46 COLD AND TIC DOULOUREUX
SIR,-Sufferers from tic douloureux may be
interested in
a
simple method which has kept me pain-free for over a year. Knowing the very low threshold for touch, I wondered if temperature change could trigger the nerve as well, and in my case
avoiding sudden cold has been most effective. This means, not going into an air-conditioned room, not using ice in drinks, avoiding cold winds, not swimming in cold water, and so on.
first envisaged. We agree with Professor Caen and Dr Sultan about the need for further studies. A L. i RtnDM A. BLOOM I. R. PEAKE J. C. GIDDINGS Department of Hæmatology, SONIA A. M. SHEARN of University Hospital Wales, Heath Park, Cardiff CF4 4XW. E. G. D. TUDDENHA
SCREENING FOR NEURAL-TUBE DEFECTS
I do not think that this is a spontaneous remission because if the affected cheek is unavoidably exposed to sudden cold, the
pain recurs. Lady Davis Institute for Medical Research, Jewish General Hospital, 3755 Chemin Cote St. Catherine Road, Montreal, Quebec H3T 1E2, Canada.
S!R,—Ifully support Dr Seller’s criticisms (Dec. 6, of the paper by Leighton et 1.’ on the potential of maternal-blood a-fetoprotein (A.F.P.) in screening for neuraltube defects. What is principally at issue in assessing the value of this procedure is the number of cases of open spina bifida where A.F.P. concentrations lie above a defined upper limit of normal. Why Leighton et al. should feel that "for the first time some tentative observations on the practical use of A.F.P. estimation in maternal blood using the results of a single laboratory" are possible when they have only analysed 6 cases of spina bifida, is not clear. What is clear is that their results are at variance with a much larger study, also based on a single
p.1141)
NAOMI FITCH
ENDOTHELIAL CELLS AND FACTOR-VIII-RELATED PROTEIN on the of von disease Willebrand’s (vWd) proposed by pathogenesis Professor Caen and Dr Sultan (]3ec. 6, p. 1129). The association between factor-vin-reiated antigen and the vascular endothelium is well established’and the synthesis by endothelial cells of this and the ristocetin platelet-aggregation cofactor has been described.34 These activities are quite possibly functions of the same molecule, sometimes referred to as factor-vin-reiated protein or von Willebrand factor.5 In several patients with vWd with prolonged bleeding-time, defective ristocetin-induced platelet aggregation, and detectable levels of factor-vm-retated protein we have found that the factor-viii-related protein is abnormal and has increased anodal electrophoretic mobility. 6The suggestion of Professor Caen and Dr Sultan that vWd is a result of an endothelial-cell defect is entirely reasonable. We have done further studies on factor-vin-reiated protein synthesised in cultures of normal endothelial cells. In four cultures derived from different umbilical cords, factor-viii-related protein was detected in the culture medium and active synthesis was demonstrated by the incorporation of 335-methionine into specific immunoprecipitate. This factor-vm-related protein showed a reaction of immunological identity with that found in normal plasma. However, its electrophoretic mobility demonstrated on crossed immunoelectrophoresis was abnormal, being-- more anodic than factor-viii-related protein in normal adult or cord plasma or serum. Factor-vm-retated protein produced by normal fetal endothelial cells in culture and that present in some plasmas thus have certain features in common. These include increased anodal mobility and apparently normal subunits on reduction8 although the vWd protein does not support ristocetin platelet aggregation. It thus seems that the presence of apparently normal subunits does not necessarily indicate that the molecules of factor-vin-related protein are identical. It seems that the material produced by endothelial cells in our cultures is a little different from that which appears in plasma as normal factor-viii-related protein suggesting that it may be further processed in some way. Although the primary defect in vWd may reside in the endothelial cell, this hypothesis does not explain the results of transfusion, and the situation seems to be more complex than at
SIR,-We have read with interest the hypothesis
laboratory,2
Bloom, A. L., Giddings,, J. C., Wilks, C. J. Nature New Biology, 1973, 241,
2.
L. W., de los Santos, R. P., Hoyer, J. R. J. clin. Invest. 1973, 52, 2737. Jaffe, E. A., Hoyer, L. W., Nachman, R. L. ibid. p. 2757. Jaffe, E. A., Nachman, R. L. ibid. 1975, 56, 698. Bloom, A. L., Peake, I. R., Giddings, J. C. Lancet, 1974, i, 576. Peake, I. R., Bloom, A. L., Giddings, J. C. New Engl. J. Med. 1974, 291, 113. Peake, I. R., Bloom, A. L., Giddings, J. C. in Abstracts of the Vth Congress International Society of Thrombosis and Hæmostasis, Paris 1975; p. 412. Gralnick, H. R., Coller, B. S., Sutton, Y. J. clin. Invest. 1975, 56, 814.
217.
3. 4. 5. 6. 7.
8.
Hoyer,
published experience.
NUMBER OF CASES OF OPEN SPINA BIFIDA AND ANENCEPHALY WHERE MATERNAL-BLOOD A.F.P. WAS MEASURED BETWEEN
15
AND
20
WEEKS OF
PREGNANCY.
Cases where A.F.P.S
were
outside the normal range
are
shown in
parentheses.
The table shows the total number of published cases of both spina bifida and anencephaly where maternal-blood A.F.P. was outside a normal range between 15 and 20 weeks of gestation. This time period is chosen because A.F.P. does not begin to rise in abnormal pregnancies until the end of the first trimester2 and because termination of pregnancy is undesirable after the 20th week. The conclusions from the table are less optimistic than those of Leighton et al.; in particular the table shows a 47% detection-rate for spina bifida against the 80% which Leighton et al. recorded. The 80% figure is not very different from the success-rate which we recorded 18 months ago when we were at a comparable level of experience. Though it is probable that detection-rates will improve with better technology and in carefully controlled prospective studies, an objective assessment of screening will not be possible until many more results have been collected. It is to this end that the U.K. Colopen
1. 2.
1.
and indeed with cumulative
Leighton, P. C., Gordon, Y. B., Kitau, M. J., Leek, A. E., Chard, T. Lancet, 1975, ii, 1012. Brock, D. J. H., Scrimgeour, J. B., Bolton, A. E., Wald, N. J., Peto, R.,
Barker, S. ibid. 1975, ii, 195. 3. Brock, D. J. H., Bolton, A. E., Monaghan, J. M. ibid. 1973, ii, 923. 4. Seller, M. J., Singer, J. D., Coltart, T. M., Campbell, S. ibid. 1974, i, 428. 5. Harris, R., Jennison, R. F., Barson, A. J., Laurence, K. M., Ruoslahti, E.,
Seppala, M. ibid. 1974, i, 429. Wald, N. J., Brock, D. J. H., Bonnar, J. ibid. 1974, i, 765. Brock, D. J. H., Bolton, A. E., Scrimgeour, J. B. ibid. 1974, i, 767. Cowchock, F. S., Jackson, L. G. ibid. 1974, ii, 48. Leek, A. E., Leighton, P. C., Kitau, M. J., Chard, T. ibid. 1974, ii, 1511. Vince, J. D., McManus, T. J., Ferguson-Smith, M. A., Ratcliffe, J. G. Br. J. Obstet. Gynœc. 1975, 82, 718. 11. Campbell, S., Pruse Davies, J., Coltart, T. M., Seller, M. J., Singer, J. D. Lancet, 1975, i, 1065
6. 7. 8. 9. 10.
47 laborative Study was instituted, and it is regrettable that participating members of that study should publish preliminary data leading to conclusions which may turn out to be mislead-
ingly optimistic. Department of Human Genetics, Western General Hospital, Edinburgh EH4 2HU.
D.
J. H. BROCK
AMNIOTIC ALPHA-FETOPROTEIN AND OMPHALOCELE
SIR,-A transabdominal amniocentesis was performed for genetic reasons in the 15th week of pregnancy in a 27-year-old patient, whose third child had had Down syndrome. The ocfetoprotein (A.F.P.) concentration in the amniotic fluid was very high, 110 µg/ml at first and 115 µg/ml a week later (upper limit of normal 50 µg/ml). The raised A.F.P. level suggested that the fetus had an open neural-tube,defect and the patient decided to have a termination, which was carried out by intravenous infusion of prostaglandin E. A female fetus with an extensive omphalocele was delivered. The liver and small intestine were in the omphalocele, but there was no skin defect. This is the second case, to our knowledge, of a raised amniotic-fluid A.F.P. concentration early in pregnancy associated with an omphalocele. Nevin and Armstrong’ reported the first. Omphalocele may be a further malformation associated with raised A.F.P. levels. Department of Obstetrics and Gynæcology, University of Zurich, 8006 Zürich,
stayed under 10 mvmin, with blood-creatinine values between 6.5 and 8.5 mg/dl. At the end of September she had slight hypogastric malaise, especially at night, but without signs of uterine irritability. On Oct. 17 she spontaneously had a high rupture of membranes. Delivery was induced with oral synthetic oxytocin. The fetal sounds were normal and there were no signs of fetal hypoxia. Delivery was normal, and a male of 35 weeks’ gestational age and 2200 g body-weight, with an Apgar score of 8 (10 after 3 min) was born. There were no visible congenital anomalies. The post-partum course was normal until amenorrhoea developed. At that time her blood-urea was 250 mg/dl, creatinine 10.9 mg/dl, and creatinine clearance 4-5 mvmin. She has since been on periodic haemodialysis. The infant’s development has been normal. This case shows conservative management can be successful in a pregnant woman with poor renal function and hypertension. Nevertheless we feel conservative treatment should only be tried in a centre with dialysis facilities and under close supervision. The control of the hypertension must have been the chief reason for the successful outcome of pregnancy, since fetal prognosis is related more to maternal blood-pressure than to uraemia. A detailed account of this case is given elsewhere.3 J. EGIDO DE LOS RíOS Nephrology Service, J. J. PLAZA PEREZ Fundación Jiménez Diaz, S. CASADO PÉREZ Avda. Reyes Católicos 2, L. HERNANDO AVENDANO. Madrid 3, Spain
JÜRG KUNZ JOSEF SCHMID
Switzerland.
PSYCHOGERIATRIC PATIENTS WHO DIE IN HOSPITAL
SUCCESSFUL PREGNANCY AND ADVANCED
SIR— You point out (Oct. 25, p.801) that the chances of a successful pregnancy are slim if the mother’s plasma-urea exceeds 60 mg/dl, especially if she is hypertensive. In Mackay’s large experience2 they were nil. We have successfully managed a pregnancy despite advanced renal failure and hypertension. A 33-year-old woman, six-months pregnant, entered the nephrology service in August 1973, when her blood-urea was found to be raised. Her first pregnancy 8 years previously had been complicated by palpebral and ankle oedema, proteinuria, and hypertension. She was treated with salt restriction and hypotensive drugs, and gave birth to a normal infant. She has since presented with polyuria, polydipsia, and nocturia, high blood-pressure (diastolic 90-100 mm Hg), and proteinuria up
to 3 g/l. Her second pregnancy had started with
vomiting and ankle cedema during the first 3 months. When we saw the patient her blood-pressure was 155/90 mm Hg; pulse 88/min, slight systolic on the basal area. Uterus palpable at height of umbilicus. Fetal heart sounds normal. Slight ankle oedema. Eye fundus normal. Laboratory assessment included Hb 6.5 g/dl, urea 160
mg/dl, creatinine 6.5 mg/dl with a clearance of 10 ml/min. Urinalysis revealed 2.7g protein/24h white and 60 red bloodcells high-power field, and evidence of urinary infection (Escherichia coly. The E.C.G. showed left-ventricular burden. She was ordered complete rest and checked daily. The diet contained 2500 kcal and 40 g proteins with supplements of calcium, iron, and vitamins. Aluminium hydroxide was added and 500 mg of progesterone were administered weekly. Packed red blood-cells were transfused to maintain the hsematocht above 20%. Blood-pressure was controlled with reserpine and
hydrallazine. Her acidosis was corrected and she was maintained in adequate salt and water balance. Creatinine clearance persistently 1.
Nevin, N. C., Armstrong, M. J. J. Obstet. Gynœc.
Br. Commonw.
826. 2.
McKay, E. V.
Aust. N.
SIR,—Stone House is the main, though
not the only, psychihospital serving the Danford and Gravesham Health District, which has a population of about 250 000. The population is not exceptional-in particular, there is no special geriatric loading such as may happen on the south coast. We have about 27 000 people over the age of 65 in our district. Between January, 1970, and June, 1975, 155 patients from
atric
RENAL FAILURE
Z. Jl Obstet. Gynœc. 1963, 3, 21.
1975, 82,
the district over the age of 65 died. Less than half had been in hospital for more than a year: Years
Up to
Up to 2 2-5 6-10 11-15 16-20 Total
Total 86 51 10
M F 36 50 12 39 3 7 22 1 3 54 101
36
86
50
4 4
155
37 had been in hospital for a month or less before they died 14 survived a week or less in hospital). The causes of death of these 14 were: bronchopneumonia (3), pulmonary embolus (3), congestive cardiac failure (3), myocardial infarction (2), cerebrovascular accident (1), cor pulmonale (1), carcinoma with metastasis (1). Of the 155 patients only 7 were admitted on this final occasion before the age of 65, and among these 7 by far the larger part of their stay occurred over the age of 65. It can be concluded therefore that district patients admitted before the age of 65 seldom remain in psychiatric hospital up to or after that age without a break until their death there. Only 32 patients had previously been admitted to this psychiatric hospital within the last 15 years or more, for an earlier episode of illness. 127 were considered at the time of their final admission to have a cerebral organic state (e.g., dementia or confusion). These patients were, on average, in their late 70s (males) or early 80s (females), and most of them had been in hospital a year or less when they died. The direct cause of death in most instances was certified as bronchopneumonia or car-
(and
3.
de los Rios, J., Plaza, J. J., Fernandez Revta. clin. esp. 1975, 137, 363.
Egido
Aparicio,
M.
A., Hernando, L.
SIR,-Sufferers from tic douloureux may be
interested in
a
simple method which has kept me pain-free for over a year. Knowing the very low threshold for touch, I wondered if temperature change could trigger the nerve as well, and in my case
avoiding sudden cold has been most effective. This means, not going into an air-conditioned room, not using ice in drinks, avoiding cold winds, not swimming in cold water, and so on.
first envisaged. We agree with Professor Caen and Dr Sultan about the need for further studies. A L. i RtnDM A. BLOOM I. R. PEAKE J. C. GIDDINGS Department of Hæmatology, SONIA A. M. SHEARN of University Hospital Wales, Heath Park, Cardiff CF4 4XW. E. G. D. TUDDENHA
SCREENING FOR NEURAL-TUBE DEFECTS
I do not think that this is a spontaneous remission because if the affected cheek is unavoidably exposed to sudden cold, the
pain recurs. Lady Davis Institute for Medical Research, Jewish General Hospital, 3755 Chemin Cote St. Catherine Road, Montreal, Quebec H3T 1E2, Canada.
S!R,—Ifully support Dr Seller’s criticisms (Dec. 6, of the paper by Leighton et 1.’ on the potential of maternal-blood a-fetoprotein (A.F.P.) in screening for neuraltube defects. What is principally at issue in assessing the value of this procedure is the number of cases of open spina bifida where A.F.P. concentrations lie above a defined upper limit of normal. Why Leighton et al. should feel that "for the first time some tentative observations on the practical use of A.F.P. estimation in maternal blood using the results of a single laboratory" are possible when they have only analysed 6 cases of spina bifida, is not clear. What is clear is that their results are at variance with a much larger study, also based on a single
p.1141)
NAOMI FITCH
ENDOTHELIAL CELLS AND FACTOR-VIII-RELATED PROTEIN on the of von disease Willebrand’s (vWd) proposed by pathogenesis Professor Caen and Dr Sultan (]3ec. 6, p. 1129). The association between factor-vin-reiated antigen and the vascular endothelium is well established’and the synthesis by endothelial cells of this and the ristocetin platelet-aggregation cofactor has been described.34 These activities are quite possibly functions of the same molecule, sometimes referred to as factor-vin-reiated protein or von Willebrand factor.5 In several patients with vWd with prolonged bleeding-time, defective ristocetin-induced platelet aggregation, and detectable levels of factor-vm-retated protein we have found that the factor-viii-related protein is abnormal and has increased anodal electrophoretic mobility. 6The suggestion of Professor Caen and Dr Sultan that vWd is a result of an endothelial-cell defect is entirely reasonable. We have done further studies on factor-vin-reiated protein synthesised in cultures of normal endothelial cells. In four cultures derived from different umbilical cords, factor-viii-related protein was detected in the culture medium and active synthesis was demonstrated by the incorporation of 335-methionine into specific immunoprecipitate. This factor-vm-related protein showed a reaction of immunological identity with that found in normal plasma. However, its electrophoretic mobility demonstrated on crossed immunoelectrophoresis was abnormal, being-- more anodic than factor-viii-related protein in normal adult or cord plasma or serum. Factor-vm-retated protein produced by normal fetal endothelial cells in culture and that present in some plasmas thus have certain features in common. These include increased anodal mobility and apparently normal subunits on reduction8 although the vWd protein does not support ristocetin platelet aggregation. It thus seems that the presence of apparently normal subunits does not necessarily indicate that the molecules of factor-vin-related protein are identical. It seems that the material produced by endothelial cells in our cultures is a little different from that which appears in plasma as normal factor-viii-related protein suggesting that it may be further processed in some way. Although the primary defect in vWd may reside in the endothelial cell, this hypothesis does not explain the results of transfusion, and the situation seems to be more complex than at
SIR,-We have read with interest the hypothesis
laboratory,2
Bloom, A. L., Giddings,, J. C., Wilks, C. J. Nature New Biology, 1973, 241,
2.
L. W., de los Santos, R. P., Hoyer, J. R. J. clin. Invest. 1973, 52, 2737. Jaffe, E. A., Hoyer, L. W., Nachman, R. L. ibid. p. 2757. Jaffe, E. A., Nachman, R. L. ibid. 1975, 56, 698. Bloom, A. L., Peake, I. R., Giddings, J. C. Lancet, 1974, i, 576. Peake, I. R., Bloom, A. L., Giddings, J. C. New Engl. J. Med. 1974, 291, 113. Peake, I. R., Bloom, A. L., Giddings, J. C. in Abstracts of the Vth Congress International Society of Thrombosis and Hæmostasis, Paris 1975; p. 412. Gralnick, H. R., Coller, B. S., Sutton, Y. J. clin. Invest. 1975, 56, 814.
217.
3. 4. 5. 6. 7.
8.
Hoyer,
published experience.
NUMBER OF CASES OF OPEN SPINA BIFIDA AND ANENCEPHALY WHERE MATERNAL-BLOOD A.F.P. WAS MEASURED BETWEEN
15
AND
20
WEEKS OF
PREGNANCY.
Cases where A.F.P.S
were
outside the normal range
are
shown in
parentheses.
The table shows the total number of published cases of both spina bifida and anencephaly where maternal-blood A.F.P. was outside a normal range between 15 and 20 weeks of gestation. This time period is chosen because A.F.P. does not begin to rise in abnormal pregnancies until the end of the first trimester2 and because termination of pregnancy is undesirable after the 20th week. The conclusions from the table are less optimistic than those of Leighton et al.; in particular the table shows a 47% detection-rate for spina bifida against the 80% which Leighton et al. recorded. The 80% figure is not very different from the success-rate which we recorded 18 months ago when we were at a comparable level of experience. Though it is probable that detection-rates will improve with better technology and in carefully controlled prospective studies, an objective assessment of screening will not be possible until many more results have been collected. It is to this end that the U.K. Colopen
1. 2.
1.
and indeed with cumulative
Leighton, P. C., Gordon, Y. B., Kitau, M. J., Leek, A. E., Chard, T. Lancet, 1975, ii, 1012. Brock, D. J. H., Scrimgeour, J. B., Bolton, A. E., Wald, N. J., Peto, R.,
Barker, S. ibid. 1975, ii, 195. 3. Brock, D. J. H., Bolton, A. E., Monaghan, J. M. ibid. 1973, ii, 923. 4. Seller, M. J., Singer, J. D., Coltart, T. M., Campbell, S. ibid. 1974, i, 428. 5. Harris, R., Jennison, R. F., Barson, A. J., Laurence, K. M., Ruoslahti, E.,
Seppala, M. ibid. 1974, i, 429. Wald, N. J., Brock, D. J. H., Bonnar, J. ibid. 1974, i, 765. Brock, D. J. H., Bolton, A. E., Scrimgeour, J. B. ibid. 1974, i, 767. Cowchock, F. S., Jackson, L. G. ibid. 1974, ii, 48. Leek, A. E., Leighton, P. C., Kitau, M. J., Chard, T. ibid. 1974, ii, 1511. Vince, J. D., McManus, T. J., Ferguson-Smith, M. A., Ratcliffe, J. G. Br. J. Obstet. Gynœc. 1975, 82, 718. 11. Campbell, S., Pruse Davies, J., Coltart, T. M., Seller, M. J., Singer, J. D. Lancet, 1975, i, 1065
6. 7. 8. 9. 10.
47 laborative Study was instituted, and it is regrettable that participating members of that study should publish preliminary data leading to conclusions which may turn out to be mislead-
ingly optimistic. Department of Human Genetics, Western General Hospital, Edinburgh EH4 2HU.
D.
J. H. BROCK
AMNIOTIC ALPHA-FETOPROTEIN AND OMPHALOCELE
SIR,-A transabdominal amniocentesis was performed for genetic reasons in the 15th week of pregnancy in a 27-year-old patient, whose third child had had Down syndrome. The ocfetoprotein (A.F.P.) concentration in the amniotic fluid was very high, 110 µg/ml at first and 115 µg/ml a week later (upper limit of normal 50 µg/ml). The raised A.F.P. level suggested that the fetus had an open neural-tube,defect and the patient decided to have a termination, which was carried out by intravenous infusion of prostaglandin E. A female fetus with an extensive omphalocele was delivered. The liver and small intestine were in the omphalocele, but there was no skin defect. This is the second case, to our knowledge, of a raised amniotic-fluid A.F.P. concentration early in pregnancy associated with an omphalocele. Nevin and Armstrong’ reported the first. Omphalocele may be a further malformation associated with raised A.F.P. levels. Department of Obstetrics and Gynæcology, University of Zurich, 8006 Zürich,
stayed under 10 mvmin, with blood-creatinine values between 6.5 and 8.5 mg/dl. At the end of September she had slight hypogastric malaise, especially at night, but without signs of uterine irritability. On Oct. 17 she spontaneously had a high rupture of membranes. Delivery was induced with oral synthetic oxytocin. The fetal sounds were normal and there were no signs of fetal hypoxia. Delivery was normal, and a male of 35 weeks’ gestational age and 2200 g body-weight, with an Apgar score of 8 (10 after 3 min) was born. There were no visible congenital anomalies. The post-partum course was normal until amenorrhoea developed. At that time her blood-urea was 250 mg/dl, creatinine 10.9 mg/dl, and creatinine clearance 4-5 mvmin. She has since been on periodic haemodialysis. The infant’s development has been normal. This case shows conservative management can be successful in a pregnant woman with poor renal function and hypertension. Nevertheless we feel conservative treatment should only be tried in a centre with dialysis facilities and under close supervision. The control of the hypertension must have been the chief reason for the successful outcome of pregnancy, since fetal prognosis is related more to maternal blood-pressure than to uraemia. A detailed account of this case is given elsewhere.3 J. EGIDO DE LOS RíOS Nephrology Service, J. J. PLAZA PEREZ Fundación Jiménez Diaz, S. CASADO PÉREZ Avda. Reyes Católicos 2, L. HERNANDO AVENDANO. Madrid 3, Spain
JÜRG KUNZ JOSEF SCHMID
Switzerland.
PSYCHOGERIATRIC PATIENTS WHO DIE IN HOSPITAL
SUCCESSFUL PREGNANCY AND ADVANCED
SIR— You point out (Oct. 25, p.801) that the chances of a successful pregnancy are slim if the mother’s plasma-urea exceeds 60 mg/dl, especially if she is hypertensive. In Mackay’s large experience2 they were nil. We have successfully managed a pregnancy despite advanced renal failure and hypertension. A 33-year-old woman, six-months pregnant, entered the nephrology service in August 1973, when her blood-urea was found to be raised. Her first pregnancy 8 years previously had been complicated by palpebral and ankle oedema, proteinuria, and hypertension. She was treated with salt restriction and hypotensive drugs, and gave birth to a normal infant. She has since presented with polyuria, polydipsia, and nocturia, high blood-pressure (diastolic 90-100 mm Hg), and proteinuria up
to 3 g/l. Her second pregnancy had started with
vomiting and ankle cedema during the first 3 months. When we saw the patient her blood-pressure was 155/90 mm Hg; pulse 88/min, slight systolic on the basal area. Uterus palpable at height of umbilicus. Fetal heart sounds normal. Slight ankle oedema. Eye fundus normal. Laboratory assessment included Hb 6.5 g/dl, urea 160
mg/dl, creatinine 6.5 mg/dl with a clearance of 10 ml/min. Urinalysis revealed 2.7g protein/24h white and 60 red bloodcells high-power field, and evidence of urinary infection (Escherichia coly. The E.C.G. showed left-ventricular burden. She was ordered complete rest and checked daily. The diet contained 2500 kcal and 40 g proteins with supplements of calcium, iron, and vitamins. Aluminium hydroxide was added and 500 mg of progesterone were administered weekly. Packed red blood-cells were transfused to maintain the hsematocht above 20%. Blood-pressure was controlled with reserpine and
hydrallazine. Her acidosis was corrected and she was maintained in adequate salt and water balance. Creatinine clearance persistently 1.
Nevin, N. C., Armstrong, M. J. J. Obstet. Gynœc.
Br. Commonw.
826. 2.
McKay, E. V.
Aust. N.
SIR,—Stone House is the main, though
not the only, psychihospital serving the Danford and Gravesham Health District, which has a population of about 250 000. The population is not exceptional-in particular, there is no special geriatric loading such as may happen on the south coast. We have about 27 000 people over the age of 65 in our district. Between January, 1970, and June, 1975, 155 patients from
atric
RENAL FAILURE
Z. Jl Obstet. Gynœc. 1963, 3, 21.
1975, 82,
the district over the age of 65 died. Less than half had been in hospital for more than a year: Years
Up to
Up to 2 2-5 6-10 11-15 16-20 Total
Total 86 51 10
M F 36 50 12 39 3 7 22 1 3 54 101
36
86
50
4 4
155
37 had been in hospital for a month or less before they died 14 survived a week or less in hospital). The causes of death of these 14 were: bronchopneumonia (3), pulmonary embolus (3), congestive cardiac failure (3), myocardial infarction (2), cerebrovascular accident (1), cor pulmonale (1), carcinoma with metastasis (1). Of the 155 patients only 7 were admitted on this final occasion before the age of 65, and among these 7 by far the larger part of their stay occurred over the age of 65. It can be concluded therefore that district patients admitted before the age of 65 seldom remain in psychiatric hospital up to or after that age without a break until their death there. Only 32 patients had previously been admitted to this psychiatric hospital within the last 15 years or more, for an earlier episode of illness. 127 were considered at the time of their final admission to have a cerebral organic state (e.g., dementia or confusion). These patients were, on average, in their late 70s (males) or early 80s (females), and most of them had been in hospital a year or less when they died. The direct cause of death in most instances was certified as bronchopneumonia or car-
(and
3.
de los Rios, J., Plaza, J. J., Fernandez Revta. clin. esp. 1975, 137, 363.
Egido
Aparicio,
M.
A., Hernando, L.
