The article entitled “Health and Safety at necropsy” by Julian Burton
provides a detailed and well written narrative regarding both the risks
and hazards faced by professionals during post-mortem examinations.[1]
Despite the presence of a relatively large publication base regarding this
topic, important aspects are highlighted, including transmissible
spongiform encephalopathies and the more modern...
The article entitled “Health and Safety at necropsy” by Julian Burton
provides a detailed and well written narrative regarding both the risks
and hazards faced by professionals during post-mortem examinations.[1]
Despite the presence of a relatively large publication base regarding this
topic, important aspects are highlighted, including transmissible
spongiform encephalopathies and the more modern, but potentially
dangerous, advances in medical technologies. However, we would wish to
clarify the issues the author raises regarding exploding bullets. The
difference between a true exploding bullet and a projectile designed to
fragment on impact is one of great importance, and one that may cause
confusion, as would appear to be the case within this article.
Bullets are composed of a casing containing an explosive powder
charge which, on striking, forces the end projectile element out at speeds
of up to 1500 metres per second, depending upon the ammunition and the
type of gun used. The projectile causes soft tissue damage through
crushing, creating a temporary cavity which contains hot gases. The tissue
is compressed radially from the centre of the cavity and, depending on its
elastic properties, results in tears to structures (as seen with injuries
to solid abdominal viscera). The recoil of the tissues, together with the
dissipation of the gases, causes the soft tissue to collapse inwards on
itself, the resultant defect being the permanent cavity.
Expansion, or hollow-point, bullets are specialised bullets designed
to deform upon impact due to a collapsible space within the projectile
tip. The result is that a single projectile will inflict greater overall
damage to a target, allowing an increased transfer of kinetic energy
compared to a standard bullet. The “benefits” include a decreased risk of
ricochet as the overall penetration distance is reduced, however, some of
the older ammunition failed to expand on impact due to pieces of clothing
obstructing the cavity.
Pre-fragmented, or frangible, bullets are composed of a pre-scored
outer jacket with a plastic round nose containing compressed lead shot
within. The result is a controlled explosion on impact producing increased
damage and less clothing related problems. The tips, however, possess no
explosive charge.
Burton describes the Winchester Black Talon SXT bullet, though
erroneously includes this within the heading of exploding bullets.[1] It
is, in fact, a type of expansion bullet. The tip is coated with a black
lubricant and has a hollow-point possessing six pre-scored serrations
designed to rapidly open outwards upon impact. The jacket of the bullet is
thickest at its tip, unlike most hollow-point bullets, to provide support
for the claw-like petals as the bullet passes through the body. The
result, in theory, is a wider permanent cavity created by a single
projectile thus increasing the likelihood of damage to a vital structure.
The bullet was voluntarily removed from the market in 1994 and remarketed
as the Ranger SXT, and later as the Ranger Talon, both available only to
law enforcement officers. Despite media assertions, these projectiles are
not “armour-piercing”, the title relating purely to a widely reported
manufacturing error in one brand of body armour, which resulted in a
recall of this product. Although such expansion bullets do indeed pose a
health and safety hazard, due to the sharp edges of the deformed
projectile, there is no risk of explosion at necropsy.
True exploding bullets were first described over a century ago, and,
though not actually in use at that time, were prohibited under the St.
Petersburg Declaration of 1868, which states that explosive or inflammable
projectiles, with a weight of less than 400 grams, should never be used in
the time of war. Examples include the Russian 7.62mm x 54R machine gun
ammunition with an internal charge of tetryl and phosphorus, and later
handgun cartridges containing Pyrodex charges with or without mercury
additives.[2] It should also be noted that individuals can easily obtain
instructions for the creation of their own bullets. The most infamous use
of such bullets was the attempted assassination of President Reagan in
1981 by John Hinckley, who used “Devastator” bullets (Bingham Limited,
USA) composed of a lacquer-sealed aluminium tip with a lead azide centre
designed to explode on impact. Though frequently referred to in works of
fiction, they are rarely encountered in forensic practice, as sales have
been restricted following the incident in 1981. Projectiles that have
failed to detonate are also not as sensitive to movement and heat as
mentioned in the article; the author refers to an article on this topic,
but fails to acknowledge a follow-up letter correcting Knight’s original
mistakes. [2,3] Burton has, unfortunately, reproduced these errors in his
text. Additionally, unexploded bullets are safe on exposure to X-rays and
ultrasound.[4] The quantity of explosive is small and, if it fails to
detonate on high-velocity impact, is unlikely to explode during autopsy
examination. We would indeed agree with the assertion that safety glasses
be used during necropsy examination of ballistic victims, however, as
Burton himself details within his own book, such eye protection should be
routine practice regardless of the cause of death.[5]
A footnote on the topic would include the use of armour-piercing
incendiary round ammunition employed during recent conflicts that possess
explosive points, such as the Raufoss Multipurpose Projectiles, (Nammo,
Norway), fired from anti-vehicle guns of varying calibre.[6] These are
not designed, nor are they produced for use against personnel. In fact,
the round will pass through the body unexploded and are thus unlikely to
be present in bodies from military conflicts. As such, it is also argued
that they do not contravene the St. Petersburg Declaration. If present
with a body, they are safe to handle, transport and store. They also
comply with NATO standards ensuring complete handling safety, even
following vertical drops of up to 15 metres.
Finally, it is interesting to note that the Devastator bullet was
developed in the 1970s for use by sky marshals, to minimise the risk of
penetration of the plane fuselage when incapacitating a hijacker; a
concept that appears to be return in light of recent world events.
References
(1) Burton, J.L. Health and Safety at necropsy. J Clin Pathol 2003;56(4):254-60.
(2) Conway, G.D., Jacobs, A. Explosive bullets: a new hazard for doctors. BMJ 1982;284:1707.
(3) Knight, B. Explosive bullets: a new hazard for doctors. BMJ 1982;284:768-9.
(4) Schlager, D., Johnson, T., McFall, R. Safety of imaging exploding
bullets with ultrasound. Ann Emerg Med 1996;289(20):183-7.
(5) Burton, J.L., Rutty, G.N. The Hospital Autopsy, Second Edition. London: Arnold Publishing, 2001
I read with great interest the paper of Mijnhout et al.[1] I also appreciated the scientific approach of the study. The main conclusion of this article showing the inability of 18FDG PET to detect sentinel node micrometastases are in line with recent studies by Wagner JD et al.[2,3], Acland KM et al.[4], Kokoska MS et al.[5], Crippa F et al.[6], and more recently Longo MI...
I read with great interest the paper of Mijnhout et al.[1] I also appreciated the scientific approach of the study. The main conclusion of this article showing the inability of 18FDG PET to detect sentinel node micrometastases are in line with recent studies by Wagner JD et al.[2,3], Acland KM et al.[4], Kokoska MS et al.[5], Crippa F et al.[6], and more recently Longo MI et al[7]. We have also obtained the same results in a prospective series of 21 melanoma patients (AJCC stage I and II), which underwent 18FDG PET + LM/SL (Belhocine T et al.[8]).
Regardless to the (right) conclusions of the authors, some points should be raised:
1.
In the study of Mijnhout et al,[1] patients' stages according to the AJCC classification (or other staging system) were not precised. This is an important point for routine decision-making. It is very likely that most of patients were classified at early-stage disease (AJCC I and II), so that 18FDG PET would be not primarily indicated in this subgroup of melanoma patients.
2.
Another point is the lack of technical precisions about the PET scanner used in this nice study. Similarly, the methodology of 18FDG PET imaging was not clearly defined (with or without attenuation correction? OSEM or FBP data reconstruction?...). Technical data are critical for evaluating the value of an imaging method.
3.
In their multivariate analysis, the authors did not include 2 key criteria of tumor biology: ulceration and satellite micrometastases. Even though the final results will not be altered, it is important from a scientific point of view to evaluate all criteria.
Finally, I congratulate the authors for their scientific contribution, which may help to best define the indications of SNB and 18FDG PET, respectively, in the management of melanoma patients.
References
(1) G S Mijnhout, O S Hoekstra, A van Lingen, P J van Diest, H J Adèr, A A Lammertsma, R Pijpers, S Meijer, and G J J Teule. How morphometric analysis of metastatic load predicts the (un)usefulness of PET scanning: the case of lymph node staging in melanoma. J Clin Pathol 2003;56:283-286.
(2) Wagner JD, Davidson D, Coleman JJ 3rd, Hutchins G, Schauwecker D, Park HM, Havlik RJ. Lymph node tumor volumes in patients undergoing sentinel lymph node biopsy for cutaneous melanoma.
Ann Surg Oncol 1999 Jun;6(4):398-404.
(3) Wagner JD, Schauwecker DS, Davidson D, Wenck S, Jung SH, Hutchins G. FDG-PET sensitivity for melanoma lymph node metastases is dependent on tumor volume.
J Surg Oncol 2001 Aug;77(4):237-42.
(4) Acland KM, Healy C, Calonje E, O'Doherty M, Nunan T, Page C, Higgins E, Russell-Jones R. Comparison of positron emission tomography scanning and sentinel node biopsy in the detection of micrometastases of primary cutaneous malignant melanoma.
J Clin Oncol 2001 May 15;19(10):2674-8.
(5) Kokoska MS, Olson G, Kelemen PR, Fosko S, Dunphy F, Lowe VJ, Stack BC Jr. The use of lymphoscintigraphy and PET in the management of head and neck melanoma.
Otolaryngol Head Neck Surg 2001 Sep;125(3):213-20.
(6) Crippa F, Leutner M, Belli F, Gallino F, Greco M, Pilotti S, Cascinelli N, Bombardieri E. Which kinds of lymph node metastases can FDG PET detect? A clinical study in melanoma. J Nucl Med 2000 Sep;41(9):1491-4.
(7) Longo MI, Lazaro P, Bueno C, Carreras JL, Montz R. Fluorodeoxyglucose-positron emission tomography imaging versus sentinel node biopsy in the primary staging of melanoma patients. Dermatol Surg 2003 Mar;29(3):245-8.
(8) Belhocine T, Pierard G, De Labrassinne M, Lahaye T, Rigo P. Staging of regional nodes in AJCC stage I and II melanoma: 18FDG PET imaging versus sentinel node detection. Oncologist 2002;7(4):271-8.
We appreciate the interest of RP Britt in our recent case report.[1]
As suggested in our report, we agree that the laboratory findings in this
case do not rule out nutritional vitamin B12 deficiency. We did, however,
feel that the precipitate nature of this lactating patient's presentation
with a documented MCV of 87.8fl four months prior to her admission, made
acute folate deficiency more lik...
We appreciate the interest of RP Britt in our recent case report.[1]
As suggested in our report, we agree that the laboratory findings in this
case do not rule out nutritional vitamin B12 deficiency. We did, however,
feel that the precipitate nature of this lactating patient's presentation
with a documented MCV of 87.8fl four months prior to her admission, made
acute folate deficiency more likely than B12 deficiency, particularly
given the difficulty that some B12 deficient women have in conceiving and
the time it takes to deplete B12 stores. It would have been informative to
monitor the reticulocyte response to B12 given alone and then after
subsequent folic acid replacement. The severity of our patient's
condition, however, clearly precluded such an approach.
It is fascinating 30 years later, that we are still wrestling with
similar problems to those highlighted by Britt et al. in 1971 [2] in that
there is no simple, reliable method of distinguishing B12 and folate
deficiency.
References
(1) Stark GL, Hamilton PJ. Dietary folate deficiency with normal
red cell folate and circulating blasts. J Clin Path 2003;56:313-315.
(2) Britt RP, Harper C, Spray GH. Megaloblastic anaemia among
Indians in Britain. QJM 1971;160:499-520.
I fully support the view that the time is ripe for demand management
of pathology tests.[1] The NHS cannot continue to provide
an open access pathology service which is used indiscriminately. The
service should be evidence-based. If we received specimens for culture
which we believe are irrelevant we withhold culture and return a report
with the comment: "Culture of this specime...
I fully support the view that the time is ripe for demand management
of pathology tests.[1] The NHS cannot continue to provide
an open access pathology service which is used indiscriminately. The
service should be evidence-based. If we received specimens for culture
which we believe are irrelevant we withhold culture and return a report
with the comment: "Culture of this specimen is not likely to be useful.
Discuss with Consultant Microbiologist if indicated".
And since we cannot
respond to a demand for "C & S" with a relevant report unless clinical
data are provided, the comment "We were unable to process this specimen
and produce a relevant report due to the lack of supporting data. Please
repeat or discuss with the Consutlant Microbiologist" is used when such
specimens are received. We do of course make telephone enquiries if we
feel the specimen cannot be repeated.
Although I agree in principle with the recommendations made by Dr
Gopal Rao et al, I note with dismay that I disagree with some of the
specific recommendations regarding inappropriate microbiology specimens.
This is due in part to local variations in the use of the laboratory but
further debate of this issue is indicated.
Reference
(1) G Gopal Rao, M Crook, and M L Tillyer. Pathology tests: is the time for demand management ripe at last? J Clin Pathol 2003;56:243-248.
Rao et al. describe a wide range of testing in pathology where
targeted effort could improve appropriateness.[1]
One of the blocks to improving use of pathology testing is the
limited evidence base. This should not stop us however trying to improve
practice.[2] The medical literature contains a large resource of reviews
and consensus guidance, some of which has an evidence base, and the...
Rao et al. describe a wide range of testing in pathology where
targeted effort could improve appropriateness.[1]
One of the blocks to improving use of pathology testing is the
limited evidence base. This should not stop us however trying to improve
practice.[2] The medical literature contains a large resource of reviews
and consensus guidance, some of which has an evidence base, and there are
many interventions, both published and unpublished, which have been
introduced to attempt to improve use of tests.
Some 95% of primary care tests are contained within a limited
repertoire of under 30 investigations across laboratory medicine. These
make up half or more of the laboratory activity in many district general
hospitals.[3]
Standardised general practice activity data also show very large
differences in testing activity between practices, and although it is
difficult to define optimal testing activity, it is apparent that there is
both over-use and under-use of tests and it is important that the pursuit
of good practice includes both stimulating the increased use of under-used
tests alongside demand control aspects of over-use.
To this end, a cross-laboratory medicine group has recently been
established[4] with representation from the Royal College of Pathologists,
Royal College of General Practitioners, Association of Clinical
Pathologists, PRODIGY, Association of Clinical Biochemists, Association of
Medical Microbiologists and British Society for Haematology. The purpose
of this group initially is to construct an information resource, bringing
together available guidance and evidence to answer a series of everyday
questions affecting primary care users, and subsequently to examine ways
in which this information can be disseminated and used in interventions.
In order to do this it would be valuable to hear from colleagues
initially in the disciplines of clinical biochemistry, haematology,
microbiology and immunology, who have set up specific initiatives to
improve practice and/or would like to participate in this exercise. Many
good ideas are slow to seed across the NHS and it is only by gathering
these together and making them widely available, that the profession will
be able to help to orchestrate a concerted approach to good practice.
References
(1) RAO GG, Crook M, Tillyer ML. Pathology tests: is the time for demand management ripe at last? J Clin Pathol 2003;56:243-248
(2) Barth JH, Jones RG. Indiscriminate investigations have adverse
effects (letter) BMJ 2003;326:393.
(3) Smellie WSA, Galloway MJ, Chinn D. Benchmarking general practice
use of pathology services: a model for monitoring change. J Clin Pathol
2000;53:476–80.
(4) Smellie WSA. Demand Management in primary care pathology. Bull R
Coll Path 2003;122:16-19.
The article by Williams et al. [1] published in April issue highlights
the analytical issues related to LH measurement, as reported.[2] The article
fails to mention problems with measurement of steroid hormones due to the
presence of closely related cross-reacting substances.[3] Traditionally,
most steroid hormones were determined after removing those cross reactants
by various methods, most co...
The article by Williams et al. [1] published in April issue highlights
the analytical issues related to LH measurement, as reported.[2] The article
fails to mention problems with measurement of steroid hormones due to the
presence of closely related cross-reacting substances.[3] Traditionally,
most steroid hormones were determined after removing those cross reactants
by various methods, most commonly by solvent extraction. Currently, direct
assays without extraction have replaced them due to increased pressure on
laboratories to improve the turnaround time. Although these newer methods
are rapid and have good precision (reproducibility), accuracy (wide
variation between methods) is still a problem. [4,5] In addition, there is
batch to batch variation for the same method.[6] Such problems have been
reported for serum female (range) testosterone, oestradiol and
progesterone.[4-6] The accuracy of measurement of serum progesterone is
affected by varying degrees of cross-reaction with other progesterone –
like steroid molecules in the serum (mostly with 17-hydroxyprogesterone).
This bias increases linearly with the increased concentration of cross-
reacting species in the patient sample. Clinically results from these
methods can lead to spuriously elevated progesterone concentration causing
confusion in interpretation and may place patients at risk.[7] The United
Kingdom National External Quality Assurance Scheme (NEQAS) is making
vigorous efforts to reduce this variation and harmonise these
measurements. *[4-6] Therefore, the readers should be aware of cross-
reaction in steroid measurements and always interpret these hormone
results in the context of relevant clinical details so as to avoid
clinical error.
* UKNEQAS has created a “Steroid Accuracy forum” to act on the
problems and invites contributions from interested readers.
References
(1) Williams C, Giannopoulos T, Sherriff EA. Investigation of infertility with the emphasis on laboratory testing and with reference to radiological imaging. J Clin Pathol 2003;56:261-267
(2) Vivekanandan S, Andrew CE. Cross reaction of human
chorionic gonadotrophin in immulite 2000 luteinizing hormone assay. Ann Clin Biochem 2002; 39:318-319.
(3) Middle J. Standardization of steroid assays. Ann Clin Biochem 1998;35:354-363.
(4) Middle JG, French J. UK NEQAS for steroid hormones: has
performance improved with automation and have standardization initiatives had any effect. Proceedings of Pathology 2000:153.
(5) Middle JG, French J. UK NEQAS Steroid Hormones: highlights from the 2001 Annual Review. Proceedings of
the Association of Clinical Biochemists national Meeting 2002:85.
(6) Middle JG, French J. UK NEQAS Steroid Accuracy Forum: aims and objectives. Proceedings of the Association of Clinical Biochemists National - Meeting 2002:89.
(7) Vivekanandan S, Tariq TA. A patient with primary amenorrhoea. CPD Bull Clin Biochem 2000;2:69
I read with interest the case report by GL Stark and PJ Hamilton [1].
In 1970 we drew attention to the occurrence of megaloblastic anaemia in
asian migrants coming to the UK [2]. Further investigation [3,4] revealed
many of these to be nutritional vitamin B12 deficiency.
The features in the case reported certainly do not rule out this
possibility in their patient. They administered three injec...
I read with interest the case report by GL Stark and PJ Hamilton [1].
In 1970 we drew attention to the occurrence of megaloblastic anaemia in
asian migrants coming to the UK [2]. Further investigation [3,4] revealed
many of these to be nutritional vitamin B12 deficiency.
The features in the case reported certainly do not rule out this
possibility in their patient. They administered three injections of
vitamin B12 which would presumably provide adequate amounts of the vitamin
for months or longer.
While carrying out a survey in Punjab N. India in recent years, we
have found many young vegetarian women with macrocytosis and sub-normal
B12 levels which we will be reporting.
References
[1] Stark G.L, Hamilton P.J. Dietary folate deficiency with normal red
cell folate and circulating blasts. J Clinical Pathology 2003; 56; 313-315
[2]Britt R.P. and Harper C. 1970 Nutritional megaloblastic anaemia in
migrants. Brit med Journal 3, 348
[3]Stewart J.S, Roberts P.D, and Hoffbrand A.v. 1970 Lancet;2;542.
We are grateful to Dr Campodonico’s for the interest shown in our
recent report of a case of chronic osteomyelitis mimicking a sarcoma.[1,2] The
main point made in the letter is the need for a high level of suspicion of
malignancy in unusual cases of chronic osteomyelitis (COM).
We entirely agree with this point of view. In fact, the reason for
reporting the present case was that to highlight the...
We are grateful to Dr Campodonico’s for the interest shown in our
recent report of a case of chronic osteomyelitis mimicking a sarcoma.[1,2] The
main point made in the letter is the need for a high level of suspicion of
malignancy in unusual cases of chronic osteomyelitis (COM).
We entirely agree with this point of view. In fact, the reason for
reporting the present case was that to highlight the reverse situation
which is extremely unusual: COM interpreted as malignancy on clinical
grounds with a large resection. The lesion described by us was completely
resected and no tumour was present despite extensive sampling of the
specimen (29 blocks).
Dr Campodonico also mentions in his letter that we suggested that a
definitive diagnosis of COM is possible via immunohistochemical stains.
This, however, was not our point. Immunohistochemistry is not diagnostic
of COM but in this case served to rule out (unlikely) malignancies such as
spindle cell carcinoma and spindle cell melanoma.
In conclusion, we agree with Dr Campodonico that a high index of
suspicion for malignancy should be maintained in unusual cases of presumed
COM. The present case, on the other hand, illustrates the reverse point,
namely that a degree of suspicion should be maintained for COM in unusual
cases of presumed malignancies adjacent to or involving bone.
References
(1) Campodonico F. Chronic osteomyelitis mimicking sarcoma [electronic response to C Gulmann C et al. Chronic osteomyelitis mimicking sarcoma] jclinpath.com 2003 http://jcp.bmjjournals.com/cgi/eletters/56/3/237#19
(2) C Gulmann, O Young, M Tolan, D O’Riordan, and M Leader. Chronic osteomyelitis mimicking sarcoma. J Clin Pathol 2003;56:237-239.
In
reply to the points raised by Cunningham et al.[1] to the British Andrology
Society post vasectomy guidelines, we feel that the authors answer their own criticism - especially the need to assess fresh samples if sperm are found in the initial sample. Our guidelines are to allow the identification of men with few motile cells following heavy c...
In
reply to the points raised by Cunningham et al.[1] to the British Andrology
Society post vasectomy guidelines, we feel that the authors answer their own criticism - especially the need to assess fresh samples if sperm are found in the initial sample. Our guidelines are to allow the identification of men with few motile cells following heavy criticism from our own referees.
24 hour old azoospermic samples, whilst unpleasant give you the same answer
and we clearly say that patient compliance is more important than time
to examination - i.e. an aged sample is better than no sample.
We recommend positive displacement pipettes & phase contrast
microscopy as these are normally found in laboratories that provide high
quality andrological services. The highly viscous nature of semen can mean
that a positive displacement pipetteis the only way to actually remove a
complete pellet. Phase contrast also offers benefits over standard bright-
field illumination as a more rapid medium for screening semen samples.
The other point raised concerned unexpected pregnancies. In our guidelines
we did state this was a difficult area to quantify, as if pregnancies did
occur we do not know how many women would seek termination rather than the
potential trauma associated with pregnancy following a supposedly
sucessful vasectomy.
Our guidelines are best practice, and we feel that in this increasingly
litigatious society this is what is required. If workers want to take the
risk of missing someone with a failed vasectomy by not following them then
that is a choice they make, but it may have to be justified in court. We
can only give best practice and leave it to their judgement.
References
(1) Richard Cunningham, David Dance, Jim Greig, and Adam Brown. Assessment of post vasectomy semen samples [electronic response to P Hancock and E McLaughlin. British Andrology Society guidelines for the assessment of post vasectomy semen samples (2002)] jclinpath.com 2003 http://jcp.bmjjournals.com/cgi/eletters/55/11/812#14
I think the time has come for the medical profession to admit a major mistake in
its history and for a moment leave pride and arrogance on one side. I have a
university degree, am father of two and have spent several days reading books
about childhood vaccination and information downloaded from the Internet. As
vaccination was a “joke” of industrial development, owing to the coincidence of
improving general...
I think the time has come for the medical profession to admit a major mistake in
its history and for a moment leave pride and arrogance on one side. I have a
university degree, am father of two and have spent several days reading books
about childhood vaccination and information downloaded from the Internet. As
vaccination was a “joke” of industrial development, owing to the coincidence of
improving general hygiene, nutrition and standard of living, and the development
and diffusion of vaccination programmes, its death will result from
post-industrial technological development and diffusion of information via the
Internet, which allows non-partial (i.e. not sponsored by pharmaceutical
corporations) information to circulate. For anyone confronted with the issue, it
seems clear that:
Vaccination is a multibillion-dollar business for the pharmaceutical
corporations, which do not sell a few well-tested medicines but huge stocks of
not so well tested vaccines to numerous governments with relatively low and
simple "Promotion costs". The doctors are unfortunately both consciously and
unconsciously part of this process.
Part of the joke of history is because oblivious children contribute to the
problem. The parents usually arrive at a decision to vaccinate their children
under the stress of the first months of parenthood and usually without any
objective information. The will to have your children vaccinated is owing to the
protective instinct that is in every parent. The paediatricians on their side get
only sponsored information!
All the statistical analysis I have read suggests that vaccination makes no
difference and the one study that suggested that it did, was sponsored by
pharmaceutical corporations.
The problem lies also in the fact that the majority of doctors are unwilling
to tell to a parent not to vaccinate because in the very rare case that the child
does actually die as a result of not being vaccinated, the parent would have
every right to sue. Nobody considers that that child would probably die as a
consequence of vaccination and that anyhow deaths related to vaccinations are
higher than the ones related to not being vaccinated (It would be enough to
consider SIDS, Sudden Infant Death Syndrome, between 5000 and 10,000 yearly only
in the USA). However, in these cases the responsible agent is practically
impossible to find!
The least anyone who read this letter could do (especially if they are going to
have children!) is to search on the Internet for the word “vaccination” and check
what he or she finds, especially on independent websites. There are also many
interesting books on this subject. A big surprise awaits them!
Dear Editor
The article entitled “Health and Safety at necropsy” by Julian Burton provides a detailed and well written narrative regarding both the risks and hazards faced by professionals during post-mortem examinations.[1]
Despite the presence of a relatively large publication base regarding this topic, important aspects are highlighted, including transmissible spongiform encephalopathies and the more modern...
Dear Editor
I read with great interest the paper of Mijnhout et al.[1] I also appreciated the scientific approach of the study. The main conclusion of this article showing the inability of 18FDG PET to detect sentinel node micrometastases are in line with recent studies by Wagner JD et al.[2,3], Acland KM et al.[4], Kokoska MS et al.[5], Crippa F et al.[6], and more recently Longo MI...
Dear Editor
We appreciate the interest of RP Britt in our recent case report.[1]
As suggested in our report, we agree that the laboratory findings in this case do not rule out nutritional vitamin B12 deficiency. We did, however, feel that the precipitate nature of this lactating patient's presentation with a documented MCV of 87.8fl four months prior to her admission, made acute folate deficiency more lik...
Dear Editor
I fully support the view that the time is ripe for demand management of pathology tests.[1] The NHS cannot continue to provide an open access pathology service which is used indiscriminately. The service should be evidence-based. If we received specimens for culture which we believe are irrelevant we withhold culture and return a report with the comment:
"Culture of this specime...
Dear Editor
Rao et al. describe a wide range of testing in pathology where targeted effort could improve appropriateness.[1]
One of the blocks to improving use of pathology testing is the limited evidence base. This should not stop us however trying to improve practice.[2] The medical literature contains a large resource of reviews and consensus guidance, some of which has an evidence base, and the...
Dear Editor
The article by Williams et al. [1] published in April issue highlights the analytical issues related to LH measurement, as reported.[2] The article fails to mention problems with measurement of steroid hormones due to the presence of closely related cross-reacting substances.[3] Traditionally, most steroid hormones were determined after removing those cross reactants by various methods, most co...
Dear Editor
I read with interest the case report by GL Stark and PJ Hamilton [1]. In 1970 we drew attention to the occurrence of megaloblastic anaemia in asian migrants coming to the UK [2]. Further investigation [3,4] revealed many of these to be nutritional vitamin B12 deficiency.
The features in the case reported certainly do not rule out this possibility in their patient. They administered three injec...
Dear Editor
We are grateful to Dr Campodonico’s for the interest shown in our recent report of a case of chronic osteomyelitis mimicking a sarcoma.[1,2] The main point made in the letter is the need for a high level of suspicion of malignancy in unusual cases of chronic osteomyelitis (COM).
We entirely agree with this point of view. In fact, the reason for reporting the present case was that to highlight the...
Dear Editor
In reply to the points raised by Cunningham et al.[1] to the British Andrology Society post vasectomy guidelines, we feel that the authors answer their own criticism - especially the need to assess fresh samples if sperm are found in the initial sample. Our guidelines are to allow the identification of men with few motile cells following heavy c...
Dear Editor
I think the time has come for the medical profession to admit a major mistake in its history and for a moment leave pride and arrogance on one side. I have a university degree, am father of two and have spent several days reading books about childhood vaccination and information downloaded from the Internet. As vaccination was a “joke” of industrial development, owing to the coincidence of improving general...
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