody. Stained CSL subunits vary from one patient to another, 31 5 kD band being revealed in (d) 1-3 and 45 kD in (d) 4-8 ; in some cases, 31and 33 kD subunits were strongly stained, with a different pattern of staining for 45 kD. (e) and (f) Same experiments with CSF from patients with neurological diseases other than multiple selerosis (non-infectious diseases not affecting blood-brain barrier in [e] and viral meningitis in [f]).In four cases band at 67 kD was immunostained. In one patient, this band was observed during acute phase only. Bands at 40 and 27 kD were detected in some cases. Arrows indicate position of molecular weight markers.
Quantitative differences in CSL antibodies in CSF are evident and not necessarily related to the protein concentration of CSF. Measurement of anti-CSL is possible, provided samples are not denatured by storage or handling. Our preliminary results with anti-CSL studies in plasma indicate high levels of CSL antibody in the plasma of patients having CSL antibody in the CSF but it is too soon to calculate the specificity and the sensitivity of this approach as a test for multiple selerosis on plasma or
serum.
CN RS Neurochemistry Centre and INSERM U44, 5 rue Blaise Pascal, 67084 Strasbourg, France
J.-P. ZANETTA
Cyclosporin treatment for severe active ulcerative colitis SIR,-We read with great pleasure Dr Lichtiger and Professor Present’s report (July 7, p 16) of the use of cyclosporin in the treatment of severe ulcerative colitis. We would draw attention to our
experience.
Between 1986 and 1989,10 patients with severe ulcerative colitis who were refractory to standard medical treatment (methylprednisolone 40 mg/day intramuscularly, hydrocortisone or 5-acetylsalicylic acid suppositories, total parenteral nutrition, and antibiotics) and were therefore candidates for surgical treatment were given cyclosporin according to an open protocol. In 2 men and 3 women (aged 27-40 years), cyclosporin was given orally at a mean dose of 8mg/kg daily for 5-6 weeks. In the other 5 patients (1 male, 4 female, 13-45), cyclosporin 4 mg/kg daily was given intravenously for at least 10 days. In the first group clinical condition greatly improved (substantial reduction of the number of daily defecations, disappearance of blood from faeces) after a mean of 4 weeks, and there was a striking reduction in the degree of inflammatory activity. Plasma cyclosporin concentrations remained within the normal therapeutic range (400-700 mg/ml) in all cases. This allowed the steroid dose to
progressively tanered and eventually discontinued, and cyclosporin was replaced by sulphasalazine. Patients then remained in complete remission for a mean of 3-6 months (range 2-8), after which, however, all patients had severe relapses needing
be
surgery. In 2 of the 5
patients in the second group the addition of cyclosporin to the drug regimen failed to modify the clinical severity of the colitis, and surgery could not be deferred. The other 3 patients showed a progressive clinical improvement after a mean of 7 days on cyclosporin, after which the steroid dose could be tapered and the drug eventually stopped. These 3 patients then received 2 mg/kg daily azathioprine; 2 patients are still in remission after 1 year and 3 months, respectively, whereas the third underwent surgery after 9 months’ follow-up owing to severe, acute exacerbation of ulcerative colitis. These data are in accord with those of Baker and J ewelF and seem to confirm that cyclosporin, whether given orally or parenterally, does not appear to have the capacity to prevent surgical treatment of the severe forms of ulcerative colitis. G. BIANCHI PORRO Gastrointestinal Unit, M. PETRILLO L. Sacco Hospital, S. ARDIZZONE 20157 Milan, Italy 1. Baker K, Jewell DD. Cyclosporin for the treatment of severe inflammatory bowel disease. Aliment Pharmacol Ther 1989; 3: 143-49.
GISSI-2: 10% reduction in mortality with heparin in acute myocardial infarction? SIR,-In GISSI-2 and its international extension (July 14, p 65; July 14, p 71), patients with suspected acute myocardial infarction (MI) were given a fibrinolytic agent and aspirin immediately, and were allocated randomly to receive either no routine anticoagulation or 12 500 U heparin twice daily, starting 12 h after the beginning of fibrinolytic infusion and continuing until hospital discharge. During the first 12 h, therefore, anticoagulant treatment in the "no heparin" and "heparin" groups should have been similar, and consequently any differences in mortality during this time are likely
440
be due solely to chance (323 deaths known to be within 12 h among 10 407 "no heparin" patients vs 336 among 10 361 "heparin" patients; NS). After 12 h, however, when the heparin injections should have begun, any differences in mortality could be due to anticoagulant treatment. In this later period, heparin was associated with a statistically significant (2 p < 0-05) 11 % (SD 6) reduction in mortality (606 "no heparin" deaths vs 537 "heparin" deaths), an effect similar in size to that seen in an overview1 of all previous trials of anticoagulant therapy in suspected acute MI. ISIS-3, which also compares aspirin alone with aspirin plus heparin (the same heparin regimen as in GISSI-2, but starting at 4 h and continuing for 7 days or until discharge if earlier), should provide data on an additional 50 000 randomised patients by early 1991. This will allow more reliable assessment of the size of any mortality benefit of routine anticoagulation in patients with suspected acute MI who are already receiving fibrinolytic and to
antiplatelet therapy. Clinical Trial Service Unit and ICRF Cancer Studies Unit, Radcliffe Infirmary, Oxford OX2 6HE, UK
RORY COLLINS MARCUS FLATHER RICHARD PETO
1. MacMahon S, Collins R, Knight C,
et al. Reduction in major morbidity and mortality by heparin in acute myocardial infarction. Circulation 1988; 78: 11-98.
Treatment of testicular cancer in Poland SIR,-Dr Boyle and Dr Kaye, who have published in Cancer Surveys (1990; 8, no 3) a paper, The Impact of Chemotherapy in Germ Cell Tumours, discussed in your letter pages (April 28, p 1033) testicular cancer in Central and Eastern Europe. I agree with the emphasis on the contribution that new forms of management (chemotherapy containing cisplatin plus surgery) have made to improvements in results in patients with testicular cancer, but I cannot agree with the conclusion that in Poland mortality from this tumour remains higher than might be expected if modern therapy strategies were being used. Boyle and Kaye compared only two time points and this may be the reason for their misleading conclusion. In Poland modern treatments were introduced from the late 1970s. Observations on more than 500 patients treated at the Cancer Centre, Warsaw, during the past decade show that the probability of 5-year survival for all patients with testicular cancer is greater than 80%.1 Outside this centre improvement has been significant but less impressive, probably because early diagnosis is less likely outside Warsaw. Incidence and mortality rates for testicular cancer in Poland (supplied by the department of cancer control and epidemiology, National Cancer Registry) are: Incidence
Mortality
Standardised
Standardised rate
rate
Year 1979 1980
1981 1982 1983 1984 1985 1986 1987
1988
No 285 330 318 371 349 395 414 494 425
(/ 1OS)
%*
1-5 1-7
0-9 (21) 1-0 (18) 0-9(17) 1-1 (17) 0 9 (18) 1’0(16) 10 76; 1-2 (15) 1-0 7
1-6 1-9 1-8 1-9 2-0 2-4 2-0
No 131 164 196 179 191
......
shown
m
M. Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Findera 101, Poland
147 126 158 158 172 Italic type
(/1()5)
%*
0-7 0-8 1-0 09 9 1-0 07 7 0-6 0-8 0-8 0-8
04 0-5(20) 0-6(18) 0-5 (19) 0-59; 0’4(19) 0-3 9; 0-4
Outbreaks of
drug-resistant tuberculosis at AIDS centre
SIR,-We have reviewed data on the resistance to isoniazid and rifampin (rifampicin) of Mycobacterium tuberculosis isolates among patients registered as having culture-proven tuberculosis in Dade County, Florida, in 1989. In almost all cases, drug tests were done at the State laboratory on initial (pre-treatment) positive culture specimens. Results were analysed by HIV antibody status and reporting source (table). Among 372 patients tested the frequency of resistance to isoniazid, rifampicin, and both isoniazid and rifampicin was 70%, 4-1%, and 5-7%, respectively. The high frequency of resistance to rifampicin, and resistance to both isoniazid and rifampicin especially, was very worrying. In contrast to patients with isoniazid-resistant organisms most patients with rifamptcmresistant tubercle bacilli were HIV seropositive and all but 1 were reported from one medical centre, where the problem was of recent onset. Among over 1200 patients who had had drug-susceptibility tests done at this centre from 1980 to 1987, resistance to rifampicin and rifampicin plus isoniazid averaged only 0-9% (range 0-2%) and 0.3% (0-1%), respectively.’ This unusual pattern of an abrupt onset of primary isoniazid and rifampicin resistance in a large-number of patients (most were HIV infected and immunosuppressed) from a single centre suggests that the cause, at least in part, was recent transmission. For example, among five household contacts of a woman with AIDS and smear positive pulmonary tuberculosis, her two youngest children aged 31 and 5 years (both HIV seropositive with AIDS) and her
57-year-old
mother
(HIV seronegative and initially tuberculin negative) acquired pulmonary tuberculosis resistant to isoniazid and rifampicin within 5 months of each other; her two eldest children, aged 6 and 9 (both HIV seronegative) converted on tuberculin skin testing several months later and remain well. Among the 25 HIV seropositive patients with rifampicin or isoniazid-rifampicin resistant organisms (table), 19 (76%) had previously attended the medical centre for AIDS-related problems and had fulfilled criteria for AIDS from 1 to 25 months (mean 9 months) before the diagnosis of tuberculosis. This late appearance of tuberculosis among patients with AIDS is unusuaf and supports recent transmission. Phage-typing done on M tuberculosis isolates from 4 with isoniazid/rifampicin and isoniazid resistant tuberculosis proved that at least these cases (with identical phage patterns) were interrelated. Drug-resistant tuberculosis could spread rapidly among HIV immunosuppressed populations for several reasons. HIV-infected intravenous drug abusers and people from countries known to have a high rate of tuberculosis may also have a high rate of drug resistance. The close contacts of HIV-infected patients are often HIV infected and immunosuppressed themselves (eg, sexual partners, young children, drug abusers, and other patients attending AIDS centres). HIV-infected contacts are likely to acquire tuberculosis soon after an exposure and thus become infecters themselves.3 Previous tuberculosis infection or
patients
DRUG RESISTANCE
(19)
0-4 0-49
GRZEGORZ MADEJ
These data are available in English1 and Polish.2-4
1. Madej G. Early results on modification of combined modality treatment (chemotherapy & surgery) for testicular cancer. Oncology 1988; 45: 137-40. 2. Madej G. Combined programme of treatment in patients with nonseminoma of the testis (in Polish). Pol Tyg Lek 1982; 24/25: 705. 3. Madej G. Combined (chemotherapy & surgery) radical treatment of patients with nonseminoma of the testis (in Polish). Nowotwory 1984; 3: 254. 4. Madej G, et al. Retroperitoneal lymph node dissection in the treatment of patients with nonseminoma of the testis (in Polish). Nowotwory 1984; 4: 335.
Figures m rtalic type denote percentages of those with susceptibility tests reported *268 reported from one medical centre of whom 44% were H IV seropositive and 885 had drug susceptibility tests reported. 159 patients reported from 53 other sources county wide, and of these 11% were HIV seropositive and 86% had drug susceptibility tests reported Whole numbers in square brackets refer to this centre t7 patients also had resistance to ethambutol, 6 were H IV seropositive
Immunoblotting patterns in experiments designed to detect CSL antibodies in CSF of patients with various neurological diseases. (a) Amido-black protein stain of partly purified CSL as antigen. Bands at 31 5,33, and 45 kD are
characteristic.
(b) Staining obtained by omitting CSF as first antibody and using labelled goat anti-human antibodies as second antibody. (c) Pattern obtained with CSF patients with meningeal haemorrhage due to mechanical trauma; note background staining with no defined bands. (d) and (g) Immunodetection of CSL bands using CSF of patients with multiple selerosis as source of CSL antibody. Stained CSL subunits vary from one patient to another, 31 5 kD band being revealed in (d) 1-3 and 45 kD in (d) 4-8 ; in some cases, 31and 33 kD subunits were strongly stained, with a different pattern of staining for 45 kD. (e) and (f) Same experiments with CSF from patients with neurological diseases other than multiple selerosis (non-infectious diseases not affecting blood-brain barrier in [e] and viral meningitis in [f]).In four cases band at 67 kD was immunostained. In one patient, this band was observed during acute phase only. Bands at 40 and 27 kD were detected in some cases. Arrows indicate position of molecular weight markers.
Quantitative differences in CSL antibodies in CSF are evident and not necessarily related to the protein concentration of CSF. Measurement of anti-CSL is possible, provided samples are not denatured by storage or handling. Our preliminary results with anti-CSL studies in plasma indicate high levels of CSL antibody in the plasma of patients having CSL antibody in the CSF but it is too soon to calculate the specificity and the sensitivity of this approach as a test for multiple selerosis on plasma or
serum.
CN RS Neurochemistry Centre and INSERM U44, 5 rue Blaise Pascal, 67084 Strasbourg, France
J.-P. ZANETTA
Cyclosporin treatment for severe active ulcerative colitis SIR,-We read with great pleasure Dr Lichtiger and Professor Present’s report (July 7, p 16) of the use of cyclosporin in the treatment of severe ulcerative colitis. We would draw attention to our
experience.
Between 1986 and 1989,10 patients with severe ulcerative colitis who were refractory to standard medical treatment (methylprednisolone 40 mg/day intramuscularly, hydrocortisone or 5-acetylsalicylic acid suppositories, total parenteral nutrition, and antibiotics) and were therefore candidates for surgical treatment were given cyclosporin according to an open protocol. In 2 men and 3 women (aged 27-40 years), cyclosporin was given orally at a mean dose of 8mg/kg daily for 5-6 weeks. In the other 5 patients (1 male, 4 female, 13-45), cyclosporin 4 mg/kg daily was given intravenously for at least 10 days. In the first group clinical condition greatly improved (substantial reduction of the number of daily defecations, disappearance of blood from faeces) after a mean of 4 weeks, and there was a striking reduction in the degree of inflammatory activity. Plasma cyclosporin concentrations remained within the normal therapeutic range (400-700 mg/ml) in all cases. This allowed the steroid dose to
progressively tanered and eventually discontinued, and cyclosporin was replaced by sulphasalazine. Patients then remained in complete remission for a mean of 3-6 months (range 2-8), after which, however, all patients had severe relapses needing
be
surgery. In 2 of the 5
patients in the second group the addition of cyclosporin to the drug regimen failed to modify the clinical severity of the colitis, and surgery could not be deferred. The other 3 patients showed a progressive clinical improvement after a mean of 7 days on cyclosporin, after which the steroid dose could be tapered and the drug eventually stopped. These 3 patients then received 2 mg/kg daily azathioprine; 2 patients are still in remission after 1 year and 3 months, respectively, whereas the third underwent surgery after 9 months’ follow-up owing to severe, acute exacerbation of ulcerative colitis. These data are in accord with those of Baker and J ewelF and seem to confirm that cyclosporin, whether given orally or parenterally, does not appear to have the capacity to prevent surgical treatment of the severe forms of ulcerative colitis. G. BIANCHI PORRO Gastrointestinal Unit, M. PETRILLO L. Sacco Hospital, S. ARDIZZONE 20157 Milan, Italy 1. Baker K, Jewell DD. Cyclosporin for the treatment of severe inflammatory bowel disease. Aliment Pharmacol Ther 1989; 3: 143-49.
GISSI-2: 10% reduction in mortality with heparin in acute myocardial infarction? SIR,-In GISSI-2 and its international extension (July 14, p 65; July 14, p 71), patients with suspected acute myocardial infarction (MI) were given a fibrinolytic agent and aspirin immediately, and were allocated randomly to receive either no routine anticoagulation or 12 500 U heparin twice daily, starting 12 h after the beginning of fibrinolytic infusion and continuing until hospital discharge. During the first 12 h, therefore, anticoagulant treatment in the "no heparin" and "heparin" groups should have been similar, and consequently any differences in mortality during this time are likely
440
be due solely to chance (323 deaths known to be within 12 h among 10 407 "no heparin" patients vs 336 among 10 361 "heparin" patients; NS). After 12 h, however, when the heparin injections should have begun, any differences in mortality could be due to anticoagulant treatment. In this later period, heparin was associated with a statistically significant (2 p < 0-05) 11 % (SD 6) reduction in mortality (606 "no heparin" deaths vs 537 "heparin" deaths), an effect similar in size to that seen in an overview1 of all previous trials of anticoagulant therapy in suspected acute MI. ISIS-3, which also compares aspirin alone with aspirin plus heparin (the same heparin regimen as in GISSI-2, but starting at 4 h and continuing for 7 days or until discharge if earlier), should provide data on an additional 50 000 randomised patients by early 1991. This will allow more reliable assessment of the size of any mortality benefit of routine anticoagulation in patients with suspected acute MI who are already receiving fibrinolytic and to
antiplatelet therapy. Clinical Trial Service Unit and ICRF Cancer Studies Unit, Radcliffe Infirmary, Oxford OX2 6HE, UK
RORY COLLINS MARCUS FLATHER RICHARD PETO
1. MacMahon S, Collins R, Knight C,
et al. Reduction in major morbidity and mortality by heparin in acute myocardial infarction. Circulation 1988; 78: 11-98.
Treatment of testicular cancer in Poland SIR,-Dr Boyle and Dr Kaye, who have published in Cancer Surveys (1990; 8, no 3) a paper, The Impact of Chemotherapy in Germ Cell Tumours, discussed in your letter pages (April 28, p 1033) testicular cancer in Central and Eastern Europe. I agree with the emphasis on the contribution that new forms of management (chemotherapy containing cisplatin plus surgery) have made to improvements in results in patients with testicular cancer, but I cannot agree with the conclusion that in Poland mortality from this tumour remains higher than might be expected if modern therapy strategies were being used. Boyle and Kaye compared only two time points and this may be the reason for their misleading conclusion. In Poland modern treatments were introduced from the late 1970s. Observations on more than 500 patients treated at the Cancer Centre, Warsaw, during the past decade show that the probability of 5-year survival for all patients with testicular cancer is greater than 80%.1 Outside this centre improvement has been significant but less impressive, probably because early diagnosis is less likely outside Warsaw. Incidence and mortality rates for testicular cancer in Poland (supplied by the department of cancer control and epidemiology, National Cancer Registry) are: Incidence
Mortality
Standardised
Standardised rate
rate
Year 1979 1980
1981 1982 1983 1984 1985 1986 1987
1988
No 285 330 318 371 349 395 414 494 425
(/ 1OS)
%*
1-5 1-7
0-9 (21) 1-0 (18) 0-9(17) 1-1 (17) 0 9 (18) 1’0(16) 10 76; 1-2 (15) 1-0 7
1-6 1-9 1-8 1-9 2-0 2-4 2-0
No 131 164 196 179 191
......
shown
m
M. Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Findera 101, Poland
147 126 158 158 172 Italic type
(/1()5)
%*
0-7 0-8 1-0 09 9 1-0 07 7 0-6 0-8 0-8 0-8
04 0-5(20) 0-6(18) 0-5 (19) 0-59; 0’4(19) 0-3 9; 0-4
Outbreaks of
drug-resistant tuberculosis at AIDS centre
SIR,-We have reviewed data on the resistance to isoniazid and rifampin (rifampicin) of Mycobacterium tuberculosis isolates among patients registered as having culture-proven tuberculosis in Dade County, Florida, in 1989. In almost all cases, drug tests were done at the State laboratory on initial (pre-treatment) positive culture specimens. Results were analysed by HIV antibody status and reporting source (table). Among 372 patients tested the frequency of resistance to isoniazid, rifampicin, and both isoniazid and rifampicin was 70%, 4-1%, and 5-7%, respectively. The high frequency of resistance to rifampicin, and resistance to both isoniazid and rifampicin especially, was very worrying. In contrast to patients with isoniazid-resistant organisms most patients with rifamptcmresistant tubercle bacilli were HIV seropositive and all but 1 were reported from one medical centre, where the problem was of recent onset. Among over 1200 patients who had had drug-susceptibility tests done at this centre from 1980 to 1987, resistance to rifampicin and rifampicin plus isoniazid averaged only 0-9% (range 0-2%) and 0.3% (0-1%), respectively.’ This unusual pattern of an abrupt onset of primary isoniazid and rifampicin resistance in a large-number of patients (most were HIV infected and immunosuppressed) from a single centre suggests that the cause, at least in part, was recent transmission. For example, among five household contacts of a woman with AIDS and smear positive pulmonary tuberculosis, her two youngest children aged 31 and 5 years (both HIV seropositive with AIDS) and her
57-year-old
mother
(HIV seronegative and initially tuberculin negative) acquired pulmonary tuberculosis resistant to isoniazid and rifampicin within 5 months of each other; her two eldest children, aged 6 and 9 (both HIV seronegative) converted on tuberculin skin testing several months later and remain well. Among the 25 HIV seropositive patients with rifampicin or isoniazid-rifampicin resistant organisms (table), 19 (76%) had previously attended the medical centre for AIDS-related problems and had fulfilled criteria for AIDS from 1 to 25 months (mean 9 months) before the diagnosis of tuberculosis. This late appearance of tuberculosis among patients with AIDS is unusuaf and supports recent transmission. Phage-typing done on M tuberculosis isolates from 4 with isoniazid/rifampicin and isoniazid resistant tuberculosis proved that at least these cases (with identical phage patterns) were interrelated. Drug-resistant tuberculosis could spread rapidly among HIV immunosuppressed populations for several reasons. HIV-infected intravenous drug abusers and people from countries known to have a high rate of tuberculosis may also have a high rate of drug resistance. The close contacts of HIV-infected patients are often HIV infected and immunosuppressed themselves (eg, sexual partners, young children, drug abusers, and other patients attending AIDS centres). HIV-infected contacts are likely to acquire tuberculosis soon after an exposure and thus become infecters themselves.3 Previous tuberculosis infection or
patients
DRUG RESISTANCE
(19)
0-4 0-49
GRZEGORZ MADEJ
These data are available in English1 and Polish.2-4
1. Madej G. Early results on modification of combined modality treatment (chemotherapy & surgery) for testicular cancer. Oncology 1988; 45: 137-40. 2. Madej G. Combined programme of treatment in patients with nonseminoma of the testis (in Polish). Pol Tyg Lek 1982; 24/25: 705. 3. Madej G. Combined (chemotherapy & surgery) radical treatment of patients with nonseminoma of the testis (in Polish). Nowotwory 1984; 3: 254. 4. Madej G, et al. Retroperitoneal lymph node dissection in the treatment of patients with nonseminoma of the testis (in Polish). Nowotwory 1984; 4: 335.
Figures m rtalic type denote percentages of those with susceptibility tests reported *268 reported from one medical centre of whom 44% were H IV seropositive and 885 had drug susceptibility tests reported. 159 patients reported from 53 other sources county wide, and of these 11% were HIV seropositive and 86% had drug susceptibility tests reported Whole numbers in square brackets refer to this centre t7 patients also had resistance to ethambutol, 6 were H IV seropositive
