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comfort available to our ancestors-a dose of opium bought at the local apothecary’s. We try to convince relatives that what we are doing is for the dying person’s good until they become as confused and callous as ourselves. We, not they, are the culprits, because we should know best what are the chances of survival and prognosis for future disability and suffering. We should be able to explain this to patients, or, more usually and appropriately, to their families, so that

pulmonary tuberculosis were notified between 1986 and 1991 in Spain (N. Martinez, National Centre of Epidemiology, unpublished data). The overall annual incidence was 217 per million for 1991, which is higher than in previous years. The most recent data available from death certificates are for 1988: pulmonary tuberculosis caused 784 deaths and extrapulmonary disease 103,3 of these being in children under 5 years of age (N. Martinez, unpublished data). I believe that the Spanish authorities should not

they can help us in making decisions about when to treat or not, and when we should be prepared to provide euthanasia (by whatever means), if requested. I am sure that Bihari and Mrs Brahams (Sept 26, p 782) are as pleased as I am by the General Medical Council’s decision (Nov 21, p 1283) to allow Dr Cox to remain on the Register. In doing so, I think they represent the feelings of most individualsl and I hope that this action may lead the way to a return to more compassionate

have discontinued BCG vaccination when tuberculosis is not yet under control. Spanish children will be exposed to a higher risk of such infection than their French counterparts, and without the protection of BCG.

medical practice. Directorate of Medicine for the

Elderly,

Hackney Hospital,

euthanasia, as implied.

disturbing is the ignoring of the data you cite. relief and terminal care have improved since the 1988 Clearly pain British Medical Association (BMA) report. The Cox case (see Lancet Sept 26, p 782 and Nov 21, p 1283), tragic and moving as it is, is the exception rather than the rule. Thus these data should suggest support of the BMA report, not abandoning it. You then cite the Dutch experience, touching very gently on the difficulites, and end with a plea to "look again across the North Sea". Indeed an objective look at the Netherlands should provide the strongest argument against liberalising the BMA position. Just a few years ago we were promised rigid adherence to "the persistently expressed wish for truly voluntary euthanasia", a consultation with other physicians, and a careful reporting of each case to the authorities. Clearly, even in so civilised and organised a country as the Netherlands virtually all these barriers have already collapsed. Thousands of patients die by euthanasia each yearl (surely not all can meet the agreed criteria?). There is a minimum of reporting, and involuntary euthanasia, based on a single physician’s decision, is not rare.2 The logic of your argument escapes me. I urge great caution before abandoning some of the principles of the medical profession, the sanctity of human life, and the prohibition of active euthanasia. even more

Faculty of Health Sciences, Ben-Gurion University of the Negev, PO Box 653, 84105 Beer-Sheva-lsrael

SHIMON GLICK

1. Van der Maas

PJ, van Delden JJM, Pijnenbor L, Looman CWN. Euthanasia and other medical decisons concerning the end of life. Lancet 1991; 338: 669-74. 2 Gomez CF. Regulating death: euthanasia and the case of the Netherlands. New York: Free Press, 1991.

BCG vaccination in

Spain

SIR,-Dr Schwoebel and colleagues (Sept 5, p 611) report the

impact of

de trabajo sobre tuberculosis. Consenso nacional para el control de la tuberculosis en España. Med Clin (Barc) 1992, 98: 24-31. 2. Lara L, Lopez A. Manual de tuberculosis en atención primaria en salud. Seville: Consejeria Salud Andalucia, 1989. 1.

Grupo

Re-use of syringes

Britain, USA and the Netherlands. Health

SIR,-As a participant in the last two Appleton conferences cited in your Sept 26 editorial, I should like to make several points. First, in the final document cited the word "consensus" was removed, because clearly no consensus was reached on this and other important points. Ironically, between the last two conferences the previous consensus document was analysed by 150 study groups in 15 countries. Of these groups, consisting of 1450 people, 34% agreed with the statement, "The statutory legalization of the intentional killing of patients is against the public interest", whereas only 24% disagreed. Outside the USA the margin was 44% in favour and only 15% against-hardly a consensus for active But

R. MARTINEZ

M. R. BLISS

London E9 6BE, UK 1. Jennett B. Euthanasia 1990: attitudes in Bull 1991; 49: 176-83.

Microbiology Service, Virgen de las Nieves Hospital, 18012 Granada, Spain

BCG vaccination on tuberculous meningitis in France in

1990, and their observations document the benefit of the programme. In Spain, health authorities have recently issued documents advising against BCG vaccination,1,2 but there are enough data to regard the discontinuation of BCG as premature. 56 385 cases of

SIR,-Dr Kumar’s report from Kerala, India (Nov 9, p 1166), about uncontrolled re-use of single-use syringes draws attention to a point that we made about a similar situation in Romania.l India, in common with much of the developing world, has a far greater tradition of recycling than the "greenest" of wealthier countries. To throw away an apparently workable item-a syringe used once only-seems wasteful, and, indeed, it is wasteful. The system used by WHO/UNICEF in the Expanded Programme on Immunisation (EPI) can be applied to a wider use in health care in areas of limited resources or where delivery systems are unpredictable. It uses syringes that can be sterilised in cheap, portable, multi-fuel autoclaves. This system (catalogue available from UNICEF) has been in use in the EPI in India and worldwide since 1984. When introduced into a new area, the system should be accompanied by training, with monitoring of good practice. It is thus possible to have a safe syringe re-use system, applicable to a wide range of health-care settings, that does not allow used syringes to find their way out onto the market. Laboratory of Hospital Infection, Central Public Health Laboratory, London NW9 5HT, UK Expanded Programme

on

Immunisation,

World Health Organization, Geneva, Switzerland 1. Hoffman PN, Evans P.

P. N. HOFFMAN

Appropriate syringes.

P. EVANS Lancet 1991; 337: 1615-16.

International library exchange system SIR,-Medical libraries in the developing world are in dire need of the material that libraries in the developed world are thinking about discarding. Libraries that are fortunate enough to have duplicates of journals, or that have a chronic shortage of space for their holdings, are often seeking a solution similar to the one initiated by the Library of the World Health Organization. The International Exchange of Duplicate Medical Literature has been operating successfully around the globe for nearly thirty years. We welcome this opportunity to inform readers of The Lancet of its existence and to thank Dr Dugdale (Sept 26, p 796) for drawing attention to this issue. The idea of the Exchange is very simple. Membership is free to libraries in the developed and developing world, and can be requested by sending in the name and address of the library to the WHO library address.Members of the Exchange send lists of their surplus books and periodicals to the WHO library, which reproduces the lists and sends them on to all members. Material older than five years is not accepted unless it is a classic reference work. Libraries request material directly from the donor library, and the donor library agrees to pay the postage. Libraries in developed countries can also request material from the lists, and can thus fill gaps in their collections. The advantage of this system is that *Direct fax: (41 22) 788 1836.

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libraries select what they need instead of receiving donations that may not be relevant to their needs. The demand is very great from requesting libraries and the supply is diminishing from donor libraries. We therefore encourage to seriously consider becoming a member of this The WHO library is also a member of the Exchange, and we find it gratifying that duplicates of our books and periodicals are immediately requested by libraries as soon as the lists are sent out. The Exchange facilitates a constant circulation of information in the health sciences before it has a chance to become outdated.

librarians

exchange.

Office of Library and Health Literature Services, World Health Organization, 1211 Geneva 27, Switzerland

YVONNE GRANDBOIS

ACE inhibitors and LDL-apheresis with dextran sulphate adsorption SIR,-Treatment of patients with severe hypercholesterolaemia extracorporeal removal of low-density lipoproteins (LDLapheresis) with dextran sulphate columns is well tolerated, with

according to our experience in almost 800 treatments in 21 patients in the LDL-apheresis atherosclerosis regression study (LAARS). Professor Olbricht and colleagues (Oct 10, p 908) describe an anaphylactoid reaction in 2 patients during the first treatment with this type of LDL-apheresis, characterised by flushing, dyspnoea, low blood pressure, and bradycardia, which they attribute to the concomitant use of an angiotensin-converting enzyme (ACE) inhibitor. They postulate that this reaction is due to a decreased bradykinin catabolism caused by the drug, together with an increased bradykinin production due to stimulation of blood cells by the negatively charged dextran sulphate. We report a patient who had been treated without adverse events for over 1 year, in whom an atypical reaction during apheresis was noted after treatment with an ACE inhibitor was instituted. The patient was a 44-year-old man with severe primary hypercholesterolaemia (9-1 mmol/1) who had had two myocardial infarctions at age 35 and 42 years. Drug treatment included simvastatin, metoprolol tartrate, and aspirin. From April, 1991, he received biweekly LDL-apheresis, which was uneventful for more than 30 treatments up to July, 1992. Captopril was then added to the regimen for mild congestive heart failure. While he was on 6-25 mg and 12-5 mg twice daily, no adverse events took place during apheresis. After a dose increase to 25 mg twice daily, he had nausea, slight drop in blood pressure, and bradycardia, which resolved spontaneously in the supine position; thereafter the procedure was completed without problems. During the next treatment, while on the same dose of captopril, he had nausea, pounding headache, and flushing of head and neck, without symptoms of dyspnoea, stridor, urticaria, blood pressure drop, or bradycardia. These symptoms started the moment that plasma from the cholesterol-binding column was returned to the patient, and subsided within minutes after the procedure was stopped. Bacterial cultures were all negative. Since the previous 30 treatments had been without adverse effects, it was decided to rechallenge the patient, during which an identical reaction was seen. Clemastine or corticosteroids intravenously had no effect, but symptoms subsided within a few minutes when treatment was stopped. Once it was recognised that this reaction could be related to the use of an ACE inhibitor, captopril was withdrawn 24 h before treatment. No adverse reactions were noted in the two following treatments. These findings indicate that: the (bradykinin-mediated) anaphylactoid reaction to LDL-apheresis with dextran sulphate during the use of captopril can be highly non-specific and does not respond to conventional treatment; that it is dose-dependent; and that, once diagnosed, it can be avoided by withdrawing captopril 24 h before treatment-but this last probably does not apply to ACE inhibitors with longer half-lives, such as enalapril. Department of Medicine, Division of General Internal Medicine, University Hospital Nijmegen, Nijmegen, Netherlands

6500 HB

A. A. KROON M. J. T. M. MOL A. F. H. STALENHOEF

Occupational exposure to glutaraldehyde in tropical climates SIR,-The safety and biocidal efficacy of glutaraldehyde’ has led its endorsement by CDC and WHO2,3 as a substitute to formaldehyde in high-level disinfection and cold-sterilisation. In less developed countries, where the supply of sterile disposables and autoclaves are inadequate, the use of glutaraldehyde to control cross-infection in clinical settings that provide invasive services seems reasonable. Since safety considerations with glutaraldehyde largely relate to its volatility, stringent precautions in handling are relevant in warm tropical climates (average ambient temperatures up to 39°C), especially when ventilation may be inadequate. These to

factors increase the risk of vapourised glutaraldehyde exceeding the recommended threshold of 0-2 parts per million.4 Unfortunately, appreciation of these considerations appear to have eluded manufacturers and users. In an outpatient clinic in Nairobi (average annual temperature 23 [SD 4] °C, cetrimide and chlorhexidine were substituted by glutaraldehyde for instrument decontamination and housekeeping about 18 months ago. The glutaraldehyde was left in an open vessel (surface area about 600 cm2 all day in each location of about 11 4m3; ventilation was through 1 44 m2 windows, which remained open for about 10 h daily during a 5-day week. Our concern that there are probably excessive glutaraldehyde fumes prompted us to study individuals who regularly worked in these environments. DETAILS OF AFFECTED RESPONDENTS

Some respondents reported symptoms that mimicked those caused by formaldehyde fumes (table).5-7 We believe that these were adverse reactions to glutaraldehyde fumes. Except in case 2, these adverse reactions probably corresponded to development of hypersensitivity to glutaraldehyde. In addition, in contrast to the familiar smell of formaldehyde,7the smell of glutaraldehyde did not prompt the taking of precautions. As with formaldehyde,* hypersensitisation to glutaraldehyde may not be a function of concentration, especially among those with hypersensitivity to multiple allergens. In this regard, the use of 2% glutaraldehyde in housekeeping in intensive care units, where patients are already likely to have respiratory distress, is of concern. In the manufacturer’s cautions for brands available in Kenya (Cidex, Sporocidin) there is no mention of the volatile nature of