Cardiopulmonary resuscitation

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62
Letters
to
the
Editor
form
of
recent
dental
infection
or
manipula-
tion.4
Our
patient
also
had
very
poor
dentition
and
valvular
heart
disease.
Various
combina-
tions
of
antibiotics
like
penicillin
and
strepto-
mycin,
cephalosporin
and
streptomycin,
penicillin,
tetracycline
and
streptomycin
have
been
successful
in
achieving
cure,
however,
at
present
high
dose
penicillin
(>
25
mU/day)
in
combination
with
an
aminoglycoside
for
six
weeks
is
favoured.4
ASHOK
VAGHJIMAL
LARRY
I
LUTWICK
EDWARD
K
CHAPNICK
Infectious
Diseases
Division,
Maimonides
Medical
Center,
4802
Tenth
Avenue,
Brooklyn,
NY
11219,
USA
1
Chong
Y,
Lin
HS,
Leesy,
Chosy.
Lactobacillus
subspecies
endocarditis.
A
case
report.
Yonseo
MedJ
1991;
32:
69-73.
2
Isenberh
D.
Lactobacillus
infective
endocarditis.
Proc
R
Soc
Med
1977;
70:
278-81.
3
Griffith
JK,
Daly
JS,
Dodge
RA.
Two
cases
of
endocarditis
due
to
Lactobacillus
species;
anti-
microbial
susceptibility,
review
and
discussion
of
therapy.
Clin
Infect
Dis
1992;
15:
250-5.
4
Sussman
JI,
Baron
EJ,
Goldberg
SM,
Kaplan
MH,
Pizarello
RA.
Clinical
manifestation
and
therapy
of
Lactobacillus
endocarditis.
Report
of
a
case
and
review
of
the
literature.
Rev
Infect
Dis
1986;
8:
771-
6.
Emergency
blood
test
guidelines
Sir,
The
audit
study
by
AG
Pennycook'
resulted
in
considerable
savings
(40%)
on
out-of-hours
investigations
in
the
Accident
and
Emergency
department
in
Southampton.
We
carried
out
a
similar
study
here
seven
years
ago
but
achieved
a
smaller
(22%)
reduction
in
on-call
investigations
over
the
first
few
months
only.2
Since
then
the
on-call
workload
for
the
laboratory
has
increased
steadily
year-on-year,
despite
instruction
of
doctors
in
the
Accident
and
Emergency
department
on
the
use
of
our
guidelines.
We
are
now
reconsidering
the
wider
use
of
emergency
investigation
guide-
lines
and
contacted
the
laboratory
in
South-
ampton
to
ask
them
about
the
effect
of
the
guidelines
on
their
workload.
They
were
not
aware
of
the
audit
study
conducted
in
their
Accident
and
Emergency
department
and
their
workload
figures
had
not
shown
any
reduction
over
the
years.
A
possible
explana-
tion
is
that
the
reduced
requesting
in
the
Accident
and
Emergency
department
was
compensated
for
by
increased
requesting
for
blood
tests
on
patients
admitted
to
other
units
in
the
hospital.
We
are
therefore
not
yet
convinced
that
significant
costs
savings
can
be
made
for
the
whole
hospital
by
the
use
of
such
guidelines
but
intend
to
explore
this
further.
C
van
HEYNINGEN
Clinical
Laboratories,
Aintree
Hospitals,
Fazakerly
Hospital,
Lower
Lane,
Liverpool
L9
7AL,
UK
1
Pennycook
A.
Are
blood
tests
of
value
in
the
primary
assessment
and
resuscitation
of
patients
in
the
A
&
E
department?
Postgrad
Med
J
1995;
71:
81-5.
2
van
Heyningen
C,
Simms
P.
Guidelines
for
out-
of-hours
clinical
chemistry
investigations
[letter].
Clin
Chem
1990;
36:
2151-2.
Cardiopulmonary
resuscitation
Sir,
In
his
interesting
article,
Kevin
Stewart
analyses
the
ethical
and
moral
principles
around
the
issue
of
how
'not
for
cardiopul-
monary
resuscitation'
decisions
(DNR
deci-
sions)
are
made.
We
would
agree
that,
in
most
cases
where
a
decision
will
be
put
into
effect,
they
can
be
made
on
the
grounds
of
futility,
ie,
it
is
not
necessary
to
offer
an
ineffective
treatment.
However,
a
larger
number
of
patients
are
admitted
to
hospital
unwell
but
not
with
a
high
likelihood
of
dying,
in
whom
death
is
nevertheless
a
possibility.
A
decision
still
needs
to
be
made
in
case
of
the
unexpected
cardiac
arrest.
In
our
study
we
did
not
find
any
way
of
being
able
to
predict
the
18%
of
patients
who
would
not
want
to
be
resusci-
tated
without
asking
them
first;
in
addition,
we
found
that
35%
of
patients
wish
to
be
actively
consulted
while
51%
did
not
mind.2
Quality
of
life
from
the
observer's
perspective
does
not
seem
to
be
a
valid
predictor
of
the
decision
made
by
the
patient.
Therefore,
it
is
necessary
to
discuss
DNR
decisions
with
competent
patients,
irrespective
of
our
view
of
their
potential
quality
of
life,
if
we
wish
to
comply
with
their
wishes.
We
do
not
say
that
this
is
easy
or
even
practical
at
the
moment
in
the
UK
but
if
it
became
routine
to
ascertain
the
patients'
view
on
DNR
decisions
on
admission
a
lot
of
the
sensitivity
around
discussion
would
disappear.
This
could
be
done
initially
by
routinely
informing
patients
of
the
hospitals'
'opt
out'
or
'opt
in'
cardio-
pulmonary
resuscitation
policy
in
hospital
literature,
although
one
suspects
that
many
will
not
read
this.
CHRISTOPHER
J
TURNBULL
GILLIAN
E
MEAD
Arrowe
Park
Hospital,
Upton,
Wirral,
Merseyside
L49
5PE,
UK
1
Stewart
K.
Discussing
cardiopulmonary
resusci-
tation
with
patients
and
relatives.
Postgrad
MedJ
1995;
71:
585-9.
2
Mead
GE,
Turnbull
CJ.
Cardiopulmonary
re-
suscitation
in
the
elderly:
patients'
and
relatives'
views.
J
Med
Ethics
1995;
21:
39-44.
Octreotide
therapy
for
diarrhoea
Sir,
Intractable
diarrhoea
complicates
systemic
amyloidosis
in
a
significant
number
of
pa-
tients.'
The
aetiology
is
thought
to
be
either
autonomic
neuropathy2
or
direct
infiltration
by
amyloid
of
gastrointestinal
submucosa.
Therapeutic
management
is
frequently
unsa-
tisfactory
due
to
resistance
to
conventional
antidiarrhoeal
agents.
Only
two
case
reports
exist
to
date
in
the
literature
describing
successful
symptomatic
control
with
the
long-acting
somatostatin
analogue
octreotide
acetate.3'4
We
report
the
third.
Case
report
An
80-year-old
woman
had
a
six-month
history
of
weight
loss,
anorexia
and
unremit-
ting
diarrhoea,
unaccompanied
by
blood
or
mucus
and
resistant
to
all
attempts
at
conventional
treatment
with
codeine,
loper-
amide
and
sulphasalazine.
Routine
biochem-
ical
and
haematological
investigations,
stool
cultures,
gastroscopy
with
biopsies,
abdom-
inal
ultrasound
and
barium
enema
examina-
tion
were
all
negative.
Histology
from
rectal
biopsies,
however,
stained
with
Congo
red
and
confirmed
a
diagnosis
of
amyloidosis,
immunohistochemistry
demonstrating
a
monoclonal
immunoglobulin
light
chain
(AL)
type.
Institution
of
octreotide
therapy
100
,g
subcutaneously
three
times
daily
resulted
in
immediate
cessation
of
her
diar-
rhoea.
Transfer
to
another
hospital
unfortu-
nately
led
to
octreotide
being
discontinued
Octreotide:
clinical
indications
*
bleeding
peptic
ulcer
·
bleeding
oesophageal
varices
·
gastrointestinal
fistula
·
pancreatic
fistula
·
acute
pancreatitis
·
short
bowel
syndrome
·
ileostomy
diarrhoea
·
diabetic
diarrhoea
*
chronic
secretory
diarrhoea
(idiopathic,
HIV)
*
secretory
tumours:
pituitary
adenomas,
gastrointomas,
insulinomas,
vipomas,
carcinoid
syndrome
Octreotide:
modes
of
action
*
reduces
splanchnic,
portal
and
mucosal
blood
flow
*
inhibits
endocrine
and
exocrine
secretions
from
somatostatin-
containing
cells
in
pancreas,
stomach
and
intestine
*
stimulates
water
and
electrolyte
absorption
from
gastrointestinal
tract
*
inhibits
gallbladder
motility
and
secretion
*
slows
gastric
emptying
and
reduces
peristalsis
in
gastrointestinal
tract
*
inhibits
hypothalamic-pituitary
hormonal
release
*
inhibits
gastrointestinal
tract
tumour
with
subsequent
recurrence
of
diarrhoea,
but
re-challenge
with
the
drug
again
achieved
immediate
symptomatic
control.
This
case
represents
the
third
reported
where
octreotide
re-challenge
resulted
in
immediate
complete
symptomatic
resolution
in
a
patient
with
hypersecretory
diarrhoea
due
to
amyloidosis.
Successful
antidiarrhoeal
ac-
tion
has
also
been
described
with
octreotide
in
patients
with
familial
amyloidotic
polyneuro-
pathy.5
Hypersecretory
diarrhoea
in
amyloi-
dosis
is
an
unlicensed
indication
for
octreotide
use,
but
further
similar
reports
may
strengthen
the
case
for
more
generalised
use
of
this
agent
in
a
distressing
condition
affecting
predominantly
elderly
patients.
IA
GILANDERS
JD
FULTON
VE
SAVE
Stracathro
Hospital,
Brechin,
Angus
DD9
7QA,
UK
1
Yamada
M,
Hatakeyama
S,
Tsukagoshi
H.
Gastrointestinal
amyloid
deposition
in
AL
(pri-
mary
or
myeloma-associated)
and
AA
(second-
ary)
amyloidosis.
Hum
Pathol
1985;
16:
1206-
21.
2
Battle
WM,
Rubin
MR,
Cohen
S,
Snape
WJ.
Gastrointestinal
motility
dysfunction
in
amyloi-
dosis.
N
EnglJMed
1979;
301:
24-5.
3
Yam
LT,
Oropilla
SB.
Octreotide
for
diarrhea
in
amyloidosis.
Ann
Intern
Med
1991;
115:
577.
4
O'Connor
CR,
O'Dorisio
TM.
Amyloidosis,
diarrhea,
and
a
somatostatin
analogue.
Ann
Intern
Med
1989;
110:
665-6.
5
Carvalho
M,
Alves
M,
Sales
Luis
ML.
Octreo-
tide
-
a
new
treatment
for
diarrhoea
in
familial
amyloidotic
polyneuropathy.
J
Neurol
Neurosurg
Psychiatry
1992;
55:
860-1.
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doi: 10.1136/pgmj.73.855.62-a
1997 73: 62Postgrad Med J
C. J. Turnbull and G. E. Mead
Cardiopulmonary resuscitation.
http://pmj.bmj.com/content/73/855/62.2.citation
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