his life was not threatened. The eventual outcome -a mobile, two legged man-is far preferable to a disarticulated or hindquarter amputation. The hospital stay of seven months was a small price to pay for the patient's present state of health. The comments relating to the cost of his postoperative care are short sighted and obviously take no account of the patient's wishes, quality of life, and the long term cost to society of a young man with a mutilating amputation. E R T C OWEN P J LEHNER
Royal Postgraduate Medical School, Hammersmith Hospital, London W12 OHS
SIR,-In his letter Dr Sydney Brandon manages to damn psychotherapy, especially the dynamic psychotherapies, with faint praise.' Contrary to the impression given by his statement that "the dynamic psychotherapies have always been practiced by a small minority of practitioners and it would be unreasonable to expect more people to provide them," ideas deriving from psychoanalysis have been applied with advantage by a wide range of health care providers over many years. The lead given by Heinz Wolff, Dennis Hill, and other pioneers who had the wisdom to see the practical applicability of psychoanalytic thought to general medicine has enriched the experience of generations of medical students. Similarly, the approach of many general practitioners has been informed by the work of Balint, as has the conceptualisation of their "specialist" role. In recent years the explosion of interest in "counselling" has provided an army of educated and humane people anxious to acquire increased skills in psychodynamic psychotherapy and to make use of them in helping the community. It would be folly to ignore this development or to trivialise the contribution such people can make to health care. Far from requiring a massive redeployment of resources, the provision of psychotherapy services can be significantly enhanced by small increases in the pool of expertise available for teaching, supervision, and consultation. One economic model for achieving this (the Isis Centre) has functioned in Oxford since 1970 and warrants wider application. STEPHEN WILSON PETER AGULNIK
Department of Psychotherapy and Counselling, Oxford Mental Health Unit, Oxford OX 1 2HU I Brandon S. Psychological therapy in the NHS. BMJ 1991;303: 523-4. (31 August.) 2 Agulnik PL, Holroyd P, Mandelbrote B. The Isis Centre: a counselling service within the National Health Service. BMJ7
1976;ii:355-7.
Oral rehydration in gastroenteritis SIR, -Drs Angela Mackenzie and Graeme Barnes confirmed that oral rehydration solutions were effective in the treatment of moderate dehydration due to gastroenteritis.' Such solutions have long been used in the developing world,23 although Drs Mackenzie and Barnes claim that intravenous rehydration is usually used in developed countries. We have been routinely using oral or nasogastric glucose-electrolyte solutions at this hospital for almost two decades. Intravenous fluids and investigative biochemistry are reserved for those children presenting with severe dehydration. Vomiting at presentation is not a contraindication to oral fluids. Over the years children with gastroenteritis have VOLUME 303
cyclical and later continuous progesterone. The 20 controls were women who had received no hormonal treatment in the previous five years. Owing to the small numbers it was not possible to obtain matched controls. The results suggest that five years of treatment with progesterone improved bone mineral density in premenopausal women (table) and that progesterone has an anabolic effect on bone metabolism in premenopausal women. KATHARINA DALTON M J T DALTON
MARK BEATTIE NIGEL EVANS
London WIN I AG
Royal Alexandra Hospital for Sick Children, Brighton BN I 3JN
Psychological therapy in the NHS
BMJ
presented with less severe dehydration. We believe this is largely due to the early use of oral glucoseelectrolyte solutions in our community, although the changing pathogenicity of micro-organisms cannot be totally excluded. Primary care doctors and nurses are more likely to recommend oral rehydration at the onset of gastroenteritis if they know it is the treatment of choice in the local hospital service. We do not believe that we are in the developing world and would suggest that Drs Mackenzie and Barnes are behind the times.
5 OCTOBER 1991
I Cundy T, Evans M, Roberts H, Wattie D, Ames R. Bone density in women receiving depot medroxyprogesterone acetate for contraception. BMJ 1991;303:13-16. (6 July.) 2 Hinchley H. DMPA and bone density. BMJ 1991;303:467. (24
1 Mackenzie A, Barnes G. Randomised controlled trial comparing oral and intravenous rehydration therapy in children with diarrhoea. BMJ 1991; 303: 393-6. (17 August.) 2 Hirschhorn N, Kinzie JL, Sachar DB, Northrup SR, Taylor JO, Ahmad SZ, et al. Decrease in net stool output in cholera during intestinal perfusion with glucose-containing solutions. N Engl JMed 1%8; 279: 176-81. 3 Hirschhorn N, McCarthy BJ, Ranney B, Hirschhorn MA, Woodward ST, Lacapa A, et al. Ad libitum oral glucoseelectrolyte therapy for acute diarrhoea in Apache children. J Pediatr 1973; 83: 562-71.
August.) 3 Kubba A. DMPA and bone density. BMJ 1991;303:467. (24 August; correction 14 September, p 651.) 4 Szarewski A, Guillebaud J, Christopher E. DMPA and bone density. BMJ 1991;303:467-8. (24 August.) 5 I obias JH, Chow J, Chambers TJ. DMPA and bone density. BMJ 1991;303:468. (24 August.) 6 Dalton K. Progesterone and progestogens. In: The premenstrual syndrome and progesterone therapy. London: Heinemann Medical, 1984:106-17. 7 Johansson EDB. Plasma levels of progesterone achieved by different routes of administration. Am J Obstet Gynecol 1971; 110:470. 8 Prior JC, Vigna YM, Schechter MT, Burgess AE. Spinal bone loss and ovulatory disturbances. N Engl J Med 1990;323: 1221-7. 9 Wilson RCD. Progesterone as a bone trophic hormone. Endocrine Review (EndocrSociety) 1990;11(2):1-2. 10 Burnett CC, Reddi AH. Influence of oestrogen and progesterone on matrix-induced endochondral bone formation. Calcif Tissue Int 1983;35:609-14.
DMPA and bone density SIR,-The conclusion by Dr Tim Cundy and colleagues that women receiving depot medroxyprogesterone acetate (DMPA) for five years or longer have lower bone mineral density than controls puzzles them and others who suggest failures of study design being responsible for the long term adverse effects of this highly effective contraceptive.25 Their surprise stems from the belief that because both DMPA and natural progesterone contain the word progesterone there is no difference between the two, but their formulas and actions differ considerably.6 Johansson showed that when DMPA was given to normal menstruating women in their luteal phase there was suppression of plasma progesterone, whereas giving progesterone resulted in a dose responsive rise in plasma progesterone.7 Prior et al have shown that low bone mineral density is associated not only with anovulation but also with a defective luteal phase,' and Wilson in his review of Prior's study emphasised the importance of always making clear the difference between progesterone and progestogen.9 Tobias et al reminded us that progesterone stimulates bone metabolism.5 The lower bone mineral density after long term administration of DMPA may result not only from suppression of ovulation but also from reduction of progesterone.6 In our ongoing study we have noticed higher bone mineral density in women treated with progesterone. Since June 1990 bone mineral density of the second to fourth lumbar vertebrae has been measured on a Lunar DPX scanner, similar to that used by Dr Cundy and colleagues. Progesterone treatment by suppository, injection, or implantation has been used regularly by 42 women for the past five years. A total of 22 premenopausal women received progesterone during 14 premenstrual days, while 20 postmenopausal women received continuous daily progesterone. There was a subgroup of 20 women who had received progesterone for ten or more years, of whom 15 had received
Advances in cell kinetics SIR,-We read with interest the recent overview by Drs David A Rew and George D Wilson on the role of thymidine analogues in the analysis of cell proliferation.' Although the techniques described represent an exciting area of research, we believe that it is important to highlight certain fundamental problems in the use of bromodeoxyuridine and iododeoxyuridine as markers of cell proliferation and their analysis using flow cytometry. These problems are currently under investigation in our laboratory. The efficacy of pulse labelling cells with a thymidine analogue in vivo is influenced by several factors including variation in blood supply, the size of endogenous nucleotide pools (particularly in tumours), and the time between cell labelling (injection) and sampling (resection/biopsy).' These can result in a failure to label proliferating cells which are inaccessible to the analogue. Intertumour and intratumour comparisons are valid only if all cells in tumour tissue have equal and even access to the analogue. In vitro infiltration of viable cells overcomes most of these problems and can act as a controlled model in cell proliferation studies. ' The flow cytometric analysis of infiltrated tissue requires disaggregation into single cell or nuclear suspensions with enzymatic or mechanical procedures, or both. Disaggregation techniques do not have the same effect on all tissue types. It is therefore imperative to ensure that the cell suspensions accurately reflect the original tissue and that
Progesterone treatment and bone mineral density Women treated with progesterone
Mean (SD) bone mineral density L2-4 (g/cm-) Mean (SD) age (years) Mean (SD) body mass index pValue*
Premenopausal (5 years) (n - 22)
Postmenopausal (5 years) (n = 20)
Combined (10 years) (n=22)
Controls (n = 20)
1218 (180) 49-8 (4-2) 24-0 (3-5) 0 009
1169 (202) 52-7 (7-2) 27-4 (5 0) 0-06
1209 (196) 53-5 (6-1) 26-2 (5 1) 0 03
1062 (147) 53-8 (5-8) 25-0 (4-8)
*Unpaired t test, progesterone treatment v controls.
855
Royal Postgraduate Medical School, Hammersmith Hospital, London W12 OHS
SIR,-In his letter Dr Sydney Brandon manages to damn psychotherapy, especially the dynamic psychotherapies, with faint praise.' Contrary to the impression given by his statement that "the dynamic psychotherapies have always been practiced by a small minority of practitioners and it would be unreasonable to expect more people to provide them," ideas deriving from psychoanalysis have been applied with advantage by a wide range of health care providers over many years. The lead given by Heinz Wolff, Dennis Hill, and other pioneers who had the wisdom to see the practical applicability of psychoanalytic thought to general medicine has enriched the experience of generations of medical students. Similarly, the approach of many general practitioners has been informed by the work of Balint, as has the conceptualisation of their "specialist" role. In recent years the explosion of interest in "counselling" has provided an army of educated and humane people anxious to acquire increased skills in psychodynamic psychotherapy and to make use of them in helping the community. It would be folly to ignore this development or to trivialise the contribution such people can make to health care. Far from requiring a massive redeployment of resources, the provision of psychotherapy services can be significantly enhanced by small increases in the pool of expertise available for teaching, supervision, and consultation. One economic model for achieving this (the Isis Centre) has functioned in Oxford since 1970 and warrants wider application. STEPHEN WILSON PETER AGULNIK
Department of Psychotherapy and Counselling, Oxford Mental Health Unit, Oxford OX 1 2HU I Brandon S. Psychological therapy in the NHS. BMJ 1991;303: 523-4. (31 August.) 2 Agulnik PL, Holroyd P, Mandelbrote B. The Isis Centre: a counselling service within the National Health Service. BMJ7
1976;ii:355-7.
Oral rehydration in gastroenteritis SIR, -Drs Angela Mackenzie and Graeme Barnes confirmed that oral rehydration solutions were effective in the treatment of moderate dehydration due to gastroenteritis.' Such solutions have long been used in the developing world,23 although Drs Mackenzie and Barnes claim that intravenous rehydration is usually used in developed countries. We have been routinely using oral or nasogastric glucose-electrolyte solutions at this hospital for almost two decades. Intravenous fluids and investigative biochemistry are reserved for those children presenting with severe dehydration. Vomiting at presentation is not a contraindication to oral fluids. Over the years children with gastroenteritis have VOLUME 303
cyclical and later continuous progesterone. The 20 controls were women who had received no hormonal treatment in the previous five years. Owing to the small numbers it was not possible to obtain matched controls. The results suggest that five years of treatment with progesterone improved bone mineral density in premenopausal women (table) and that progesterone has an anabolic effect on bone metabolism in premenopausal women. KATHARINA DALTON M J T DALTON
MARK BEATTIE NIGEL EVANS
London WIN I AG
Royal Alexandra Hospital for Sick Children, Brighton BN I 3JN
Psychological therapy in the NHS
BMJ
presented with less severe dehydration. We believe this is largely due to the early use of oral glucoseelectrolyte solutions in our community, although the changing pathogenicity of micro-organisms cannot be totally excluded. Primary care doctors and nurses are more likely to recommend oral rehydration at the onset of gastroenteritis if they know it is the treatment of choice in the local hospital service. We do not believe that we are in the developing world and would suggest that Drs Mackenzie and Barnes are behind the times.
5 OCTOBER 1991
I Cundy T, Evans M, Roberts H, Wattie D, Ames R. Bone density in women receiving depot medroxyprogesterone acetate for contraception. BMJ 1991;303:13-16. (6 July.) 2 Hinchley H. DMPA and bone density. BMJ 1991;303:467. (24
1 Mackenzie A, Barnes G. Randomised controlled trial comparing oral and intravenous rehydration therapy in children with diarrhoea. BMJ 1991; 303: 393-6. (17 August.) 2 Hirschhorn N, Kinzie JL, Sachar DB, Northrup SR, Taylor JO, Ahmad SZ, et al. Decrease in net stool output in cholera during intestinal perfusion with glucose-containing solutions. N Engl JMed 1%8; 279: 176-81. 3 Hirschhorn N, McCarthy BJ, Ranney B, Hirschhorn MA, Woodward ST, Lacapa A, et al. Ad libitum oral glucoseelectrolyte therapy for acute diarrhoea in Apache children. J Pediatr 1973; 83: 562-71.
August.) 3 Kubba A. DMPA and bone density. BMJ 1991;303:467. (24 August; correction 14 September, p 651.) 4 Szarewski A, Guillebaud J, Christopher E. DMPA and bone density. BMJ 1991;303:467-8. (24 August.) 5 I obias JH, Chow J, Chambers TJ. DMPA and bone density. BMJ 1991;303:468. (24 August.) 6 Dalton K. Progesterone and progestogens. In: The premenstrual syndrome and progesterone therapy. London: Heinemann Medical, 1984:106-17. 7 Johansson EDB. Plasma levels of progesterone achieved by different routes of administration. Am J Obstet Gynecol 1971; 110:470. 8 Prior JC, Vigna YM, Schechter MT, Burgess AE. Spinal bone loss and ovulatory disturbances. N Engl J Med 1990;323: 1221-7. 9 Wilson RCD. Progesterone as a bone trophic hormone. Endocrine Review (EndocrSociety) 1990;11(2):1-2. 10 Burnett CC, Reddi AH. Influence of oestrogen and progesterone on matrix-induced endochondral bone formation. Calcif Tissue Int 1983;35:609-14.
DMPA and bone density SIR,-The conclusion by Dr Tim Cundy and colleagues that women receiving depot medroxyprogesterone acetate (DMPA) for five years or longer have lower bone mineral density than controls puzzles them and others who suggest failures of study design being responsible for the long term adverse effects of this highly effective contraceptive.25 Their surprise stems from the belief that because both DMPA and natural progesterone contain the word progesterone there is no difference between the two, but their formulas and actions differ considerably.6 Johansson showed that when DMPA was given to normal menstruating women in their luteal phase there was suppression of plasma progesterone, whereas giving progesterone resulted in a dose responsive rise in plasma progesterone.7 Prior et al have shown that low bone mineral density is associated not only with anovulation but also with a defective luteal phase,' and Wilson in his review of Prior's study emphasised the importance of always making clear the difference between progesterone and progestogen.9 Tobias et al reminded us that progesterone stimulates bone metabolism.5 The lower bone mineral density after long term administration of DMPA may result not only from suppression of ovulation but also from reduction of progesterone.6 In our ongoing study we have noticed higher bone mineral density in women treated with progesterone. Since June 1990 bone mineral density of the second to fourth lumbar vertebrae has been measured on a Lunar DPX scanner, similar to that used by Dr Cundy and colleagues. Progesterone treatment by suppository, injection, or implantation has been used regularly by 42 women for the past five years. A total of 22 premenopausal women received progesterone during 14 premenstrual days, while 20 postmenopausal women received continuous daily progesterone. There was a subgroup of 20 women who had received progesterone for ten or more years, of whom 15 had received
Advances in cell kinetics SIR,-We read with interest the recent overview by Drs David A Rew and George D Wilson on the role of thymidine analogues in the analysis of cell proliferation.' Although the techniques described represent an exciting area of research, we believe that it is important to highlight certain fundamental problems in the use of bromodeoxyuridine and iododeoxyuridine as markers of cell proliferation and their analysis using flow cytometry. These problems are currently under investigation in our laboratory. The efficacy of pulse labelling cells with a thymidine analogue in vivo is influenced by several factors including variation in blood supply, the size of endogenous nucleotide pools (particularly in tumours), and the time between cell labelling (injection) and sampling (resection/biopsy).' These can result in a failure to label proliferating cells which are inaccessible to the analogue. Intertumour and intratumour comparisons are valid only if all cells in tumour tissue have equal and even access to the analogue. In vitro infiltration of viable cells overcomes most of these problems and can act as a controlled model in cell proliferation studies. ' The flow cytometric analysis of infiltrated tissue requires disaggregation into single cell or nuclear suspensions with enzymatic or mechanical procedures, or both. Disaggregation techniques do not have the same effect on all tissue types. It is therefore imperative to ensure that the cell suspensions accurately reflect the original tissue and that
Progesterone treatment and bone mineral density Women treated with progesterone
Mean (SD) bone mineral density L2-4 (g/cm-) Mean (SD) age (years) Mean (SD) body mass index pValue*
Premenopausal (5 years) (n - 22)
Postmenopausal (5 years) (n = 20)
Combined (10 years) (n=22)
Controls (n = 20)
1218 (180) 49-8 (4-2) 24-0 (3-5) 0 009
1169 (202) 52-7 (7-2) 27-4 (5 0) 0-06
1209 (196) 53-5 (6-1) 26-2 (5 1) 0 03
1062 (147) 53-8 (5-8) 25-0 (4-8)
*Unpaired t test, progesterone treatment v controls.
855
