EIKENELLA
1
1441 MEDICINES ACROSS THE COUNTER SIR,—I was interested to read (June 9, p. 1297) the suggestion that simple safe remedies should be available from supermarkets and vending machines. I believe that there are many pharmacists and doctors who would be unwilling to attach the description " safe, simple remedy " to any medicine currently available. Advertising slogans such as quicker, faster relief " and " the sort that doctors prefer " are applied to medicines at present available from supermarkets. These descriptions plus free availability tend to imply safety and encourage patients to adopt a careless attitude to both the taking and handling of medicines. There is ample evidence of patients hoarding medicines, both prescribed and those purchased for self-medication, suggesting incorrect use. Purchase of all medicines from a pharmacy does not necessarily mean that patients would be discouraged from purchasing excessive quantities of analgesics and laxatives, but advice on the type of preparations, dose, and duration of use is often given from well-managed pharmacies. This health-care advice is not available from supermarkets and vending machines. There are many problems caused by chronic self-medication with analgesics, laxatives, and antihistamines. Aspirin and paracetamol are also widely implicated in cases of self-poisoning. Despite the reduction in pack sizes, I believe greater control should be exercised in the supply of all medicines. We should take care that we do not become anaathetised, tranquillised, and hypervitaminised-as a nation. 6 Lockhart Terrace, Roslin, Midlothian, Scotland. IAN W. MARSHALL. EIKENELLA SIR,-Your interesting annotation (June 2, p. 1227) on this group of bacteria mentions the fact that seven strains of Eikenella corrodens have been reported from the United Kingdom, and raises the question of importance of these organisms as a cause of infection. It may be of interest to record that we isolated a gram-negative rod from the drainage wound of a 7-year-old boy who had a pelvic collection of pus following appendicectomy. Three organisms were isolated from the original swab, a scanty growth of Escherichia coli and Staphylococcus albus, plus the gram-negative rod. This organism grew slightly better on the primary anaerobic blood-agar culture than on blood-agar incubated aerobically, but subsequently the organism grew well aerobically with no apparent improve- ment in growth upon incubation in an atmosphere of 10% C02. The colonies pitted the surface of blood-agar plates. During investigations into the identity of the organism it was found to be hxmin (X factor)-dependent when grown on peptone-water agar but not dependent on V factor. In view of the haemin dependence of this gram- negative rod, it was forwarded to Prof. K. Zinnemann, of the University of Leeds, for further investigation. He confirmed the finding that the strain was haamin-dependent and also the pitting nature of the colonies. The organism gave a delayed, weakly positive, catalase reaction and the oxidase test was strongly positive. Professor Zinnemann considered these characteristics to be very suggestive that the strain belonged to the species Bacteroides corrodens as described by Jackson et al.,l although he noted that the antibiotic-sensitivity pattern which we observed-i.e., resistant to penicillin and streptomycin, but sensitive to ampicillin and tetracycline-was different from that 1. Jackson, F. L., Goodman, Y. E., Bel, F. R., Pui Ching Wong, Whitehouse, R. L. S. J. med. Microbiol. 1971, 4, 171. recorded by Jackson et al., who used a different technique. However, it was similar to that observed by Khairat 2 working with the strictly anaerobic species Bacteroides corrodens. Hence, it seems that this is yet another instance of the isolation of Eikenella corrodens from clinical material in the U.K. The relationship of this organism to the patient’s illness is uncertain, but its presence in pus from a drainage wound suggests that it may have been acting either as a pathogen or a secondary invader in this situation. It is interesting to note that the organism was found in a mixed culture, which, as noted in your annotation, is often the case. Ruchill Hospital, Glasgow G20 9NB. R. J. FALLON. SELECTIVE THYROID VENOUS CATHETERISATION IN THE LOCALISATION OF PARATHYROID ADENOMA SIR,-The report by Mr Davies and his colleagues (May 19, p. 1079) further emphasises the role of venous catheterisation and radioimmunoassay of parathyroid hormone in the localisation of abnormal parathyroid glands in difficult cases of primary hyperparathyroidism. Our experience now numbers over 100 cases and we therefore should like to make the following comments on this technique. The authors employed large-neck-vein catheterisation exclusively, and specifically made no attempt to catheterise the thyroid veins. The use of " selective venous catheterisation " in their title is some- what misleading. Our early efforts were also directed towards large-vein sampling, but our results have shown that this approach does not offer consistent accuracy.3 3 One reason for this is the dilution of parathyroid hormone that undoubtedly occurs as parathyroid effluent reaches the large veins of the neck. Anatomical considerations are also important, as exemplified in their discussion of case 6. An increase in parathyroid-hormone concentration at the junction of the left and right innominate veins was con- sidered to predict a mediastinal adenoma. It has been shown, however, that this site in the innominate system may receive drainage from either inferior thyroid vein as well as the common inferior thyroid vein, if present.4 4 The inferior thyroid veins receive parathyroid venous drainage from their ipsilateral superior and inferior para- thyroid glands.5 5 Thus, an increase at that innominate site without values from the selective thyroid veins could mean adenoma in any one of the four usual cervical loca- tions as well as a mediastinal site. Indeed, in our experience, a raised concentration of parathyroid hormone at that site is much more likely to be representative of a cervical adenoma. Similarly, in their case 1, the rise in parathyroid- hormone concentration in the left innominate vein, without values from selective thyroid veins, could have meant adenoma anywhere in the neck as well as the mediastinum. Selective thyroid venous catheterisation, on the other hand, offers a reliable means of preoperative localisation. Lateralisation has been achieved with 80-90% accuracy with selective thyroid sampling, compared to 25-30% for large-vein sampling. Our criteria for large-vein lateralisa- tion are more rigid than those reported. Raised parathyroid- hormone levels in the internal jugular veins reliably predict the side of disease, but high innominate-vein levels are of little predictive value. 2. Khairat, O. J. Path. Bact. 1967, 94, 29. 3. Bilezikian, J. P., Doppman, J. L., et al. Unpublished. 4. Shimkin, P. M., Doppman, J. L., Pearson, K. D., Powell, D. Am. J. Roentgenol. (in the press). 5. Doppman, J. L., Hammond, W. G. Radiology, 1970, 95, 603.
Transcript of EIKENELLA
1441
MEDICINES ACROSS THE COUNTER
SIR,—I was interested to read (June 9, p. 1297) thesuggestion that simple safe remedies should be availablefrom supermarkets and vending machines. I believe thatthere are many pharmacists and doctors who would beunwilling to attach the description " safe, simple remedy "to any medicine currently available.
Advertising slogans such as quicker, faster relief "and " the sort that doctors prefer " are applied to medicinesat present available from supermarkets. These descriptionsplus free availability tend to imply safety and encouragepatients to adopt a careless attitude to both the taking andhandling of medicines. There is ample evidence of patientshoarding medicines, both prescribed and those purchasedfor self-medication, suggesting incorrect use.Purchase of all medicines from a pharmacy does not
necessarily mean that patients would be discouraged frompurchasing excessive quantities of analgesics and laxatives,but advice on the type of preparations, dose, and durationof use is often given from well-managed pharmacies. Thishealth-care advice is not available from supermarkets andvending machines. There are many problems caused bychronic self-medication with analgesics, laxatives, andantihistamines. Aspirin and paracetamol are also widelyimplicated in cases of self-poisoning.
Despite the reduction in pack sizes, I believe greatercontrol should be exercised in the supply of all medicines.We should take care that we do not become anaathetised,tranquillised, and hypervitaminised-as a nation.6 Lockhart Terrace,
Roslin,Midlothian,Scotland. IAN W. MARSHALL.
EIKENELLA
SIR,-Your interesting annotation (June 2, p. 1227) onthis group of bacteria mentions the fact that seven strainsof Eikenella corrodens have been reported from the UnitedKingdom, and raises the question of importance of theseorganisms as a cause of infection. It may be of interest torecord that we isolated a gram-negative rod from thedrainage wound of a 7-year-old boy who had a pelviccollection of pus following appendicectomy. Three
organisms were isolated from the original swab, a scantygrowth of Escherichia coli and Staphylococcus albus, plusthe gram-negative rod. This organism grew slightlybetter on the primary anaerobic blood-agar culture thanon blood-agar incubated aerobically, but subsequently theorganism grew well aerobically with no apparent improve-ment in growth upon incubation in an atmosphere of10% C02. The colonies pitted the surface of blood-agarplates. During investigations into the identity of theorganism it was found to be hxmin (X factor)-dependentwhen grown on peptone-water agar but not dependent onV factor. In view of the haemin dependence of this gram-negative rod, it was forwarded to Prof. K. Zinnemann,of the University of Leeds, for further investigation. Heconfirmed the finding that the strain was haamin-dependentand also the pitting nature of the colonies. The organismgave a delayed, weakly positive, catalase reaction and theoxidase test was strongly positive. Professor Zinnemannconsidered these characteristics to be very suggestive thatthe strain belonged to the species Bacteroides corrodensas described by Jackson et al.,l although he noted that theantibiotic-sensitivity pattern which we observed-i.e.,resistant to penicillin and streptomycin, but sensitive toampicillin and tetracycline-was different from that
1. Jackson, F. L., Goodman, Y. E., Bel, F. R., Pui Ching Wong,Whitehouse, R. L. S. J. med. Microbiol. 1971, 4, 171.
recorded by Jackson et al., who used a different technique.However, it was similar to that observed by Khairat 2
working with the strictly anaerobic species Bacteroidescorrodens.Hence, it seems that this is yet another instance of the
isolation of Eikenella corrodens from clinical material in theU.K. The relationship of this organism to the patient’sillness is uncertain, but its presence in pus from a drainagewound suggests that it may have been acting either as apathogen or a secondary invader in this situation. It is
interesting to note that the organism was found in a mixedculture, which, as noted in your annotation, is often thecase.
Ruchill Hospital,Glasgow G20 9NB. R. J. FALLON.
SELECTIVE THYROID VENOUSCATHETERISATION IN THE
LOCALISATION OF PARATHYROID ADENOMA
SIR,-The report by Mr Davies and his colleagues(May 19, p. 1079) further emphasises the role of venouscatheterisation and radioimmunoassay of parathyroidhormone in the localisation of abnormal parathyroidglands in difficult cases of primary hyperparathyroidism.Our experience now numbers over 100 cases and wetherefore should like to make the following comments onthis technique. The authors employed large-neck-veincatheterisation exclusively, and specifically made no
attempt to catheterise the thyroid veins. The use of" selective venous catheterisation " in their title is some-what misleading. Our early efforts were also directedtowards large-vein sampling, but our results have shownthat this approach does not offer consistent accuracy.3 3One reason for this is the dilution of parathyroid hormonethat undoubtedly occurs as parathyroid effluent reaches thelarge veins of the neck. Anatomical considerations arealso important, as exemplified in their discussion of case 6.An increase in parathyroid-hormone concentration at thejunction of the left and right innominate veins was con-sidered to predict a mediastinal adenoma. It has been
shown, however, that this site in the innominate systemmay receive drainage from either inferior thyroid veinas well as the common inferior thyroid vein, if present.4 4The inferior thyroid veins receive parathyroid venousdrainage from their ipsilateral superior and inferior para-thyroid glands.5 5 Thus, an increase at that innominatesite without values from the selective thyroid veins couldmean adenoma in any one of the four usual cervical loca-tions as well as a mediastinal site. Indeed, in our experience,a raised concentration of parathyroid hormone at thatsite is much more likely to be representative of a cervicaladenoma. Similarly, in their case 1, the rise in parathyroid-hormone concentration in the left innominate vein, withoutvalues from selective thyroid veins, could have meantadenoma anywhere in the neck as well as the mediastinum.
Selective thyroid venous catheterisation, on the otherhand, offers a reliable means of preoperative localisation.Lateralisation has been achieved with 80-90% accuracywith selective thyroid sampling, compared to 25-30% forlarge-vein sampling. Our criteria for large-vein lateralisa-tion are more rigid than those reported. Raised parathyroid-hormone levels in the internal jugular veins reliably predictthe side of disease, but high innominate-vein levels are oflittle predictive value.
2. Khairat, O. J. Path. Bact. 1967, 94, 29.3. Bilezikian, J. P., Doppman, J. L., et al. Unpublished.4. Shimkin, P. M., Doppman, J. L., Pearson, K. D., Powell, D.
Am. J. Roentgenol. (in the press).5. Doppman, J. L., Hammond, W. G. Radiology, 1970, 95, 603.
