1301 cases
the levels of the
gluconeogenic
aminoacids
It is not clear whether these changes in the pattern of aminoacids in the blood are due to some intrinsic defect of muscle metabolism, which is common to Duchenne muscular dystrophy and to the congenital muscle disease of mice, or whether they merely reflect a reduction in muscle mass. However, our work makes it clear that any metabolic stress, and especially fasting, will aggravate the process of muscle wasting, by calling upon the muscles to release aminoacids, a process which cannot be long sustained without a loss of structural protein from the muscles. Department of Neuropathology, Institute of Psychiatry, London SE5 8AF
Department of Applied Physiology and Surgical Science, Royal College of Surgeons,
AMNIOCENTESIS RATES IN OLDER WOMEN
(alanine, gly-
cine, threonine, and serine) are reduced while the branchedchain aminoacids (valine, leucine, and isoleucine) are raised.
SIR,-Alberman et al.l suggested that in the South East Thames Regional Health Authority during 1977 there may have been a referral rate as high as 48% for amniocentesis for pregnant women over 40 years of age who are at high risk for Down syndrome. Since they did not expect more than 68-77% of these patients to want amniocentesis, assuming that dissemination of knowledge does not change booking habits, they felt that they had almost reached saturation point in the long struggle towards full use of the available service.
E. SPARGO O. E. PRATT
London WC2A 3PN
P. M. DANIEL
Department of Child Health, Hammersmith Hospital, London W12
HEATHER STEPHENS
NON-SURGICAL TREATMENT OF BILIARY OBSTRUCTION
SiR,-We share the Royal Free Hospital workers’ enthusiasm for the percutaneous insertion of biliary drainage tubes in patients with malignant obstruction (Nov. 17, p. 1040), but differ in our approach to patients with bileduct stones. Dr Dooley and his colleagues imply that endoscopic retrograde cholangiography (ERC) carries a greater risk of cholangitis than does percutaneous transhepatic cholangiography (PTC) in patients with dilated bileducts. Both procedures can cause cholangitis,I,2 but the risk is very small in experienced hands;3 we have not caused cholangitis during our last 1000 ERCP examinations. Our main disagreement with the Royal Free group concerns the treatment of patients with acute cholangitis due to bileduct stones. Endoscopic diathermy sphincterotomy provides adequate drainage and removal of the cause. If the patient has already undergone cholecystectomy, no further treatment is required. If the gallbladder is still in place, the patient needs only a simple cholecystectomy when the acute illness has subsided. Drainage can certainly be effective percutaneously, but this route is less attractive for the patient who will still require operative duct exploration and, possibly, a sphincteroplasty (as in one of the Royal Free cases). Follow-up studies indicate that endoscopic sphincterotomy provides adequate drainage even in patients with dilated ducts; the orifice is often as large as a sur-
gical sphincteroplasty. When necessary, the endoscopic approach also allows temporary placement of a drainage tube brought out through the patient’s nose,’ and even the insertion of an endoprosthesis
(unpublished). Gastrointestinal Unit, Middlesex Hospital, London W1N 8AA
PETER B. COTTON BERNARD H. LAURENCE
Department of Radiology, Middlesex Hospital
RICHARD MASON
the levels of the
gluconeogenic
aminoacids
It is not clear whether these changes in the pattern of aminoacids in the blood are due to some intrinsic defect of muscle metabolism, which is common to Duchenne muscular dystrophy and to the congenital muscle disease of mice, or whether they merely reflect a reduction in muscle mass. However, our work makes it clear that any metabolic stress, and especially fasting, will aggravate the process of muscle wasting, by calling upon the muscles to release aminoacids, a process which cannot be long sustained without a loss of structural protein from the muscles. Department of Neuropathology, Institute of Psychiatry, London SE5 8AF
Department of Applied Physiology and Surgical Science, Royal College of Surgeons,
AMNIOCENTESIS RATES IN OLDER WOMEN
(alanine, gly-
cine, threonine, and serine) are reduced while the branchedchain aminoacids (valine, leucine, and isoleucine) are raised.
SIR,-Alberman et al.l suggested that in the South East Thames Regional Health Authority during 1977 there may have been a referral rate as high as 48% for amniocentesis for pregnant women over 40 years of age who are at high risk for Down syndrome. Since they did not expect more than 68-77% of these patients to want amniocentesis, assuming that dissemination of knowledge does not change booking habits, they felt that they had almost reached saturation point in the long struggle towards full use of the available service.
E. SPARGO O. E. PRATT
London WC2A 3PN
P. M. DANIEL
Department of Child Health, Hammersmith Hospital, London W12
HEATHER STEPHENS
NON-SURGICAL TREATMENT OF BILIARY OBSTRUCTION
SiR,-We share the Royal Free Hospital workers’ enthusiasm for the percutaneous insertion of biliary drainage tubes in patients with malignant obstruction (Nov. 17, p. 1040), but differ in our approach to patients with bileduct stones. Dr Dooley and his colleagues imply that endoscopic retrograde cholangiography (ERC) carries a greater risk of cholangitis than does percutaneous transhepatic cholangiography (PTC) in patients with dilated bileducts. Both procedures can cause cholangitis,I,2 but the risk is very small in experienced hands;3 we have not caused cholangitis during our last 1000 ERCP examinations. Our main disagreement with the Royal Free group concerns the treatment of patients with acute cholangitis due to bileduct stones. Endoscopic diathermy sphincterotomy provides adequate drainage and removal of the cause. If the patient has already undergone cholecystectomy, no further treatment is required. If the gallbladder is still in place, the patient needs only a simple cholecystectomy when the acute illness has subsided. Drainage can certainly be effective percutaneously, but this route is less attractive for the patient who will still require operative duct exploration and, possibly, a sphincteroplasty (as in one of the Royal Free cases). Follow-up studies indicate that endoscopic sphincterotomy provides adequate drainage even in patients with dilated ducts; the orifice is often as large as a sur-
gical sphincteroplasty. When necessary, the endoscopic approach also allows temporary placement of a drainage tube brought out through the patient’s nose,’ and even the insertion of an endoprosthesis
(unpublished). Gastrointestinal Unit, Middlesex Hospital, London W1N 8AA
PETER B. COTTON BERNARD H. LAURENCE
Department of Radiology, Middlesex Hospital
RICHARD MASON
