104 BUMETANIDE IN RENAL FAILURE
SIR,--Bourkel has described how bumetanide is well tolerated in renal-failure patients who have experienced ototoxicity with frusemide. The following case-report suggests other advantages of bumetanide. A 51-year-old woman with gluten enteropathy in full remission on a gluten-free diet, reattended with a 3-week history of increasing oedema, weight gain, and oliguria. Investigation confirmed a nephrotic syndrome with non-selective proteinuria, and renal biopsy showed membranous glomerulonephritis. Her fluid retention could only be controlled with frusemide 750 mg and spironolactone 200 mg daily. Over the next 2 months, a generalised scaling rash developed, worst on the exposed areas of the body. The patient had had no previous rashes or known treatment with sulphonamides. Selective withdrawal of her various medicaments strongly suggested that this photosensitivity was due to frusemide ; she was put on ethacrynic acid instead, but could not tolerate this drug because of vomiting. Re-introduction of frusemide resulted in a prompt relapse of her skin condition. Bumetanide was then given (9 mg twice daily) and this controlled the oedema and hypertension without untoward effect. The patient’s renal function has improved, the lowest level of creatinine clearance having been 25 ml/min. The recent introduction of a high dose (5 mg) tablet focuses attention on the place of bumetanide in chronic renal failure. Musculoskeletal pain is an occasional problem in those patients with very low filtration rates.2 This may be minimised by carefully titrating the dose of bumetanide in individuals and giving the dose twice daily. With these provisos it would seem that bumetanide is a valuable alternative to frusemide in chronic renal failure. Hemlington Hospital, Middlesbrough, Cleveland TS8 9DS
P. McCORMACK
poraries, this still gives cause for concern. If, as Smith and his colleagues suggest, two or three doses are required for effective immunity, rather than the present single dose booster, then effective herd immunity against poliomyelitis in the U.K. could well be reaching an unacceptably low level. University Health Centre, Reading RG2 7HE
D. F. ROWLANDS
WOODPECKERS’ TONGUES al.’ suggest that the
woodpecker’s geniohyoid during hammering, but study of the ana-3 tomy of the tongue of the green woodpecker (Picus viridu)2’ shows that this is not possible. Isometric contraction of a muscle is mechanically feasible only when the part into which it is inserted is prevented from moving by contraction of antagonist muscles. The antagonist of the geniohyoid in the woodpecker is the tracheohyoid muscle, which retracts the tongue when larynx and trachea are fixed in position by the opposing actions of geniothyroid and cleidothyroid muscles. The insertions of geniohyoid and tracheohyoid on the hyoid bone are widely separated, the latter. being distal, and simultaneous contraction of the two pairs of muscles would lead to buckling of the hyoid, which is thin and SIR,-May
et
may be contracted
very delicate. Even if isometric contraction of the geniohyoid were possible, the muscle would remain in the soft tissues of the neck and be of no value as a shock absorber for the skull. If the geniohyoid contracts normally and is applied to the skull, the tongue and its bony skeleton are inevitably extended between 2 and 10 cm beyond the end of the beak.3 Any woodpecker foolish enough to hammer with a contracted geniohyoid would injure his tongue. These observations do not need the elaborate
investigative techniques mentioned by May et al. Medical Unit, St Mary’s Hospital Medical School, London W2
DAVID GORDON
POLIOMYELITIS TODAY
SIR,-I read with interest your editorial
on
PÆDIATRIC OUTPATIENT FOLLOW-UP
poliomyelitis.3
You point to disturbing gaps in immunity and note the study by Smith et al. who reported that in 14% of police cadets aged 16-18 lacked antibody to at least one virus type. This led me to make some inquiries on the average percentage absence of children in their final year (age 15) at a number of secondary schools, and I found that a 10-15% absence-rate is quite usual in this group. In my experience, when visits are made to schools by school health service staff to administer polio and other booster immunisations at this age, only one visit is made to each school during the year. Hence the finding of lack of immunity in 14% could be expected, and, with the present system of one annual visit, is unlikely to be improved given the prevailing absence-rate. Another much smaller group of "administratively captured" students are seen by those of us working in university health services. Of those new undergraduates entering this university in 1974 and 1975 under the age of 19, 23% and 24%, respectively, were found to require a booster polio immunisation as they had been missed at the appropriate time during their school years. It might be expected that this specially selected group of students, together with their parents, have better than average motivation for preventive immunisation programmes, but, even assuming that a similar rate of missed boosters prevails in the other 90% or so of their school contem-
SiR,-You
stone,4 solved
simply. We deal with many children with chronic ill(e.g. diabetes, cadiac disease, cystic fibrosis, and epilepsy) and many with persisting handicaps (cerebral palsy and spina bifida); we also have the extra dimension of development nesses
which spreads
Bourke, E. Lancet, 1976, i, 917. Berg, K. J., Tromsdal, A., Widere, T.-E. Eur. J. Clin. Pharmac. 1976, 9,
265. 3. Lancet, 1976, i, 1004. 4. Smith, J. W. G., and others.
J. Hyg.,
Camb. 1976, 76, 235.
our
commitment
to an
individual child
over a
longer period. We also have to face two problems: the child cannot be responsible for himself and may have irresponsible parents; and the average general practice is geared to being called by the patient or parent, if needed, and does not normally accept an imposed follow-up as part of its normal work. To cover this situation the paediatrician has an appointment book. It is common practice for the notes of the "non-attenders" to be shown to the consultant and where needed, new appointments are made and repeated until the child returns for review or alternative
plans are made. If you can find us general practices which will regularly follow-up their chronic cases or find us the areas with enough health visitors with time to act in this capacity, then many of us would cheerfully shed a significant section of our follow-up
load. P. R. A., Fuster, J. M., Newman, P., Hirschman, A. Lancer, 1976, i. 1347. 2. Waller, R. Phil. Trans. R. Soc. Lond. 1716, 29, 509. 3. Leiber, A. Verleichende Anatomie der Sprechtzunge Zool. Stuttg. 1907, 20, 1. 4. Lancet, 1976, i, 1168. 1.
1 2.
right, "Come Again-3 Months" is a millpaediatrics there are problems which cannot be
are
but in
May,
SIR,--Bourkel has described how bumetanide is well tolerated in renal-failure patients who have experienced ototoxicity with frusemide. The following case-report suggests other advantages of bumetanide. A 51-year-old woman with gluten enteropathy in full remission on a gluten-free diet, reattended with a 3-week history of increasing oedema, weight gain, and oliguria. Investigation confirmed a nephrotic syndrome with non-selective proteinuria, and renal biopsy showed membranous glomerulonephritis. Her fluid retention could only be controlled with frusemide 750 mg and spironolactone 200 mg daily. Over the next 2 months, a generalised scaling rash developed, worst on the exposed areas of the body. The patient had had no previous rashes or known treatment with sulphonamides. Selective withdrawal of her various medicaments strongly suggested that this photosensitivity was due to frusemide ; she was put on ethacrynic acid instead, but could not tolerate this drug because of vomiting. Re-introduction of frusemide resulted in a prompt relapse of her skin condition. Bumetanide was then given (9 mg twice daily) and this controlled the oedema and hypertension without untoward effect. The patient’s renal function has improved, the lowest level of creatinine clearance having been 25 ml/min. The recent introduction of a high dose (5 mg) tablet focuses attention on the place of bumetanide in chronic renal failure. Musculoskeletal pain is an occasional problem in those patients with very low filtration rates.2 This may be minimised by carefully titrating the dose of bumetanide in individuals and giving the dose twice daily. With these provisos it would seem that bumetanide is a valuable alternative to frusemide in chronic renal failure. Hemlington Hospital, Middlesbrough, Cleveland TS8 9DS
P. McCORMACK
poraries, this still gives cause for concern. If, as Smith and his colleagues suggest, two or three doses are required for effective immunity, rather than the present single dose booster, then effective herd immunity against poliomyelitis in the U.K. could well be reaching an unacceptably low level. University Health Centre, Reading RG2 7HE
D. F. ROWLANDS
WOODPECKERS’ TONGUES al.’ suggest that the
woodpecker’s geniohyoid during hammering, but study of the ana-3 tomy of the tongue of the green woodpecker (Picus viridu)2’ shows that this is not possible. Isometric contraction of a muscle is mechanically feasible only when the part into which it is inserted is prevented from moving by contraction of antagonist muscles. The antagonist of the geniohyoid in the woodpecker is the tracheohyoid muscle, which retracts the tongue when larynx and trachea are fixed in position by the opposing actions of geniothyroid and cleidothyroid muscles. The insertions of geniohyoid and tracheohyoid on the hyoid bone are widely separated, the latter. being distal, and simultaneous contraction of the two pairs of muscles would lead to buckling of the hyoid, which is thin and SIR,-May
et
may be contracted
very delicate. Even if isometric contraction of the geniohyoid were possible, the muscle would remain in the soft tissues of the neck and be of no value as a shock absorber for the skull. If the geniohyoid contracts normally and is applied to the skull, the tongue and its bony skeleton are inevitably extended between 2 and 10 cm beyond the end of the beak.3 Any woodpecker foolish enough to hammer with a contracted geniohyoid would injure his tongue. These observations do not need the elaborate
investigative techniques mentioned by May et al. Medical Unit, St Mary’s Hospital Medical School, London W2
DAVID GORDON
POLIOMYELITIS TODAY
SIR,-I read with interest your editorial
on
PÆDIATRIC OUTPATIENT FOLLOW-UP
poliomyelitis.3
You point to disturbing gaps in immunity and note the study by Smith et al. who reported that in 14% of police cadets aged 16-18 lacked antibody to at least one virus type. This led me to make some inquiries on the average percentage absence of children in their final year (age 15) at a number of secondary schools, and I found that a 10-15% absence-rate is quite usual in this group. In my experience, when visits are made to schools by school health service staff to administer polio and other booster immunisations at this age, only one visit is made to each school during the year. Hence the finding of lack of immunity in 14% could be expected, and, with the present system of one annual visit, is unlikely to be improved given the prevailing absence-rate. Another much smaller group of "administratively captured" students are seen by those of us working in university health services. Of those new undergraduates entering this university in 1974 and 1975 under the age of 19, 23% and 24%, respectively, were found to require a booster polio immunisation as they had been missed at the appropriate time during their school years. It might be expected that this specially selected group of students, together with their parents, have better than average motivation for preventive immunisation programmes, but, even assuming that a similar rate of missed boosters prevails in the other 90% or so of their school contem-
SiR,-You
stone,4 solved
simply. We deal with many children with chronic ill(e.g. diabetes, cadiac disease, cystic fibrosis, and epilepsy) and many with persisting handicaps (cerebral palsy and spina bifida); we also have the extra dimension of development nesses
which spreads
Bourke, E. Lancet, 1976, i, 917. Berg, K. J., Tromsdal, A., Widere, T.-E. Eur. J. Clin. Pharmac. 1976, 9,
265. 3. Lancet, 1976, i, 1004. 4. Smith, J. W. G., and others.
J. Hyg.,
Camb. 1976, 76, 235.
our
commitment
to an
individual child
over a
longer period. We also have to face two problems: the child cannot be responsible for himself and may have irresponsible parents; and the average general practice is geared to being called by the patient or parent, if needed, and does not normally accept an imposed follow-up as part of its normal work. To cover this situation the paediatrician has an appointment book. It is common practice for the notes of the "non-attenders" to be shown to the consultant and where needed, new appointments are made and repeated until the child returns for review or alternative
plans are made. If you can find us general practices which will regularly follow-up their chronic cases or find us the areas with enough health visitors with time to act in this capacity, then many of us would cheerfully shed a significant section of our follow-up
load. P. R. A., Fuster, J. M., Newman, P., Hirschman, A. Lancer, 1976, i. 1347. 2. Waller, R. Phil. Trans. R. Soc. Lond. 1716, 29, 509. 3. Leiber, A. Verleichende Anatomie der Sprechtzunge Zool. Stuttg. 1907, 20, 1. 4. Lancet, 1976, i, 1168. 1.
1 2.
right, "Come Again-3 Months" is a millpaediatrics there are problems which cannot be
are
but in
May,
