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"SEE, IT DOESN’T HURT ..."

SIR,-In England Now is one of your most agreeable fea-tures, but I cannot allow the contributor remembering"Wicked Willie" (Dec. 23/30) to say that it is good to encour-age children to believe false statements by adults merely tostop those children crying when hurt by an injection. Surelyit is wrong for parents and doctors-especially when they areboth-to dissemble to their children. Are not tears a human

expression of emotion, therapeutic in themselves and thereforeto be encouraged?92 Handsworth Wood Road,Birmingham B20 2PL ELSIE MAY

A CODE ON THE CHEST

SiR,-I would like to report an unusual case of pneumonia.A 13-year-old boy presented in May, 1978 with a 3-day history

of right-sided pleuritic chest pain and a 5-month history ofcough productive of clear sputum, with occasional haemoptysis.Whilst playing the game ’Mastermind’ at Christmas, he hadhidden a blue 1.4 cm peg in his mouth, to deceive his

opponent. Discovery resulted in deep inspiration-and disap-pearance of the peg. On admission to hospital he was febrile,with clinical signs of consolidation and collapse at the rightbase. A chest X-ray confirmed these findings but did notreveal a foreign body. However, at bronchoscopy, the master-mind peg (see figure) was removed from the right lower lobebronchus. The fever and the clinical and X-ray signs sooncleared with benzylpenicillin and physiotherapy, and he wasdischarged after 3 days.

I thank Dr G. de J. Lee for permission to report this case.

Department of Cardiology,Radcliffe Infirmary, Oxford N. S. ASHFORD*

*Present address: Department of Geriatric Medicine, Churchill Hospital,Oxford.

URINARY INFECTION AFTER MICTURATINGCYSTOGRAPHY

SiR,—Dr Maskell and her colleagues’ report a urinary in-fection-rate of 30% after micturating cystourethrography(M.c.u.) and suggest that antibacterial prophylaxis should begiven for a few days before and after the investigation. Wedrew similar conclusions from a very similar study done fouryears ago2 with the aim of defining the rate of urinary infec-tion after M.c.u. and the effect of short-term chemoprophy-laxis. 142 children of both sexes aged two months to sixteenyears were studied. All had sterile urine and none was undertreatment at the time of the investigation. The bladder cathe-terisation was done by a physician working under aseptic con-ditions. Half the children (71) were given nitrofurantoin, a uri-nary antiseptic, for four days after the M.c.u. at a dose of 1mg/kg bodyweight every twelve hours. The other halfremained without treatment. Urine culture (dipslide) was done

,at home by the mother or in hospital by a nurse four to six

1. Maskell, R., Pead, L., Vinnicombe, J. Lancet, 1978, ii, 1191.2 Guignard, J. P., Fawer, C. L., Kroener, A., Quéloz, J., Landry, M. Schweiz.

med. Wschr. 1975,105, 1654.

days after the M.c.u. All patients with 104 colonies or more /mlwere subsequently re-examined in the hospital. A finding of103 colonies/ml or less was considered to indicate artefactualcontamination of the urine.

Significant bacteriuria ( 105 organisms/ml) was found in5 out of 71 patients receiving no prophylaxis (7%) after cysto-graphy. None of the patients given nitrofurantoin had a uri-nary infection after the M.c.u. (r<002, chi-squared test). Noneof the infected patients had symptoms. Contaminated urinesamples were found in 9% of the cultures done at home andin 4% of the cultures done in hospital. The difference was notstatistically significant.From these observations, one can draw the following conclu-

sions :

(1) The 30% infection-rate reported by Maskell et al. could,and should, be significantly reduced, at least by a factor offour, by performing the M.c.u. under stricter asepsis.

(2) Infection after M.c.u. is frequently asymptomatic. Sincemost patients undergoing cystography are at risk of havingurological abnormalities, screening for bacteriuria after theprocedure is essential.

(3) The screening can easily and reliably be performed bythe mother at home. The frequency of contamination of theurine is similar whether the procedure is done by a well-instructed and motivated mother or by a nurse.

(4) Short-term chemoprophylaxis with low doses of nitrofur-antoin, a safe and low-cost urinary antiseptic, can prevent in-fection after cystography.Service de Pediatrie,Centre Hospitalier Universitaire Vaudois,1011 Lausanne, Switzerland JEAN-PIERRE GUIGNARD

CARCINOEMBRYONIC ANTIGEN IN LIVERDISEASE

SIR,-Dr Hine and colleagues’ confirm previous reports ofraised levels of carcinoembryonic antigen (C.E.A.) in the sera ofpatients with obstructive liver disease. Such findings are easyto understand in the light of the knowledge that several serumglycoproteins are excreted into the bile. Ashwell and MorelPhave proposed that any glycoprotein with exposed galactoseresidues will be transported from blood to bile, and Thomas etal. have shown that some C.E.A. undergoes this fate inthe mouse. In addition, there is now very strong evidence thatpolymeric IgA (which has a higher carbohydrate content thanother immunoglobulins) is transported actively from blood tobile.4 5 Interference with this pathway would explain the raisedlevels of serum-IgA and antibodies to enterobacteria thatoccur in some hepatobiliary diseases.

In view of these findings it would be a great help to us allif someone with access to the necessary reagents and assayswould analyse human bile and find out if C.E.A. really is apathological entity or just a normal serum glycoprotein that iskept at very low levels by the functioning of a healthy hepato-biliary system. Although much time and money have beenspent on the topic of c..n. a small further effort might rescueit from the slough of immuno-oncological despond and instateit as a respectable piece of physiology.Chester Beatty Research Institute,Institute of Cancer Research,Royal Marsden Hospital,Sutton, Surrey J. G. HALL

1. Hine, K. R., Leonard, T. C., Booth, S. N., Dykes, D. W. Lancet, 1978, ii,1337.

2. Ashwell, G., Morell, A. G. Adv. Enzymol. 1974, 41, 99.3. Thomas, P., Birbeck, M. S. C., Cartwright, P. Biochem. Soc. Trans. 1977,

5, 312.4. Orlans, E., Peppard, J., Reynolds, J., Hall, J. G. J. exp. Med. 1978, 147,

588.5. Jackson, G. D. F., Lemaitre-Coelho, I., Vaerman, J. P., Bazin, H., Beckers,

A. Eur. J. Immun. 1978, 8, 1236. Heremans, J. F. in The Antigens; vol. II (edited by M. Sela). New York,

1974.

7. Bj&oslash;rnboe, M., Prytz, H., &Oslash;rksov, F. Lancet, 1972, i, 58.