501
readmitted for virus infection and for diarrhoea and vomiting, respectively. A third patient had neurological symptoms, and multiple sclerosis was diagnosed. The length of stay of these
patients was: Mean
length of stay in days (range) 2-4 (1-t) Vaginal Abdominal 2.8 (1--6) Thus the length of stay of these patients was little more than that claimed for LAVH patients, and the readmission rate does not Operation
Transbronchial biopsy showing the structure of vegetable fibre with polarising filters (haematoxylin and eosin,
X135). showed signs of peripheral neuropathy, but no serious neurological deficiencies. Chest radiography showed multiple spotted pulmonary infiltrations on the right upper and middle lobes.
Immunological, bacteriological, and serological tests were negative. Bronchoscopy was done, because he improved only slightly on antibiotics. Cytochemical and histological examination showed no signs of infection, vasculitis, or malignant disease, and bacteriological tests remained negative. Improvement of pulmonary infiltrations was obtained with intensive parenteral antibiotics, and the Cimino shunt was done. The patient insisted on diuretic treatment with ethacrynic acid and frusemide to delay haemodialysis. In January, 1991, he was readmitted because of progressive peripheral and pulmonary oedema, and haemodialysis was begun. Multiple pulmonary infiltrations in the right upper lobe were again found, which differed from previous findings in size and localisation. All serological indices remained negative; bronchoscopy was repeated, and control biopsies showed vegetable fibre with necrosis (figure). The patient then reported intensive abuse of snuff during the past months. After he stopped this, his radiographs improved rapidly. His lungs remained stable until August, 1991, when he died because of a heart attack after dialysis. Since snuffing is still common in central Europe, we think that this practice should be considered more often in aspiration pneumonia, especially in patients with reduced systemic or pulmonary defence mechanisms. F. HOPPICHLER M. LECHLEITNER P. KÖNIG
J. R. PATSCH Departments of Internal Medicine, Pathology, and Neurology, University Hospital Innsbruck, A-6020 Innsbruck, Austria
H. BRAUNSTEINER M. TÖTSCH G. LUEF
1. Balow JE. Nephrology forum: renal vasculitis. Kidney Int 1985, 27: 954-64. 2. Savage COS, Winearls CG, Jones S, Marshall PD. Prospective study of radiommunoassay for antibodies against neutrophil cytoplasm in the diagnosis of systemic vasculitis. Lancet 1987; ii: 1389-93 3. Goldblum SE, Reed WP. Host defenses and immunologic alterations associated with chronic hemodialysis. Ann Intern Med 1980; 93: 597-613.
Laparoscopically assisted vaginal hysterectomy SIR,-Your correspondents Dr Magos (Oct 26, p 1091), Mr Scrimgeour (Dec 7, p 1465), and Dr Fernandez (Jan 11, p 123) remark upon the advantages of laparoscopically assisted vaginal hysterectomy (LAVH) over traditional methods and draw attention to the shortened stay in hospital and therefore reduced costs. It has been my practice for over 25 years to encourage patients to go home early after operation, because I thought this to be in the interests of the
patient, and not for economical expediency. I have been prompted therefore to review my last 50 patients who had
hysterectomy. These patients were consecutive and unselected and the indication in all was symptoms related to uterine function and disease. Indications for abdominal hysterectomy were: pain (n = 5), uterine size (6), ovarian cyst (3), carcinoma (2), endometriosis (1), poor descent (1), and patient’s request (1). 2 patients were
No of patients 31 19
indicate that any patients were discharged prematurely. A major advantage in the orthodox method is the much shorter operating time and this factor alone should outweigh the advantages put forward for LAVH. Some of the abdominal hysterectomies (those in which pain was the indication for the abdominal route) could have been done vaginally if laparoscopy had been done before starting surgery, but the small difference in length of hospital stay would indicate that this was hardly worth while. St John’s
Hospital,
Chelmsford, Essex CM2 9BG, UK
G. L. S. RANKIN
Foscarnet for CMV retinitis SiR,—Your Dec 14 editorial was a thoughtful discussion of the foscamet-ganciclovir cytomegalovirus (CMV) retinitis trial in patients with AIDS. The trial was prematurely terminated despite efficacy for induction and maintenance therapy of CMV retinitis because of an apparent 4-month survival advantage in foscamettreated patients. This finding resulted in the distribution of a clinical alert from the US National Eye Instituted Your editorial offers several hypotheses to explain the observed survival advantage and discusses the confounding variable of possible differences in antiretroviral therapy between the two groups. Much more discussion of these key issues will probably take place when results of the trial are published. Two additional points deserve attention. The survival benefit found with foscamet was seen in a subgroup of patients with a predicted creatinine clearance (CrCI) of 1or more ml/min per kg. For patients with a predicted creatinine clearance of less than 1 ’2 ml/min per kg, a survival benefit was seen in ganciclovir treated patients. This modest 25% decrease in renal function is commonly seen in clinical practice, including in patients with AIDS. In addition, therapy with foscamet is substantially more expensive than treatment with ganciclovir. At my institution an induction course of 2-3 weeks with foscamet costs US$1694-2541 and maintenance therapy costs US$21900 per year. A similar induction course with ganciclovir costs US$840-1260 and maintenance therapy is US$10 950 per year. These cost figures include only acquisition cost and pharmacy expendables, and do not take into account labour or other expenses. Until more information is available, it would seem prudent to choose foscamet for the initial treatment of CMV retinitis only when the patient has relatively preserved renal function and would most likely benefit with prolonged survival. Patients with renal dysfunction should be treated with ganciclovir because of enhanced survival, in the context of a large cost differential between the two drugs. Department of Medicine, Hahnemann University, Philadelphia, Pennsylvania 19102, USA 1.
CRAIG A. WOOD
Kupfer C, Jabs D. Clinical alert to physicians and others who treat patients with AIDS. Bethesda: National Eye Institute, National Institutes of Health, October 17, 1991.
Need for second-generation anti-HCV testing in haemophilia SIR,-Dr Wan Chan and colleagues (Nov 30, p 1391) report the existence of more than one strain of hepatitis C virus (HCV). We have retested samples with two second-generation enzyme assays (Abbott, Innogenetics) from 35 patients with haemophilia who had already been tested by a first-generation assay (Ortho). All 14 samples originally positive for anti-HCV reacted positive with both
readmitted for virus infection and for diarrhoea and vomiting, respectively. A third patient had neurological symptoms, and multiple sclerosis was diagnosed. The length of stay of these
patients was: Mean
length of stay in days (range) 2-4 (1-t) Vaginal Abdominal 2.8 (1--6) Thus the length of stay of these patients was little more than that claimed for LAVH patients, and the readmission rate does not Operation
Transbronchial biopsy showing the structure of vegetable fibre with polarising filters (haematoxylin and eosin,
X135). showed signs of peripheral neuropathy, but no serious neurological deficiencies. Chest radiography showed multiple spotted pulmonary infiltrations on the right upper and middle lobes.
Immunological, bacteriological, and serological tests were negative. Bronchoscopy was done, because he improved only slightly on antibiotics. Cytochemical and histological examination showed no signs of infection, vasculitis, or malignant disease, and bacteriological tests remained negative. Improvement of pulmonary infiltrations was obtained with intensive parenteral antibiotics, and the Cimino shunt was done. The patient insisted on diuretic treatment with ethacrynic acid and frusemide to delay haemodialysis. In January, 1991, he was readmitted because of progressive peripheral and pulmonary oedema, and haemodialysis was begun. Multiple pulmonary infiltrations in the right upper lobe were again found, which differed from previous findings in size and localisation. All serological indices remained negative; bronchoscopy was repeated, and control biopsies showed vegetable fibre with necrosis (figure). The patient then reported intensive abuse of snuff during the past months. After he stopped this, his radiographs improved rapidly. His lungs remained stable until August, 1991, when he died because of a heart attack after dialysis. Since snuffing is still common in central Europe, we think that this practice should be considered more often in aspiration pneumonia, especially in patients with reduced systemic or pulmonary defence mechanisms. F. HOPPICHLER M. LECHLEITNER P. KÖNIG
J. R. PATSCH Departments of Internal Medicine, Pathology, and Neurology, University Hospital Innsbruck, A-6020 Innsbruck, Austria
H. BRAUNSTEINER M. TÖTSCH G. LUEF
1. Balow JE. Nephrology forum: renal vasculitis. Kidney Int 1985, 27: 954-64. 2. Savage COS, Winearls CG, Jones S, Marshall PD. Prospective study of radiommunoassay for antibodies against neutrophil cytoplasm in the diagnosis of systemic vasculitis. Lancet 1987; ii: 1389-93 3. Goldblum SE, Reed WP. Host defenses and immunologic alterations associated with chronic hemodialysis. Ann Intern Med 1980; 93: 597-613.
Laparoscopically assisted vaginal hysterectomy SIR,-Your correspondents Dr Magos (Oct 26, p 1091), Mr Scrimgeour (Dec 7, p 1465), and Dr Fernandez (Jan 11, p 123) remark upon the advantages of laparoscopically assisted vaginal hysterectomy (LAVH) over traditional methods and draw attention to the shortened stay in hospital and therefore reduced costs. It has been my practice for over 25 years to encourage patients to go home early after operation, because I thought this to be in the interests of the
patient, and not for economical expediency. I have been prompted therefore to review my last 50 patients who had
hysterectomy. These patients were consecutive and unselected and the indication in all was symptoms related to uterine function and disease. Indications for abdominal hysterectomy were: pain (n = 5), uterine size (6), ovarian cyst (3), carcinoma (2), endometriosis (1), poor descent (1), and patient’s request (1). 2 patients were
No of patients 31 19
indicate that any patients were discharged prematurely. A major advantage in the orthodox method is the much shorter operating time and this factor alone should outweigh the advantages put forward for LAVH. Some of the abdominal hysterectomies (those in which pain was the indication for the abdominal route) could have been done vaginally if laparoscopy had been done before starting surgery, but the small difference in length of hospital stay would indicate that this was hardly worth while. St John’s
Hospital,
Chelmsford, Essex CM2 9BG, UK
G. L. S. RANKIN
Foscarnet for CMV retinitis SiR,—Your Dec 14 editorial was a thoughtful discussion of the foscamet-ganciclovir cytomegalovirus (CMV) retinitis trial in patients with AIDS. The trial was prematurely terminated despite efficacy for induction and maintenance therapy of CMV retinitis because of an apparent 4-month survival advantage in foscamettreated patients. This finding resulted in the distribution of a clinical alert from the US National Eye Instituted Your editorial offers several hypotheses to explain the observed survival advantage and discusses the confounding variable of possible differences in antiretroviral therapy between the two groups. Much more discussion of these key issues will probably take place when results of the trial are published. Two additional points deserve attention. The survival benefit found with foscamet was seen in a subgroup of patients with a predicted creatinine clearance (CrCI) of 1or more ml/min per kg. For patients with a predicted creatinine clearance of less than 1 ’2 ml/min per kg, a survival benefit was seen in ganciclovir treated patients. This modest 25% decrease in renal function is commonly seen in clinical practice, including in patients with AIDS. In addition, therapy with foscamet is substantially more expensive than treatment with ganciclovir. At my institution an induction course of 2-3 weeks with foscamet costs US$1694-2541 and maintenance therapy costs US$21900 per year. A similar induction course with ganciclovir costs US$840-1260 and maintenance therapy is US$10 950 per year. These cost figures include only acquisition cost and pharmacy expendables, and do not take into account labour or other expenses. Until more information is available, it would seem prudent to choose foscamet for the initial treatment of CMV retinitis only when the patient has relatively preserved renal function and would most likely benefit with prolonged survival. Patients with renal dysfunction should be treated with ganciclovir because of enhanced survival, in the context of a large cost differential between the two drugs. Department of Medicine, Hahnemann University, Philadelphia, Pennsylvania 19102, USA 1.
CRAIG A. WOOD
Kupfer C, Jabs D. Clinical alert to physicians and others who treat patients with AIDS. Bethesda: National Eye Institute, National Institutes of Health, October 17, 1991.
Need for second-generation anti-HCV testing in haemophilia SIR,-Dr Wan Chan and colleagues (Nov 30, p 1391) report the existence of more than one strain of hepatitis C virus (HCV). We have retested samples with two second-generation enzyme assays (Abbott, Innogenetics) from 35 patients with haemophilia who had already been tested by a first-generation assay (Ortho). All 14 samples originally positive for anti-HCV reacted positive with both
