470 P. pneumotropica; freeze-dried cultures those who are interested. as
are
available
to
SIR,-Dr McIntosh (Aug. 7, p. 300) raises
problem
Bacteriology Deaprtment, Royal Victoria Hospital,
C. RUSSELL
Belfast BT12 6BA
HANDBAG PARÆSTHESIA
SiR,—I examined recently a physician who had attended a conference and returned with a slowly resolving paraesthesia of the right forearm. She had been carrying her camera equipment in a bag draped over her right antecubital fossa. After 3-4 days her symptoms developed. Examination disclosed an area of decreased sensation to pain and light touch over the radial aspect of her right forearm extending from the posterior aspect of the thenar region to the antecubital fossa. The rest of her examination was normal. The region of paresthesia corresponded to the area supplied by the lateral cutaneous nerve, a distal branch of the musculocutaneous nerve which emerges from between the brachialis and biceps muscles just above the lateral humeral epicondyle. It is relatively superficial in the antecubital fossa and subject to various injuries. Injury to the nerve from venepuncture has been reported.’1 I feel that the partesthesia in this patient was secondary to nerve compression by the strap of a heavy bag, but I can find no reference to a similar disorder. This mononeuropathy should be fairly common and will undoubtedly be seen by others in practice. Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana 46202, U.S.A.
BRADFORD R. HALE
A.L.G. AND RENAL TRANSPLANTATION
SIR,-You have lately reviewed’ the position of anti-lymphocyte globulin (A.L.G.) in immunosuppressive treatment of kidney-transplanted patients. We agree that controlled investigations using A.L.G. in reasonably long periods of treatment are needed, and you report that such a clinical trial is under way in Britain. A controlled clinical investigation of the immunosuppressive effect of A.L.G. (Behringwerke) in kidney transplantation has been in progress at two transplantation centres in Denmark for the past six months. The project is being carried out in cooperation with the Danish State Medical Research Council. Treatments are given intravenously: 20 mg/kg/day for 14 days, 10 mg/kg every other day for the following 14 days, 10 mg/kg twice weekly in the subsequent month, and finally 10 mg/week in the third month. The final period of treatment is
given to ambulatory patients. A sequential test of the Wilcoxon type (A. M. Gehan) has been chosen for the statistical analysis. Of the tests available, this one provides best use of the data and thus permits the most rapid completion of the project. Improvement of 1-year graft survival by 20% has been chosen for the alternative hypothesis. Limits of significance are fixed so that the probability of error does not exceed 30% if the null hypothesis, no effect, is true, and does not exceed 15% if the alternative hypothesis is true. These limits accord with the fact that an acceptance of the null hypothesis makes A.L.G. acceptance of the alternative makes a of hypothesis repetition the project attractive. On the basis of programme simulations optimal randomisation between treated and control patients has been fixed at 1/5, and the number of A.L.G.-treated patients needed to obtain a significant result has been calculated to be 30-40. The project is expected to be completed within about two years.
.treatment
irrelevant and
an
Klevervaenget 26C, UK.3000, Odense, Denmark
1.
COMMUNICATION AND THE CANCER PATIENT
S. A. BIRKELAND
Sunderland, S. Nerves and Nerve Injuries; pp. 708, 803. Edinburgh, 1968.
of communication with the
cancer to
many
patients is
cancer
once
again the
patient. The word
synonymous with
a
death sentence,
By and large the general public is still misinformed about
malignant disease. This is a result of a number of factors: fear of the disease (and dying), inaccurate information about malignant disease (usually acquired from other patients and friends equally ignorant about cancer), and the refusal of so many doctors to talk honestly and frankly to patients about the problems of cancer. In my experience, very few patients collapse and lose hope when told the diagnosis of cancer. If patients are acclimatised gradually to the diagnosis most accept it remarkably well. This spares them that terrible uncertainty of whether or not they are suffering from cancer. For example, a man with a mass on chest X-ray is told at the first interview that he has a shadow on the lung which could represent a growth. After admission to hospital for histological confirmation of the diagnosis (during which time the patient has time to accept the fact that he may have cancer) he is told the diagnosis. At this stage it is important to conduct the interview with the spouse. This method of communication defuses the atmosphere of uncertainty which surrounds the subject of cancer. It helps to develop that personal relationship between the doctor and patient which is so vital in planning a course of treatment and aftercare, likely to be prolonged. It enables the patient at the earliest opportunity in the doctor-patient relationship to talk about his anxieties and worries. Dr McIntosh found that many patients preferred the anxiety arising from uncertainty as to whether or not they had malignant disease to knowing the true diagnosis. I am sure that this is in no small part due to the ignorance and fear of malignant disease in the general public. Perhaps if doctors adopted a policy of honest, frank, but sympathetic communication with patients who have malignant disease, much of the terror and anxiety surrounding the problem of cancer would disappear. 8 coombs
Lodge,
Warren Walk, London SE7
JOHN PRIOR
HIGH-DENSITY LIPOPROTEIN IN DIABETICS
SIR,—We are analysing data on the metabolism of a group of Sunderland diabetics who have a high prevalence of microangiopathy and yet have, on the whole, low fasting serum lipids. Our results should be compared with those from Carolina.1
It will be noted that the serum-cholesterol levels are higher in the diabetics and yet their absolute H.D.L.-cholesterol and apo-A lipoprotein levels do not differ from normal. Indee4 among the diabetics the L.D.L. and V.L.D.L. cholesterol value. were higher than normal. The same patients clearly hare : low-grade coagulopathy, as shown by their lower a2-andthrombin values. Thus in Sunderland diabetics H.D.L. is no relevant to microangiopathy and the data do not suggesta’ important relation to atherosclerotic disease. E. N. WARDLE Royal Infirmary, P. TRINDER Sunderland 1.
Lopes-Virella, M. F., Colewell, J. A. Lancet, 1976, i, 1291.
are
available
to
SIR,-Dr McIntosh (Aug. 7, p. 300) raises
problem
Bacteriology Deaprtment, Royal Victoria Hospital,
C. RUSSELL
Belfast BT12 6BA
HANDBAG PARÆSTHESIA
SiR,—I examined recently a physician who had attended a conference and returned with a slowly resolving paraesthesia of the right forearm. She had been carrying her camera equipment in a bag draped over her right antecubital fossa. After 3-4 days her symptoms developed. Examination disclosed an area of decreased sensation to pain and light touch over the radial aspect of her right forearm extending from the posterior aspect of the thenar region to the antecubital fossa. The rest of her examination was normal. The region of paresthesia corresponded to the area supplied by the lateral cutaneous nerve, a distal branch of the musculocutaneous nerve which emerges from between the brachialis and biceps muscles just above the lateral humeral epicondyle. It is relatively superficial in the antecubital fossa and subject to various injuries. Injury to the nerve from venepuncture has been reported.’1 I feel that the partesthesia in this patient was secondary to nerve compression by the strap of a heavy bag, but I can find no reference to a similar disorder. This mononeuropathy should be fairly common and will undoubtedly be seen by others in practice. Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana 46202, U.S.A.
BRADFORD R. HALE
A.L.G. AND RENAL TRANSPLANTATION
SIR,-You have lately reviewed’ the position of anti-lymphocyte globulin (A.L.G.) in immunosuppressive treatment of kidney-transplanted patients. We agree that controlled investigations using A.L.G. in reasonably long periods of treatment are needed, and you report that such a clinical trial is under way in Britain. A controlled clinical investigation of the immunosuppressive effect of A.L.G. (Behringwerke) in kidney transplantation has been in progress at two transplantation centres in Denmark for the past six months. The project is being carried out in cooperation with the Danish State Medical Research Council. Treatments are given intravenously: 20 mg/kg/day for 14 days, 10 mg/kg every other day for the following 14 days, 10 mg/kg twice weekly in the subsequent month, and finally 10 mg/week in the third month. The final period of treatment is
given to ambulatory patients. A sequential test of the Wilcoxon type (A. M. Gehan) has been chosen for the statistical analysis. Of the tests available, this one provides best use of the data and thus permits the most rapid completion of the project. Improvement of 1-year graft survival by 20% has been chosen for the alternative hypothesis. Limits of significance are fixed so that the probability of error does not exceed 30% if the null hypothesis, no effect, is true, and does not exceed 15% if the alternative hypothesis is true. These limits accord with the fact that an acceptance of the null hypothesis makes A.L.G. acceptance of the alternative makes a of hypothesis repetition the project attractive. On the basis of programme simulations optimal randomisation between treated and control patients has been fixed at 1/5, and the number of A.L.G.-treated patients needed to obtain a significant result has been calculated to be 30-40. The project is expected to be completed within about two years.
.treatment
irrelevant and
an
Klevervaenget 26C, UK.3000, Odense, Denmark
1.
COMMUNICATION AND THE CANCER PATIENT
S. A. BIRKELAND
Sunderland, S. Nerves and Nerve Injuries; pp. 708, 803. Edinburgh, 1968.
of communication with the
cancer to
many
patients is
cancer
once
again the
patient. The word
synonymous with
a
death sentence,
By and large the general public is still misinformed about
malignant disease. This is a result of a number of factors: fear of the disease (and dying), inaccurate information about malignant disease (usually acquired from other patients and friends equally ignorant about cancer), and the refusal of so many doctors to talk honestly and frankly to patients about the problems of cancer. In my experience, very few patients collapse and lose hope when told the diagnosis of cancer. If patients are acclimatised gradually to the diagnosis most accept it remarkably well. This spares them that terrible uncertainty of whether or not they are suffering from cancer. For example, a man with a mass on chest X-ray is told at the first interview that he has a shadow on the lung which could represent a growth. After admission to hospital for histological confirmation of the diagnosis (during which time the patient has time to accept the fact that he may have cancer) he is told the diagnosis. At this stage it is important to conduct the interview with the spouse. This method of communication defuses the atmosphere of uncertainty which surrounds the subject of cancer. It helps to develop that personal relationship between the doctor and patient which is so vital in planning a course of treatment and aftercare, likely to be prolonged. It enables the patient at the earliest opportunity in the doctor-patient relationship to talk about his anxieties and worries. Dr McIntosh found that many patients preferred the anxiety arising from uncertainty as to whether or not they had malignant disease to knowing the true diagnosis. I am sure that this is in no small part due to the ignorance and fear of malignant disease in the general public. Perhaps if doctors adopted a policy of honest, frank, but sympathetic communication with patients who have malignant disease, much of the terror and anxiety surrounding the problem of cancer would disappear. 8 coombs
Lodge,
Warren Walk, London SE7
JOHN PRIOR
HIGH-DENSITY LIPOPROTEIN IN DIABETICS
SIR,—We are analysing data on the metabolism of a group of Sunderland diabetics who have a high prevalence of microangiopathy and yet have, on the whole, low fasting serum lipids. Our results should be compared with those from Carolina.1
It will be noted that the serum-cholesterol levels are higher in the diabetics and yet their absolute H.D.L.-cholesterol and apo-A lipoprotein levels do not differ from normal. Indee4 among the diabetics the L.D.L. and V.L.D.L. cholesterol value. were higher than normal. The same patients clearly hare : low-grade coagulopathy, as shown by their lower a2-andthrombin values. Thus in Sunderland diabetics H.D.L. is no relevant to microangiopathy and the data do not suggesta’ important relation to atherosclerotic disease. E. N. WARDLE Royal Infirmary, P. TRINDER Sunderland 1.
Lopes-Virella, M. F., Colewell, J. A. Lancet, 1976, i, 1291.
