766

difficulties6 no rapid test exists to define the extent of platelet dysfunction resulting from aspirin. To see if TEG would be helpful in predicting the risk of bleeding in patients on aspirin, we investigated seven female and eighteen male healthy volunteers (age 20-45) years) who were given aspirin (150 mg daily) for 14 days. No one entering the trial had taken aspirin or non-steroidal drugs in the previous two weeks. One volunteer was excluded because of high-dose aspirin treatment for influenza. Blood was taken for TEG samplingZ before aspirin ingestion and after 14 days. TEG indices did

not

differ before and after treatment:

*Not significant versus pre-aspirin (Student’s t-test). This lack of effect on TEG is not surprising since platelet aggregation by thrombin is unaffected by aspirin and TEG does not measure platelet adhesion/release mechanisms. In contrast, TEG is very sensitive in the evaluation of agents affecting platelet

aggregation.7 We have found that TEG is a simple and practical method to detect potential bleeding diatheses before regional anaesthesia, especially with respect to coagulopathy or platelet problems in pre-eclampsia. TEG will identify patients with an unusually sensitive response to subcutaneous heparin. However, it does not seem to be useful in the evaluation of the extent of platelet dysfunction after aspirin. Department of Anaesthesia, Royal Free Hospital, London NW3 2QG, UK

S. V. MALLETT

Department of Anaesthesia, Southampton General Hospital, Southampton

M. PLATT

1. Wildsmith JAW, McClure JH. Anticoagulant drugs and central nerve blockade. Anaesthesia 1991; 46: 613-14. 2. Zuckerman L, Cohen E, Vagher JP, et al. Comparison of thrombelastography with common coagulation tests. Thromb Haemostas 1981; 46: 752-56. 3. Lee BY, Salah T, Trainor FS, et al. Monitoring hepann therapy with thrombelastograph and activated partial thromboplastin time. World J Surgery 1980; 4: 323-30. 4. Kelton JG, Hunter DJS, Neame PB. A platelet function defect in pre-eclampsia. Obstet Gynecol 1985, 65: 107-12. 5. Campell C, Nahmold M. Is thrombelastography useful for the evaluation of coagulapathies in high risk partunents. Anesthesiology 1990; 73: A993. 6. Hindman BJ, Koka BV. Usefulness of the post-aspirin bleeding time. Anesthesiology 1986; 64: 368-70. 7 Tuman KJ, Speiss BD, Schock RE, et al. Use of thrombelastograph in the management of Von Willebrand’s disease during cardiopulmonary bypass. J Cardiol Thoracic Anaesthesia 1987; 4: 321-24.

preservatives, solvents, and thrombocytopenic purpura

Wood

SIR,-We report the case of a 17-year-old woman who had idiopathic thrombocytopenic purpura (ITP) while employed on the production line of a company that formulated wood preservatives. In August, 1989, she presented to her general practitioner with a three-day history of bruising and a one-day history of nosebleeds. She had no history of easy bruising or of recent infection or influenza-like illness. She had been taking trinordiol, an oral contraceptive, for over a year. Her work included the filling and packing of tins containing liquid wood preservative. Among the ingredients of the wood preservatives were pentachlorophenol, tributyl-tin oxide, lindane, and permethrin, all formulated in a petroleum-based solvent. She did not wear a mask (she was only provided with one recently) but she did wear ’Perspex’ glasses and linen gloves. Her gloves were frequently soaked with the contents of the tins and her clothes were sometimes

wet too.

Ventilation in the

factory

was

poor, and the

frequently exposed to fumes which, she claimed, made her feel very dizzy, lightheaded, and nauseous for much of the time she was working. Clinical examination revealed extensive bruising on the arms and legs and a purpuric rash on the lower legs. There was no lymphadenopathy or organomegaly and the presumptive diagnosis woman was

ITP. Her platelet count was 4 x 10"/I, and a bone-marrow aspirate showed considerable megakaryocytosis. Platelet-associated was

immunoglobulin was negative. Her anti-nuclear antibody titre was slightly raised but DNA binding was negative. Prednisolone 80 mg daily was prescribed. Her bruising resolved and the platelet count rose to normal within four weeks. The prednisolone dose was gradually reduced and the drug was discontinued after ten weeks of therapy, shortly after the patient returned to work. Two weeks after she stopped the steroids her platelet count fell again and bruising returned; prednisolone was reintroduced at 40 mg per day. Her platelet count returned to normal within two weeks. During therapy the patient experienced severe dyspepsia, unacceptable weight gain, and hirsutism. In view of these side-effects she requested a splenectomy if the platelet count were to fall again when the dose was reduced. When the prednisolone dose was gradually reduced she returned to work but her platelet count fell again to 69 x 109/1 at a prednisolone dose of 5 mg. Splenectomy was done in June, 1990, and one week later her platelet count was 508 x 109/1. One week later, and a week after discontinuation of prednisolone, the patient had a count of 708 x 109/1, and a normal platelet count has since been maintained without therapy. ITP is most common in young women and may occasionally be related to bowel infection, drug exposure, or underlying lymphoma-all causes ruled out in this case. Her work with wood preservatives may be important. The process was often changed, depending on the preservative being made, and the patient was exposed to a wide variety of chemicals, notably solvent fumes. When workers at the factory complained about the fumes, an independent inquiry confirmed solvent exposure (evidenced by the frequency of employee complaints of nausea and headaches). Ventilation in the factory was inadequate, and exposure to chemicals could also have occurred through accidental spillages or the absence of protective clothing. Patients with ITP often relapse after reduction of their prednisolone dosage. In our patient the relapses coincided with her return to work. We cannot state with certainty that these chemicals caused ITP. However, other cases of ITP have been reported in association with exposure to turpentinel and to insecticides such as chlordane and heptachlor.2 Our patient’s ITP may have been related to exposure to chemicals in the workplace. Department of Chemical Pathology and Immunology, Old Medical School, University of Leeds, Leeds LS2 9JT, UK

ALASTAIR HAY

Department of Haematology, Royal United Hospital, Bath

C. R.

J. SINGER

1

Wahlberg P, Nyman D. Turpentine and thrombocytopemc purpura. Lancet 1969, ii;

2.

Epstein SS, Ozonoff D. Leukemias and blood dyscrasias following exposure chloradone and heptachlor. Carcinogenesis Mutagenesis Teratogenesis 1987;

215-16. to

527-40

What’s the Chancellor’s name? SIR,-Asking the name of the Chancellor is used in Germany for bedside testing of higher cognitive function much as the Prime Minister’s is used in the UK. We have not, however, encountered the difficulties with overfamiliarity that Dr Fuller and Dr Meeran (June 1, p 1362) report to have been corrected when John Major succeeded Margaret Thatcher. Even after 11 years with the same Chancellor, the test is still valuable in Germany. Sometimes the answer indicates the time period the patient is living in (eg, Adenauer or "AdolfKohl). One elderly woman answered with the name of Max Merkel, a formerly well-known football coach. We use the name of the Chancellor as only part of a series of eight standardised questions, the others being name, age, date of birth, day’s date, place, capital of France, and adding 12 and 17. Sometimes we probe further by asking for the names of everyday utensils. Although these questions cannot replace psychological testing, they provide more and reproducible information than simply labelling a patient with the diagnosis "dementia". Medizinische Klinik, Krankenhaus Koln-Holweide, 5000 Koln 80, Germany

LOTHAR M. KIRSCH