checklist below (adapted from Jolles and patient require blood products in the myxedema, pyoderma gangrenosum, psori- Hughes4) summarises the general consid- future. asis, and pretibial myxedema. Int erations prior to the commencement of Reassuringly, the incidence of serious Immunopharmacol 2006;6:579–91 5 Brennan VM, Salomé-Bentley NJ, Chapel hdIVIG. reactions to IVIG is low and usually due to HM. Prospective audit of adverse reactions concurrent infection or over-rapid admin- occurring in 459 primary antibody-deficient ’s checklist for high dose IVIg: istration. A prospective study of 459 anti- patients receiving intravenous immuno- 1. Liver function, renal function, full body deficient patients established on IVIG globulin. Clin Exp Immunol 2003;133: blood count, and hepatitis screen showed that no serious reactions occurred 247–51 6Munks R, Booth JR, Sokol RJ. A compre- (avoid hdIVIG in rapidly progressive in over 13,000 infusions across twelve cen- hensive IgA service provided by a blood renal disease). tres and using six different IVIG products. transfusion centre. Immunohaematol- 2. Immunoglobulin levels to exclude IgA The rate of milder reactions was 0.8%.5 ogy.1998;14:155–60 deficiency. If no IgA present In the UK, primary immunodeficiency (<0.05g/l), measure anti-IgA patients who infuse at home no longer antibodies. require the automatic prescription of Systematic review of systematic 3. Exclude high titre rheumatoid factor adrenaline auto-injectors even though reviews of and cryoglobulinaemia. incidence of complete IgA deficiency with Editor – Derry et al (Clin Med July/August 4. Preferably ensure that a sufficient anti-IgA antibodies is higher in antibody supply of a single product and batch deficient patients (especially IgAD with 2006 pp 381–6) have advanced acupunc- of IVIG is available to expose the IgG subclass deficiency) than the general ture research significantly by their review patient to a minimum number of population. Furthermore a large study of 35 systematic reviews. Since I am an donors and to avoid unnecessary demonstrated that far fewer individuals author of 14 of these articles, I feel I should product changes. with IgAD and anti-IgA antibodies than comment. The analyses by Derry et al 5. Take any baseline specimens, would be expected developed transfusion imply that the authors of many reviews examination findings, or photographs reactions6. were too ‘optimistic’ regarding the value of required in order to later document The diagnosis of IgAD and measurement acupuncture mainly because they often any objective response. of anti-IgA antibodies is therefore useful in based their conclusions on biased data. I 6. Follow manufacturer’s guidelines defining patients at increased risk of reac- think that this may well be true. We need to regarding reconstitution and rate of tions to IVIg but the presence of even high be more, not less, critical when assessing infusion (and maintain good titre anti-IgA antibodies may not preclude complementary/ hydration and fluid intake). the use of an IVIg product low in IgA (CAM). Ironically, many CAM enthusiasts 7. Provide patient information regarding where the risk–benefit ratio merits it. believe that the work of my team is already too critical. high-dose IVIG therapy and consent. T EL-SHANAWANY 8. Store a sample of serum so that any Specialist Registrar in Immunology Believers in acupuncture will probably future research questions or matters University Hospital of Wales, Cardiff point towards a range of weaknesses in the analyses by Derry et al. The article has, of relating to transmission of infective WAC SEWELL agents may be addressed. Visiting Professor of Immunology course, several limitations but these should University of Lincoln, Lincoln not distract us from its provocative conclu- If anti-IgA antibodies are detected and SA MISBAH sion: there is ‘no robust evidence that are at high titre it may well still be possible Consultant Immunologist acupuncture works for any indication.’ to use an IVIg product low in IgA (see Table Churchill Hospital, Oxford Using an entirely different approach, which 1: Properties of IVIg preparations currently STEPHEN JOLLES included a review of those trials which con- available in the UK, in our original article) Consultant Immunologist and Allergist trol for effects through the use of starting the infusion at a slow rate and, if University Hospital of Wales, Cardiff the new non-penetrating sham devices, I tolerated, gradually being increased under recently arrived at a strikingly similar the supervision of experienced staff and in a References overall verdict: ‘Acupuncture remains setting where full resuscitation facilities are 1Cunningham-Rundles C. Physiology of IgA steeped in controversy. Some findings are available. The current generation of IVIg and IgA deficiency. J Clin Immunol encouraging but others suggest that its products are generally lower in IgA than has 2001;21:303–9. 2 Lilic D, Sewell WAC. IgA deficiency: what clinical effects mainly depend on a placebo previously been the case. Premedication we should–or should not–be doing. J Clin response.’1 Critical assessment like this of such as antihistamine, paracetamol and Path 2001;54:337–8 Derry et al is a very rare thing in CAM. But hydrocortisone may also be used at initia- 3 Bjorkander J, Hammarstrom L, Smith C et CAM researchers should remember that it tion of IVIg or during change of product. al. Immunoglobulin prophylaxis in patients is mainly this approach which advances This is not generally needed for subsequent with antibody deficiency syndromes and anti-IgA antibodies. J Clin Immunol 1987; healthcare. infusions. Consideration may also be given 7:8–15 EDZARD ERNST to a medic alert bracelet documenting the 4Jolles S, Hughes J. Use of IGIV in the treat- Professor of Complementary Medicine high titre anti-IgA antibodies should the ment of atopic dermatitis, urticaria, sclero- Peninsula Medical School, Exeter

508 Clinical Medicine Vol 6 No 5 September/October 2006 LETTERS TO THE EDITOR

Reference Whilst it may well be the case that the resulting as a complication from surgery in 1Ernst E. Acupuncture – a critical analysis. general public’s understanding of this area which the intention is to save life. JInt Med 2006;259:125–37. is inadequate, I firmly believe that they have On his final point, we will simply have to got hold of a truth which many profes- disagree. We hear much about supposed sionals are trying to deny, namely that the human rights, and very little about respon- Assisted dying choice of the time of one’s death is a funda- sibilities. I do not accept that the choice of mental human right and that it is not the the time of one’s death is a fundamental Editor – Though I do not for a moment place of legislators or health professionals to human right, and I would be interested to question his bona fides, I believe that deny that right. know the premise on which this assertion is Stephenson (Clin Med July/August 2006 pp made. If Fisken really believes this, and if 374–7) is profoundly mistaken and, ROGER A FISKEN Consultant Physician this ‘right’ is not to be denied to people by indeed, that he condemns his position with Friarage Hospital legislators and health professionals, then his own arguments. He says that ‘in most Northallerton, North Yorkshire presumably he would advocate that assisted cases [my emphasis] the physical symp- Reference dying be available to anyone who asks, of toms of terminal illness can be relieved’ whatever age and whatever condition of and that even where patients have complex 1Anonymous. A personal view of assisted dying. Clin Med 2006;6:412–7. health? A slippery slope indeed. symptoms ‘they can usually [my emphasis again] be alleviated.’ These statements are JEFFREY STEPHENSON obviously correct but are, frankly, irrele- St Luke’s Hospice, Plymouth In response to Fisken vant: as Stephenson himself agrees, those Reference who advocate the availability of assisted My statements about what can be achieved 1Anonymous. A personal view of assisted dying do so in relation to an ‘extremely by are hardly irrelevant as it is dying. Clin Med 2006;6:412–7. small proportion [of terminally ill important to establish the benchmark for people]’; however small that proportion what is possible. The appalling care high- may be, the fact is that such people exist, as lighted by the author in the same issue, to Assisted dying is eloquently demonstrated by another whom Fisken refers, although tragically all author in the same issue.1 There are people too common is nonetheless suboptimal.1 Editor – While I share some of Dr Jeffrey who are resistant to opiates or who find Palliative care is certainly not a panacea for Stephenson’s concerns regarding assisted their side effects intolerable and the same all end-of-life ills, but whatever the limita- dying, I feel that several of the points raised goes for the most commonly used anti- tions there is always something that can be need further attention. Firstly, I think it is emetic drugs. What are we going to provide done to bring a measure of relief. presumptive to state that most of us for these people? There will always remain some people working with the terminally ill are strongly No one would suggest that assisted dying who would like the option of assisted against a change in the current law. Those is an easy matter on which to legislate, but dying. However, at what cost to others do working in palliative medicine with sufficient determination it is possible we elevate their autonomy above other who have spoken out on this subject tend to set aside absolutist arguments and to pro- concerns? Fisken’s faith in our legislators is to be strongly against assisted dying. I’m vide for the needs of vulnerable people even admirable, but I’m afraid that I have rather sure that there must be other workers in in contentious areas, as the 1967 Abortion less faith in human . He does his palliative medicine, however, who have Act showed. I would remind Stephenson, cause little favour by making the compar- been examining the moral issues involved incidentally, that the Hippocratic oath also ison with the 1967 Abortion Act. I doubt and feel that they cannot dismiss the idea forbids abortion, yet many doctors are those who framed that legislation would without further discussion and thought. content to terminate pregnancies under have had any idea that the result would be Secondly, I have worked with patients appropriate circumstances. abortion on demand, with only a tiny frac- who had symptoms that could not be alle- Stephenson’s attempt to raise a series of tion of these being for foetal abnormality. viated through palliative care. These have moral absolutes in opposition to assisted Furthermore, while some may argue that included patients with progressive neuro- dying is honourable but ultimately illogical: there is scope for debate over viability of logical disease who were profoundly dis- for example, to say that some doctors will life or personhood of an embryo, there is abled, but who had no remedial symptoms ‘kill or facilitate the killing’ of their patients absolutely no doubt that assisted dying such as pain or nausea, and patients is an emotive statement which bears no involves ending a life. who have had symptoms such as fatigue relation to the reality of what is being dis- While ‘kill’ and ‘facilitating the killing’ and weakness, which we have been unable cussed. In the days of surgery before asepsis may be emotive terms, I’m afraid they do to reverse. There may be a very small pro- and proper anaesthesia, operative and post- accurately represent the reality of what is portion of our patients who, whatever we operative mortality was high, yet it would being discussed. Euphemisms cannot hide do, wish to end their lives, and this should have been wrong to have described sur- the fact that the intention in assisted dying be acknowledged. geons as ‘wounding or facilitating the is to unnaturally end a life, and there is a With regards to violation of the Hippo- wounding’ of their patients. world of difference between this and death cratic oath, a longstanding tradition

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