Provision of help after major disasters

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IgGi antibody (MAb) directed against non-specific crossreactingantigen (NCA-95)/carcinoembryonic antigen (CEA) on maturegranulopoietic marrow cells and granulocytes in peripheral blood.441 consecutive patients were investigated-15 with non-Hodgkinlymphoma, 13 with Hodgkin’s disease, 9 with breast carcinoma, and4 with small-cell bronchogenic carcinoma. Immunoscintigraphy ofthe marrow was done with 370 MBq of 99mTc-labelled MAb("Scintimun-Granulozyt", Behringwerke AG, Marburg, FRG)and gamma camera spot scans of the whole body 3-5 h afterinjection. 3-10 days later, colloid marrow scans with 370 MBq of99mTc-labelled NC (’So1co’, Nanocoll Nuclear GmbH, Grenzach-Wyhlen, FRG) and whole-body spot scans were done between 0 5 hand 1-5 h after injection. In 30 patients we also did a conventionalwhole-body spot view bone scan 3 h after injection of 550 MBq of99mTc-labelled methylene-diphosphonate (MDP).Both MAb and NC were better than MDP in the detection and

localisation of bone marrow/skeletal lesions. The bone scan wasabnormal in 17 of 30 patients, whereas the marrow scan wasabnormal in 24 when both marrow-seeking agents were used. TheMAb showed a marrow uptake 2-5 times higher than NC in allpatients, and even small marrow lesions (about 1 cm diameter) weredetectable. In all patients, there was good uptake in the lowerthoracic and upper lumbar vertebrae as well as the lower ribs.

Cross-reactivity of MAb with CEA or binding to granulocytes inperipheral blood was not a difficulty and there were no adversereactions to the MAb injections. All the 59 marrow lesions seen onthe NC scan were also found on the MAb scan. The immunoscanlocalised an additional 28 marrow lesions. About 80% of themarrow lesions thus revealed were confirmed as tumours bymarrow biopsy, plain radiographs, computed tomography, ormagnetic resonance tomography.These data clearly show that immunoscintigraphy is not only

better than bone scintigraphy but also conventional colloid

scintigraphy for diagnosis of bone-marrow involvement in solidtumours and malignant lymphomas. Immunoscintigraphy of themarrow is sensitive, safe, easy to do, and cost-effective.

Department of Nuclear Medicine,Georg August University of Gottingen,D-3400 Gottingen, West Germany

DIETER L. MUNZDIRK SANDROCK

Department of Radiology,Municipal Hospital of Oldenburg,Oldenburg NORBERT RILINGER

1. Munz DL. Bone marrow imaging: basic concepts and clinical results. Der Nuklearmed1984, 7: 251-68.

2. Munz DL, Kotter R, Kornemann. I, Brandhorst I, Hor G Bone marrow scanningversus bone scanning m the early diagnosis of neoplastic involvement of the skeletalsystem: a comparanve parallel study. In Schmidt HAE, Adam WE, eds.Nuklearmedizin imaging of metabolism and organ function Stuttgart: Schattauer,1984; 664-68.

3 Ito Y, Okuyama S, Suzuki M, Sakurai M, Sato T, Takagi H. Bone marrowscintigraphy in the early diagnosis of experimental metastatic bone carcinoma.Cancer 1973; 31: 1222-29.

4. Reske SN, Karstens JH, Gloeckner W, et al Radioimmunoimaging for diagnosis ofbone marrow involvement in breast cancer and malignant lymphoma. Lancet 1989;i: 299-301

Provision of help after major disasters

SIR,- The management and staff of The People to People HealthFoundation (project HOPE) applaud your publication of Dr Autierand colleagues’ report (June 9, p 1388) of overenthusiastic,immediate response to the disaster in Armenia. Throughindividuals assigned to our programme in Yerevan, we can confirmthese fmdings. Project HOPE, in its 32nd year of experience inlesser developed countries and in disasters, supports the proposedrecommendations.

Project HOPE feels that it is very important that a team of its staffvisit the site and discover the priority needs of the country requiringassistance together with the adequacy of warehousing for storageand the availability of handling equipment, which influence howdonations will be packaged. We have established that indiscriminateshipping of clothing, medical equipment and supplies, and

pharmceutical products overloads the fragile system of the earlystages of a disaster and provides little assistance. We agree with yourassessment that there should be a representative on site to receive

goods and assure adequate distribution. At Project HOPE we willnot ship supplies unless we have on site either a representative fromthe home office or a long-time associate of the Project. Our aim is toensure proper use of the donation and to be in a position to providedocumentation to the donor that his product has not fallen tocommercial opportunists.

Project HOPE has provided assistance in Armenia on the basis ofthese principles and can report that its donations have all been usedto support the health care infrastructure. Similar procedures arealso followed in its humanitarian assistance programmes forPanama and Nicaragua, where major donations are being suppliedto sustain the people during the early phase of these countries’ newdevelopment.The People to People Health Foundation,Project HOPE,Millwood, Virginia 22646, USA PAUL W. GRUNMEIER

Cardiac rupture and fibrinolytic therapySIR,-Your editorial’ pointed out the increased first-day mortalityrate in patients receiving fibrinolytic therapy for acute myocardialinfarction, largely attributable to cardiac rupture.2 We wouldemphasise that rupture can occur sub-acutely, a potentiallytreatable condition3 that needs to be considered both in patientspresenting with chest pain and shock and in those deteriorating afterfibrinolysis. We report two illustrative cases.

Patient 1. A previously healthy 66-year-old woman was admittedwith a 10-h history of severe central chest pain, having had 2episodes of a similar, less intense pain over the previous week. Shewas poorly perfused and blood pressure was 100/80 mm Hg in botharms. The jugular venous pressure was 4 cm, with a negativeKussmaul’s sign, and a gallop rhythm was present. The

electrocardiogram showed acute infero/posterior myocardialinfarction with Q waves. The chest radiograph was normal. 1-5 MUstreptokinase was given. She remained shocked and anuric despitetreatment with inotropes and diuretics. Cardiac rupture was

suspected and echocardiography revealed a pericardial fluidcollection with a well-functioning left ventricle. Pericardiocentesisyielded 50 ml blood before the patient had a fatal cardiac arrest.Necropsy showed extensive postero/lateral myocardial infarctioncontaining an area of softening through which dissection of 150 mlof blood had occurred. The infarct was judged to be 5-10 days old.

Patient 2. A previously well 69-year-old woman was admittedwith a 2-h history of severe central chest pain. Pulse was 70 beats perminute (bpm) and blood pressure was 140/90 mm Hg withoutevidence of heart failure. The electrocardiogram showed sinusrhythm rate 70 beats per minute with ST elevation in the

anteroseptal leads, consistent with acute myocardial infarction. Thechest radiograph was normal. Aspirin 300 mg was given, and anintravenous infusion of streptokinase 1.5 MU over 1 h was begun. 4h later she had further chest pain, became profoundly hypotensive,and Kussmaul’s sign developed. Other physical signs and the chestradiograph were unchanged. Echocardiography showed a

moderately large pericardial effusion. Despite maximum doses ofinotropes and colloid infusion she died 21 h after admission.

Necropsy showed anteroseptal, transmural, haemorrhagicinfarction with rupture into the pericardium, which contained 200ml of blood.We believe patient 1 presented with collapse and pain because of

cardiac rupture, although this was unrecognised until after

fibrinolytics were given. Such a discrepancy between clinical andpathological estimates of infarct age before cardiac rupture has beenrecorded and presumably results from initially silent infarctionpresenting with pain at the time of dissection. Patient 2 had chestpain and shock after fibrinolysis, and administration of

streptokinase probably contributed to the development of, orexacerbated, free-wall rupture and tamponade.

Subacute cardiac rupture should be considered in patients withchest pain and shock-particular warning features beingelectrocardiographic evidence of well-established infarction and theabsence of left ventricular failure. Traditional signs of tamponadeare unreliable and might not allow its distinction from right