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attendance of those invited was poor. The resulta reduction of population mortality from breast
cancer of 29% in women aged 55 plus-despite the
poor attendance is actually most impressive for this
seven year (relatively early) analysis of results. It is
in line with those of the other randomised trials of
screening in Scandinavia and New York.
City Hospital,
Nottingham NG.5 I PB
1 Weston S. Breast screening in Scandinavia. Br Mled J 1990;
300:352. 10 Februarv.l
losis and the acquired immunodeficiency syndrome at a New
York City Hospital: 1978-1985. Chest 1987;91:176-80.
3 Selwyn PA, Hartel D, Lewis VA, ei ul. A prospective study of the
risk of tuberculosis among intravenous drug users with human
immunodeficiencN sirus infection. N Engl J Med 1989;320:
545- 50.
4 Batalla J, Gatell JM, Cavla JA, Plasencia A, Jansa Jl\, Parellada
N. Predictors of the survival of AIDS cases in Barcelona,
Spain. AIDS 1989;3:361-6.
5 Fuchs D, Hausen A, Reibnegger G, W'erner ER, Dierich MP,
Wachter H. Neopterin as a marker for activated cell mediated
immunity: application in HIV infection. Immunology Today
1988;9: 150-5.
6 Zangerle R, Fritsch 1P, Fuchs D, W'achter H. Is neopterin helpful
in distinguishing between different disease patterns in AIDS?
Pteridines (in press).
apologise for this editorial error.-ED,
HIV infection and tuberculosis
Assessment of care of children
with sickle cell disease
SIR,-Dr R Milne assessed the quality of care
SIR,-In their editorial Mr John M Watson and of children with sickle cell disease discovered
Mr 0 Noel Gill discussed the increasing prevalence on neonatal screening.' In addition we wish to
of tuberculosis in patients infected with human emphasise that carers should be alerted to observe
immunodeficiency virus type I (HIV-I).' They affected children for signs that need prompt
concluded that the increasing incidence of tuber- action-for example, increasing spleen size-and
culosis is not seen only within the United States" that such children have open access to a paediatric
but is also emerging in Great Britain. In the United ward.
We have already commented on the experience
States tuberculosis is most prevalent in intravenous
drug users infected with HIV,) and thus it will be in Reading,2 where several factors have further
even more important in European countries such improved the service, prompted by the realisation
as Spain, Italy, and Austria, where an unpropor- in October 1988 that a child with sickle cell
tionately high percentage of patients with AIDS anaemia had been born to a couple who were not
are drug users. For example, one third of patients aware of the implications of their risk state (A
Burke, unpublished work). Of the 6000 children
with AIDS in Barcelona have tuberculosis.4
We would like to add our experience in the born in Reading a year, only 600 are born to
Austrian Tyrol of tuberculosis in people with parents from ethnic minorities, so we cannot yet
HIV- I infection. In 1988 in Innsbruck 12 patients justify screening all neonates.
The haematology laboratory recognised that it
were diagnosed as having AIDS. Extrapulmonary
tuberculosis was the indicator disease in four of could diagnose and record carriers of haemoglobin
them.' Diagnosis was proved by culture-for disorders and issue cards with information.
example, from urine, stool, or pleural samples. Couples at risk could be identified (as already
The concentration of urinary neopterin -a marker undertaken for those at risk of rhesus disease);
for activated macrophages6-was greatly increased counselling anu education would then take place
in all of the patients. Interestingly, the four with and neonatal screening automatically follow,
tuberculosis had far higher urinary neopterin although existing routes whereby carriers are
concentrations (range 1189-6671 [tmol neopterin/ identified would continue to be encouraged. The
mol creatinine) than the eight other patients medical laboratory scientific officers took a valuable
(589-1663 itmol neopterin/mol creatinine; p=0O03, initiative in collating the required computer data
Wilcoxon rank test), three of whom had Pneumo- and organising a local haemoglobinopathy card, as
cystis can-nii pneumonia, two had cytomegalovirus a quality product, to encourage community
retinitis, two had AIDS dementia complex, and participation.' The local support group, Reading
one had candida oesophagitis. Concentrations of OSCAR (Organisation for Sickle Cell Anaemia
P2-microglobulin and CD4+ T cell counts did not Research), and the laboratory joined in seeing
differ between the two groups of patients. During that people could attend haemoglobinopathy
antituberculous treatment neopterin concentra- counselling courses like that run at the Central
Middlesex Hospital.' To date, two scientific
tions immediately started to decline.
The early diagnosis of tuberculosis in patients officers, a hospital social worker, and three health
who are positive for HIV antibody is well known to professionals from the support group have acquired
pose problems. As extremely high neopterin con- skills to help inform hospital and community
centrations were seen in our four patients with members.
Most importantly the district medical officer and
tuberculosis it is likely that neopterin testing could
help as an early indicator of tuberculosis in such the district health authority supported our plea to
patients. Tuberculosis cannot easily be distin- make education the priority. They have funded a
guished from other diseases that are associated haemoglobinopathy counsellor, who links closely
with similar constitutional symptoms. Skin testing with the laboratory and obstetric department to
is not useful in people infected with HIV who distribute cards and information. She is responsible
received BCG vaccination in their childhood. for seeing that a neonate identified as having a
Sputum culture can be too time consuming for an sickling disorder attends the joint haematology and
early decision. In addition, determination of paediatric clinic and that the family gets the
neopterin concentration may prove helpful to support it needs. She offers continuing education
monitor the response to and to optimise the for parents, while ensuring that the general practitioner and others concerned -for example, school
duration and dose of tuberculostatic treatment.
teachers -are appropriately informed.
We believe that participation in the service and
education will result in optimal management. We
are watching closely the effect and acceptability of
this programme in the community and hope to
Department of Dermatology and V'enereologv and
report more fully in the future.
Institute of M\edical Chemistrs and Biochemistry,
Unisversity of Innsbruck,
A-6020 Innsbruck, Austria
1 Watson Jlv, Gill ON. HIV infection and tuberculosis. BrMedJ
1990;300:63-5. (13 January.)
2 Handwerger S, hlildvan D, Senie R, McKinley FW. Tubercu-
Haematology Laboratorv,
Royal Berkshire Hospital,
Reading, Berkshire RG I SAN
I Milne RIG. Assessment of care of children with sickle cell
disease: implications for neonatal screening programmes.
Br.VMed7 1990;300:371-4. '10 Februars.i
2 Barton C, Watson A. Neonatal screening for haemoglobino-
pathies. BrMedJ 1988;297:200.
3 Richmond J. Haemoglohin card scheme. Gazette of the Instill4ti ol
Medical Laboratorne Sciences 1989 September:5 18-9.
4 Anionwu E. Running a sickle cell centre: community counselling.
In: Cruickshank JK, Beavers DG, eds. Ethnic factors in health
and disease. Bristol: Wright, 1989.
Haemolytic disease of the
SIR,-We welcome Dr L A Derrick Tovev's
informative article on haemolytic disease of the
newborn, which reflects his long interest in the
topic.' We have to assume, however, that he is
expressing personal views when he says that
it is recommended that prophylactic anti-D
immunoglobulin should be given at 28 and
34 weeks' gestation and again when he says that it is
recommended that antenatal prophylaxis is given
at least in the first pregnancy. There is, in fact, no
recommendation relating to the use of anti-D
immunoglobulin for prenatal prophylaxis in the
United Kingdom, either from the Department
of Health, the Scottish Home and Health Department, or the Royal College of Obstetricians and
Dr Tovey's data from Yorkshire strongly suggest a beneficial effect from giving 500 IU at 28 and
34 weeks. There is also abundant circumstantial
evidence from other sources that two doses of
250 IU may be similarly effective, and to test this
hypothesis a multicentre trial has been designed
and initiated and it is hoped that the results of this
will facilitate the making of a formal recommendation so that the best use of limited supplies of
anti-D immunoglobulin, which is prepared from
human volunteers, is made. The trial is expected to
provide conclusive evidence as to the value of
prenatal prophylaxis within the next 18 months.
Queen Mother's Maternity Hospital,
Glasgow G3 8SH
National Blood Transfusion Sersice,
Manchester M13 9LL
1 lFoves LAD. Haemolytic disease of the newborn and its
presNention. BrMedJ 1990;300:313-6. (3 February.)
NSAIDs and peptic ulcers
SIR,-I would like to suggest that the extrapolations that Dr C J Hawkey makes about how to
prevent damage induced by non-steroidal antiinflammatory drugs and the cost of such prevention are seriously flawed.'
The first point concerns the frequency of serious
gastrointestinal events associated with nonsteroidal anti-inflammatory drugs. Dr Hawkey
makes no mention of the record linkage study by
Beardon et al2 in which the incidence of serious
gastrointestinal events was compared in some
25 000 patients taking non-steroidal anti-inflammatory drugs and in age and sex matched controls.
The sample size on which he based his projections
regarding incidence of serious events associated
with non-steroidal anti-inflammatory drugs in the
general population was a case-control study of 230
patients.' The study by Beardon et al was not only
controlled but was conducted in the Tayside region
of Scotland and relevant to European practice.
Furthermore, the yearly turnover of the population is low, in contrast to the American populations
Dr Hawkey quoted. This point is important when
looking for serious events as missing only a few
may affect the results. The Tayside study clearly
showed an age related effect and an incidence of
24 MARCH 1990