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,

105 it essential that repeated folin some cases. This is no simmaintained is years low-up ple consultation; it is the observation of a changing scene from which parent, child, family doctor, and education service can gain, and it is one of the ways by which paediatricians learn. "Stamp collecting" is an unkind term for the process by which a consultant continues to learn by observation of special cases. Paediatrics is full of new things, and their evolution is often slow.

The

development aspect makes over

Pædiatric Department, Royal Albert Edward Infirmary,

Wigan WN 1

2NN

justice. Most people, given free choice, would opt to travel a few miles rather than do without or endure a long waiting period. It would be unfortunate if equity is pursued to the point of ignoring hospital performance. The present financial stringency is forcing management to question more closely than hitherto the cost and benefit of both old and new policies. We should not miss this unique opportunity of setting up a financial

which will promote the

growth

of greater

Oxford

Regional Health Authority, Headington, Oxford OX3 7LF

A. BARR

R. M. FORRESTER

PLASMA-PROPRANOLOL IN INFLAMMATORY DISEASE

DOCTORS ON COMMITTEES

SIR,-One’s heart bleeds for Professor Brumfitt and his colwhose administration duties include membership of "not less than 15 local hospital and medical-school committees and working-parties". My personal experience in the periphery, where committees are also found, leads me to suppose that only an aggressive attitude will prevent this activity taking over time which should be devoted to the care of patients, basically a more agreeable exercise. One simply refuses to go to committee meetings which clash with outpatients or ward rounds, or evening meetings which interfere with such life-enhancing activities as playing hockey, relearning a musical instrument, or, if one is in desperate case, spending time with the family. One finds that one is then going only to the really essential committees and that the other ones are looked after by one’s colleagues who may be more tolerant than oneself, or else the committee just packs up.

leagues’

Southend

structure

efficiency.

SIR,-Propranolol in a single oral dose of up to 40 mg undergoes first-pass metabolism such that about 80% is metabolised to 4-hydroxy propranolol.’ (Above 40 mg there is a fairly linear relationship between dose and plasma level.) 4-hydroxy propranolol is a p-blocker of similar potency to the parent drug, the main difference being an intrinsic sympathomimetic effect of similar degree to oxprenolol. The clinical significance of propranolol blood levels can only be judged in relation to 4-hydroxy propranolol levels. This does not explain why inflammatory diseases modify propranolol pharmakokinetics, but without information on 4-hydroxy propranolol levels the work by Mrs Babb and her colleagues2 cannot be interpreted. 18 Sutherland Avenue,

Jacobs Well, near

Guildford

A.

Surrey GU4 7QX

J. F. FLETCHER

Hospital,

Westchff-on-Sea, Essex SS0 0RY

ANTHONY J. P. WILLIS

REALLOCATION OF RESOURCES

StR,-Barnard and Ham2 rightly draw attention to the similarity between current revenue allocation problems and those facing regional hospital boards twenty years ago. Some of the anomalies present at nationalisation have been rectified or ameliorated through the capital building programme and by other means. Of course, some remain because it is impossible, in a mammoth service like the N.H.S. with its enormous investments and deeply rooted traditions, to change quickly. Evolution, rather than revolution, is the keynote. The method of allocating revenue (now c4000 million per annum for England) between the 14 regional health authorities on a basis of weighted population and hospital case load seems fair, though, at present, it ignores special factors associated with high risk and deprived areas which may justify preferential consideration. What has received less consideration and publicity is the allocation within regions. The Resource Allocation Working Party3 has suggested that R.H.A.S should follow the method used nationally. Superficially this seems logical and fair. Further reflection, however, leads to the belief that such a policy could adversely affect the volume of patient care.

Hospitals vary greatly in the efficiency with which they use their resources.45 Curtailing the budget of an efficient hospital will restrict or even reduce the number of patients treated while there is no automatic guarantee that the transferred money will result in a commensurate increase in output of the benefiting hospital. Shifting revenue from efficient to less efficient hospitals, therefore, amounts to a false sense of territorial 1 Brumfitt, W. Hoffbrand, A. V., Wills, M. R. Lancet, 1976, i, 1072 2 Barnard K., Ham, C Lancet, 1976, i. 1399. 3. First Interim Report of the Resource Allocation Working Party. Department of Health and Social Security. 1975 4 Feldstein, M S. Economic Analysis for Health Service Efficiency Amsterdam. 1967. 5. Barr, A Lancet, 1968, i, 353

*** The legend to the table in the letter Birmingham workers should have read: "... patients with inflammatory disease (E.S.R.>20 mm/h)". We apologise to Mrs Babb and her colleagues for this mistake.-ED. L.

by the

PYOGENIC LIVER ABSCESS a misleading impression of the involved in this uncommon infection. Although Escherichia coli and Streptococcus fcecalis have been, in many series, the commonest organisms isolated, it is highly likely that the lack of adequate anaerobic cultures accounted for the frequently reported finding of "sterile" pus. An extensive review by Sabbaj et al. has emphasised the vital role of anaerobic bacteria in the pathogenesis of liver abscess. Anaerobic organisms are often found as the sole pathogen but also in mixed cultures with such organisms as E. coli and Strep. faecalis. Improved anaerobic culture techniques are providing the answer to the "sterile" liver abscess. We agree that surgical drainageof a pyogenic liver abscess is mandatory, but would emphasise that anaerobic bacteria require very different antibiotic therapy from that appropriate for E. coli and Strep. faecalis, and their isolation and identification are therefore an essential part of the successful management of this dangerous disease. The source of the bacteria responsible for a pyogenic liver abscess is, as you point out, seldom found, but in our opinion it is an unimportant factor in determining the patient’s prognosis.

SiR,-Your editorial3 gives

pathogens

Departments of Microbiology and Medicine, St Thomas’s Hospital Medical School, London SE1 7EH

IAN PHILLIPS SUSANNAH EYKYN NIGEL BATEMAN

1.

Riess, W.,

2

by W. Schweizer), p. 276. Bern, 1974 Babb, J., Bishop, H., Schneider, R. E., Hawkins, C. F., Hoare,

and others in

&bgr;-blockers;

Present Status and Future

Prospects

edited

A. M. Lan-

1976, i, 1413. 3. Lancet, 1976, i, 1170. 4 Sabbaj, J., Sutter, V. L., Finegold, S. M. Ann intern. Med. 1972, 77, 629. cet,