1486
follows a similar pattern running just short of discussing recent advances. A typical evening goes like this: "You must tell us (we are curious) what do you do?" (Are you a phlebotomist, pharmacist, lab assistant?) "It is unusual to see women in General Surgery." (Why don’t you stick to marriage, nappies, and the above?) "Are there many women surgeons in India?" (Maybe opting for surgery is a peculiarity native to female doctors in India.) "You don’t have an Indian accent." (I apologise, but point out that not all Scots have an English accent.) "Are you sure you are a vegetarian?" (Do you turn carnivorous when your religious elders are looking the other way?) "Do you mean you don’t drink at all?" (Are you a success story of the alcoholic anonymous?) "Is that your husband?" (The junior registrar or for that matter any overseas doctor on the same table.) "So your husband is a physician-unusual but interesting partnership." (Are you constantly at each other’s throat trying to prove which discipline is superior, more challenging, &c?) "Does your husband suffer from an inferiority complex?" (He should, I know I would.) "Are women in India likely to opt for breast reconstruction after mastectomy? (Are they educated enough to decide to want such a
procedure?) "When are you going back to India?" (You will never make it here. Tough luck, old girl, two handicaps-female gender and brown skin.) Needless to say, I am petrified at the thought of surgical dinners-nothing quite like a TV dinner for a vegetarian teetotaller from New Delhi. St Charles Hospital, London W10 6DZ, UK
SUNITA SHROTRIA
Treatment of CMV retinitis SIR,-Dr Morris (Jan 25, p 247) argues that the treatment of cytomegalovirus (CMV) retinitis with ganciclovir or foscarnet intravenously has yet to be proven effective and that it is associated with serious adverse effects. Our clinical experience shows that high-dose intravitreal ganciclovir is a highly effective, although only virostatic, treatment of CMV retinitis.1 We agree that the intravenous administration of ganciclovir has a variable clinical response. Most often this is a result of dose reduction due to myelosuppressive side-effects, allowing retinitis to progress. Inadequate tissue concentrations are probably the cause of the poor response, but this may also happen with standard-dose regimens. A report of ganciclovir concentrations during retinal detachment surgery in 18 patients receiving the drug intravenously showed that the mean intravitreal concentrations were subtherapeutic in all cases? . We disagree that clinical trials are needed to establish the efficacy of ganciclovir, since our studies and those of others3 have demonstrated that intravitreal administration is successful. Such trials may be needed to establish whether expensive systemic therapy is necessary to treat an isolated manifestation of CMV infection such as CMV retitinitis, especially because combined myelosuppression often necessitates the withdrawal of zidovudine
therapy. Further progress in the treatment of CMV retinitis will come about with injectable, sustained-release ganciclovir compounds, unless an effective oral drug of low toxicity is developed. Department of Ophthalmology, University of New South Wales, Prince of Wales Hospital, NSW 2031, Australia
S. H. YOUNG N. MORLET M. T. CORONEO
Young SH, Morlet N, Heery S, Coroneo MT. High dose intravitreal ganciclovir in the treatment of cytomegalovirus retinitis. Med J Aust (in press). 2. Quiceno JI, Kupperman BD, Conner JD, et al. HPLC analysis of intravitreal ganciclovir concentration after intravenous administration in AIDS patients with CMV retinitis. Invest Ophthalmol Vis Sci 1992; 32 (suppl): 750. 3. Cochereau-Massin I, Lehoang P, Lautier-Frau M, et al. Efficacy and tolerance of intravitreal ganciclovir in cytomegalovirus retinitis m acquired immune deficiency syndrome. Ophthalmology 1991; 98: 1348-55. 1.
Familial clustering of HCV SIR,-Mother-to-child and sexual transmission of hepatitis C virus (HCV) do occur but the rate is controversial.1-4 We have studied patterns of transmission from patients with chronic hepatitis C to family members. The 37 patients had chronic hepatitis C diagnosed histologically, virologically (HCV RNA), and serologically (C100 ELISA or second-generation ELISA, Ortho). We looked for HCV RNA in their 37 spouses and 67 children. As controls, 10 patients with chronic hepatitis B without HCV antibodies or HCV RNA were identified, and their 10 spouses and 16 children were checked for HCV. HCV RNA was detected by the reverse transcriptase nested polymerase chain reaction with primers of the 5’-non-coding region.s In the families with chronic hepatitis C infection, 12 spouses (32%) and 14 children (21%) had HCV RNA: HCV RNA in /n
mother/father /77of/?e/7/af/?
Proportion of children (and Cl for %) 95% C/ 55% with HCV RNA %; w/
follows a similar pattern running just short of discussing recent advances. A typical evening goes like this: "You must tell us (we are curious) what do you do?" (Are you a phlebotomist, pharmacist, lab assistant?) "It is unusual to see women in General Surgery." (Why don’t you stick to marriage, nappies, and the above?) "Are there many women surgeons in India?" (Maybe opting for surgery is a peculiarity native to female doctors in India.) "You don’t have an Indian accent." (I apologise, but point out that not all Scots have an English accent.) "Are you sure you are a vegetarian?" (Do you turn carnivorous when your religious elders are looking the other way?) "Do you mean you don’t drink at all?" (Are you a success story of the alcoholic anonymous?) "Is that your husband?" (The junior registrar or for that matter any overseas doctor on the same table.) "So your husband is a physician-unusual but interesting partnership." (Are you constantly at each other’s throat trying to prove which discipline is superior, more challenging, &c?) "Does your husband suffer from an inferiority complex?" (He should, I know I would.) "Are women in India likely to opt for breast reconstruction after mastectomy? (Are they educated enough to decide to want such a
procedure?) "When are you going back to India?" (You will never make it here. Tough luck, old girl, two handicaps-female gender and brown skin.) Needless to say, I am petrified at the thought of surgical dinners-nothing quite like a TV dinner for a vegetarian teetotaller from New Delhi. St Charles Hospital, London W10 6DZ, UK
SUNITA SHROTRIA
Treatment of CMV retinitis SIR,-Dr Morris (Jan 25, p 247) argues that the treatment of cytomegalovirus (CMV) retinitis with ganciclovir or foscarnet intravenously has yet to be proven effective and that it is associated with serious adverse effects. Our clinical experience shows that high-dose intravitreal ganciclovir is a highly effective, although only virostatic, treatment of CMV retinitis.1 We agree that the intravenous administration of ganciclovir has a variable clinical response. Most often this is a result of dose reduction due to myelosuppressive side-effects, allowing retinitis to progress. Inadequate tissue concentrations are probably the cause of the poor response, but this may also happen with standard-dose regimens. A report of ganciclovir concentrations during retinal detachment surgery in 18 patients receiving the drug intravenously showed that the mean intravitreal concentrations were subtherapeutic in all cases? . We disagree that clinical trials are needed to establish the efficacy of ganciclovir, since our studies and those of others3 have demonstrated that intravitreal administration is successful. Such trials may be needed to establish whether expensive systemic therapy is necessary to treat an isolated manifestation of CMV infection such as CMV retitinitis, especially because combined myelosuppression often necessitates the withdrawal of zidovudine
therapy. Further progress in the treatment of CMV retinitis will come about with injectable, sustained-release ganciclovir compounds, unless an effective oral drug of low toxicity is developed. Department of Ophthalmology, University of New South Wales, Prince of Wales Hospital, NSW 2031, Australia
S. H. YOUNG N. MORLET M. T. CORONEO
Young SH, Morlet N, Heery S, Coroneo MT. High dose intravitreal ganciclovir in the treatment of cytomegalovirus retinitis. Med J Aust (in press). 2. Quiceno JI, Kupperman BD, Conner JD, et al. HPLC analysis of intravitreal ganciclovir concentration after intravenous administration in AIDS patients with CMV retinitis. Invest Ophthalmol Vis Sci 1992; 32 (suppl): 750. 3. Cochereau-Massin I, Lehoang P, Lautier-Frau M, et al. Efficacy and tolerance of intravitreal ganciclovir in cytomegalovirus retinitis m acquired immune deficiency syndrome. Ophthalmology 1991; 98: 1348-55. 1.
Familial clustering of HCV SIR,-Mother-to-child and sexual transmission of hepatitis C virus (HCV) do occur but the rate is controversial.1-4 We have studied patterns of transmission from patients with chronic hepatitis C to family members. The 37 patients had chronic hepatitis C diagnosed histologically, virologically (HCV RNA), and serologically (C100 ELISA or second-generation ELISA, Ortho). We looked for HCV RNA in their 37 spouses and 67 children. As controls, 10 patients with chronic hepatitis B without HCV antibodies or HCV RNA were identified, and their 10 spouses and 16 children were checked for HCV. HCV RNA was detected by the reverse transcriptase nested polymerase chain reaction with primers of the 5’-non-coding region.s In the families with chronic hepatitis C infection, 12 spouses (32%) and 14 children (21%) had HCV RNA: HCV RNA in /n
mother/father /77of/?e/7/af/?
Proportion of children (and Cl for %) 95% C/ 55% with HCV RNA %; w/
