BRITISH MEDICAL JOURNAL
4 SEPTEMBER 1976
587
force" are unlikely to be bettered in the for- grand multipara who had delivered five babies seen in the blood glucose recovery rates. The seeable future by modern pharmacological vaginally. The only other complication was an important ancillary properties of these fepisode of haemoglobinuria in a patient who blockers are shown in the table below. and surgical substitutes. PETER NIXON appears to have suffered an accidental intraThere is no correlation between these venous injection of hypertonic urea. The ancillary pharmacological properties and the Cardiac Department, Charing Cross Hospital (Fulham), urine of this patient contained 4 g of haemo- rate of blood glucose recovery from hypoLondon W6 globin per litre. An intravenous infusion of glycaemia. The simple conclusion is that some Holmes, T W, and Rahe, R H, Journal of Psycho- dextrose produced a good diuresis and the r,3-blockers are more specific than others. somatic Research, 1967, 11, 213. urine was cleared of haemoglobin. The patient Atenolol and acebutalol are claimed to be 2 Mendels, J, and Weinstein, N, Psychosomatic Medicine, failed to abort after 24 hours and an oxytocin highly specific P,-blockers and they would 1972, 34, 527. Ransley, C, and Nixon, P G F, unpublished data. infusion was started, after which the cervix seem to have advantages over other 5-blockers Nixon, P G F, Practitioner. In press. dilated and a dead fetus was delivered after for use in subjects prone to hypoglycaemia. 5 Kennedy, A, Lancet, 1957, 2, 261. 6 Kagan, A R, and Levi, Social Science and Medicine, 12 hours. There was no incidence of severe 1974, 8, 225. S P DEACON 7Nixon, P G F, et al, British Journal of Sports Medicine, haemorrhage. Prophylactic antibiotics in the London Road Hospital, 1976, 10, 54. form administered for of co-trimoxazole were Boston, Lincs Mackenzie, J, Diseases of the Heart and Aorta. London, five days. Fourteen patients required evacuaOxford Medical Publications, 1908. tion of retained products of conception and a further two were readmitted for persistent Hypertension as a problem of public vaginal bleeding, but in only one of these health Prophylactic use of bronchodilators cases were chorionic villi retrieved. One SIR,-In your leading article "Bronchodilators, patient was readmitted for pelvic infection in SIR,-Currently the investigation and treatment of hypertension usually depends on the new and old" (14 August, p 387) you did not spite of prophylactic antibiotics. patient's consultation of his doctor for related mention the prophylactic use of these drugs. R V CLEMENTS or unrelated symptoms. Since hypertension is When wheezing is produced by exercise or North Middlesex Hospital, common and treatable and since it is often when nocturnal wheezing is a prominent London N18 clinical feature two puffs of a portable presS KHUNDA symptomless perhaps a public health approach City, to the problem would be best. As a pilot study surised aerosol containing a long-acting Medical a sharply demarcated population such as that P2-adrenoceptor stimulant such as salbutamol Baghdad, Iraq of the Isle of Wight could be subjected to a full or terbutaline before exercising or going to screening procedure and by experiment the bed at night frequently prevents wheezing best strategy for the investigation and treatoccurring, and many young asthmatics who Effects of beta-blocking drugs on ment could be established. There is little follow this advice can play games which would insulin-induced hypoglycaemia doubt that the magnitude and importance of be impossible without such treatment beforeSIR,-The report by Dr R J Newman (21 the problem of hypertension is such that it hand. K N V PALMER August, p 447) that acebutalol did not impair cannot be adequately dealt with within the blood glucose recovery following insulin- current framework of medical practice. University Department of Medicine, induced hypoglycaemia complements the Foresterhill, Aberdeen report by myself and Dr D Barnett (31 July, D B JAMES p 272) that atenolol did not impair blood Marlow, Bucks glucose recovery under similar conditions. Mid-trimester termination The cardioselective or Pl-adrenergic blocking drugs thus offer a new therapeutic approach Treatment of blood/injury/illness phobia SIR,-With reference to your leading article to the treatment of angina pectoris and hyperon this subject (5 June, p 1357) we would tension in diabetic subjects since they would SIR,-Most people know of someone who like to report our series of mid-trimester seem to be free of hypoglycaemic side effects. faints at the sight of blood. Many doctors may abortions using a combination of intraThe recovery of the blood glucose level from remember medical students in their own setamniotic hypertonic urea and prostaglandin hypoglycaemia is dependent on several even themselves-who did so on the first day mechanisms, including hepatic glycogenolysis, in the operating theatre or in casualty. It E2. A series of 58 patients was analysed in lactate feedback from muscles to liver for seems, then, not an uncommon part of the 1973-4 at the North Middlesex Hospital, gluconeogenesis, and decreased peripheral human repertory but one that may be outwhere the technique has since been adopted glucose uptake. The major mechanism in- grown-or treated. Our inquiries from as the routine for second trimester abortion. volved is hepatic glycogenolysis and these veterinary surgeons suggest that it is peculiarly Fifty-six of the patients were seeking mid- results suggest that the adrenergic receptors human. If injecting or operating on an animal trimester abortions; one was a diabetic with mediating hepatic glycogenolysis are of the P, they do not worry about bradycardic syncope an intrauterine death at 30 weeks and the last type. This hypothesis is further supported by in the animal-only in the watching human. Some people are so afraid of blood, tissue a patient who had suffered eclampsia at 21 the observation of Dr A G Leitch and others weeks. Ureaphil (lyophilised urea powder) (14 February, p 365) that intravenous infusion injury, injections, and venepuncture that they 80 g in 120 ml of physiological saline was of salbutamol, a P, stimulant, produced a rise refuse necessary medical and surgical proemployed, followed by 5 mg of prostaglandin in plasma glucose levels. The report by Dr cedures. In marked contrast to other phobics, E,, each drug being injected separately into Newman that metoprolol did delay the return who become tachycardic in the presence of the the amniotic cavity after the extraction of as to normoglycaemia and that it was not sig- phobic stimuli and rarely faint, blood/injury/ much liquor as possible. The continuing nificantly different from propranolol is un- injection phobics after initial tachycardia pregnancies varied in gestation from 14 to expected. The Pl-blockers share the ability to become profoundly bradycardic and faint22 weeks and the average induction interval antagonise the effects of catecholamines on the a very effective avoidance mechanism.' was 11J hours. There was no significant heart but differ in their effects on other Experience has shown, however, that they can difference between nulliparous and multi- tissues. Although Dr C Davidson and his be successfully treated using a behavioural parous patients. In one patient the method colleagues (3 July, p 7) have shown that the approach2 3-for example, by exposing them failed; the pregnancy was of some 15 weeks' antihypertensive activity of 3-adrenergic an- to the phobic stimuli in a graded way, perhaps gestation and the amniotic sac could not be tagonists is not significantly influenced by while they are tilted slightly head-down to identified; she was subsequently aborted their ancillary pharmacological properties, prevent the fainting. We are particularly interested in treating successfully vaginally. these might be responsible for the differences We did not encounter any complications due to the alleged increase in blood concentration of fibrin degradation products or a fall Blood glucose Membrane Intrinsic in fibrinogen level and platelet count. We recovery from stabilising Cardioselectivity sympathomimetic Beta-blocking agent hypoglycaemia activity activity did, however, observe two severe reactions to prostaglandin, with hypotension, bradycardia, Atenolol No delay _ + No delay + .. .. + + shivering, and dyspnoea; one patient ruptured Acebutalol .. Delayed .. _ + _ Metoprolol her uterus and in retrospect was probably Propranolol Delayed .. .. + _ unsuitable for the technique since she was a
4 SEPTEMBER 1976
587
force" are unlikely to be bettered in the for- grand multipara who had delivered five babies seen in the blood glucose recovery rates. The seeable future by modern pharmacological vaginally. The only other complication was an important ancillary properties of these fepisode of haemoglobinuria in a patient who blockers are shown in the table below. and surgical substitutes. PETER NIXON appears to have suffered an accidental intraThere is no correlation between these venous injection of hypertonic urea. The ancillary pharmacological properties and the Cardiac Department, Charing Cross Hospital (Fulham), urine of this patient contained 4 g of haemo- rate of blood glucose recovery from hypoLondon W6 globin per litre. An intravenous infusion of glycaemia. The simple conclusion is that some Holmes, T W, and Rahe, R H, Journal of Psycho- dextrose produced a good diuresis and the r,3-blockers are more specific than others. somatic Research, 1967, 11, 213. urine was cleared of haemoglobin. The patient Atenolol and acebutalol are claimed to be 2 Mendels, J, and Weinstein, N, Psychosomatic Medicine, failed to abort after 24 hours and an oxytocin highly specific P,-blockers and they would 1972, 34, 527. Ransley, C, and Nixon, P G F, unpublished data. infusion was started, after which the cervix seem to have advantages over other 5-blockers Nixon, P G F, Practitioner. In press. dilated and a dead fetus was delivered after for use in subjects prone to hypoglycaemia. 5 Kennedy, A, Lancet, 1957, 2, 261. 6 Kagan, A R, and Levi, Social Science and Medicine, 12 hours. There was no incidence of severe 1974, 8, 225. S P DEACON 7Nixon, P G F, et al, British Journal of Sports Medicine, haemorrhage. Prophylactic antibiotics in the London Road Hospital, 1976, 10, 54. form administered for of co-trimoxazole were Boston, Lincs Mackenzie, J, Diseases of the Heart and Aorta. London, five days. Fourteen patients required evacuaOxford Medical Publications, 1908. tion of retained products of conception and a further two were readmitted for persistent Hypertension as a problem of public vaginal bleeding, but in only one of these health Prophylactic use of bronchodilators cases were chorionic villi retrieved. One SIR,-In your leading article "Bronchodilators, patient was readmitted for pelvic infection in SIR,-Currently the investigation and treatment of hypertension usually depends on the new and old" (14 August, p 387) you did not spite of prophylactic antibiotics. patient's consultation of his doctor for related mention the prophylactic use of these drugs. R V CLEMENTS or unrelated symptoms. Since hypertension is When wheezing is produced by exercise or North Middlesex Hospital, common and treatable and since it is often when nocturnal wheezing is a prominent London N18 clinical feature two puffs of a portable presS KHUNDA symptomless perhaps a public health approach City, to the problem would be best. As a pilot study surised aerosol containing a long-acting Medical a sharply demarcated population such as that P2-adrenoceptor stimulant such as salbutamol Baghdad, Iraq of the Isle of Wight could be subjected to a full or terbutaline before exercising or going to screening procedure and by experiment the bed at night frequently prevents wheezing best strategy for the investigation and treatoccurring, and many young asthmatics who Effects of beta-blocking drugs on ment could be established. There is little follow this advice can play games which would insulin-induced hypoglycaemia doubt that the magnitude and importance of be impossible without such treatment beforeSIR,-The report by Dr R J Newman (21 the problem of hypertension is such that it hand. K N V PALMER August, p 447) that acebutalol did not impair cannot be adequately dealt with within the blood glucose recovery following insulin- current framework of medical practice. University Department of Medicine, induced hypoglycaemia complements the Foresterhill, Aberdeen report by myself and Dr D Barnett (31 July, D B JAMES p 272) that atenolol did not impair blood Marlow, Bucks glucose recovery under similar conditions. Mid-trimester termination The cardioselective or Pl-adrenergic blocking drugs thus offer a new therapeutic approach Treatment of blood/injury/illness phobia SIR,-With reference to your leading article to the treatment of angina pectoris and hyperon this subject (5 June, p 1357) we would tension in diabetic subjects since they would SIR,-Most people know of someone who like to report our series of mid-trimester seem to be free of hypoglycaemic side effects. faints at the sight of blood. Many doctors may abortions using a combination of intraThe recovery of the blood glucose level from remember medical students in their own setamniotic hypertonic urea and prostaglandin hypoglycaemia is dependent on several even themselves-who did so on the first day mechanisms, including hepatic glycogenolysis, in the operating theatre or in casualty. It E2. A series of 58 patients was analysed in lactate feedback from muscles to liver for seems, then, not an uncommon part of the 1973-4 at the North Middlesex Hospital, gluconeogenesis, and decreased peripheral human repertory but one that may be outwhere the technique has since been adopted glucose uptake. The major mechanism in- grown-or treated. Our inquiries from as the routine for second trimester abortion. volved is hepatic glycogenolysis and these veterinary surgeons suggest that it is peculiarly Fifty-six of the patients were seeking mid- results suggest that the adrenergic receptors human. If injecting or operating on an animal trimester abortions; one was a diabetic with mediating hepatic glycogenolysis are of the P, they do not worry about bradycardic syncope an intrauterine death at 30 weeks and the last type. This hypothesis is further supported by in the animal-only in the watching human. Some people are so afraid of blood, tissue a patient who had suffered eclampsia at 21 the observation of Dr A G Leitch and others weeks. Ureaphil (lyophilised urea powder) (14 February, p 365) that intravenous infusion injury, injections, and venepuncture that they 80 g in 120 ml of physiological saline was of salbutamol, a P, stimulant, produced a rise refuse necessary medical and surgical proemployed, followed by 5 mg of prostaglandin in plasma glucose levels. The report by Dr cedures. In marked contrast to other phobics, E,, each drug being injected separately into Newman that metoprolol did delay the return who become tachycardic in the presence of the the amniotic cavity after the extraction of as to normoglycaemia and that it was not sig- phobic stimuli and rarely faint, blood/injury/ much liquor as possible. The continuing nificantly different from propranolol is un- injection phobics after initial tachycardia pregnancies varied in gestation from 14 to expected. The Pl-blockers share the ability to become profoundly bradycardic and faint22 weeks and the average induction interval antagonise the effects of catecholamines on the a very effective avoidance mechanism.' was 11J hours. There was no significant heart but differ in their effects on other Experience has shown, however, that they can difference between nulliparous and multi- tissues. Although Dr C Davidson and his be successfully treated using a behavioural parous patients. In one patient the method colleagues (3 July, p 7) have shown that the approach2 3-for example, by exposing them failed; the pregnancy was of some 15 weeks' antihypertensive activity of 3-adrenergic an- to the phobic stimuli in a graded way, perhaps gestation and the amniotic sac could not be tagonists is not significantly influenced by while they are tilted slightly head-down to identified; she was subsequently aborted their ancillary pharmacological properties, prevent the fainting. We are particularly interested in treating successfully vaginally. these might be responsible for the differences We did not encounter any complications due to the alleged increase in blood concentration of fibrin degradation products or a fall Blood glucose Membrane Intrinsic in fibrinogen level and platelet count. We recovery from stabilising Cardioselectivity sympathomimetic Beta-blocking agent hypoglycaemia activity activity did, however, observe two severe reactions to prostaglandin, with hypotension, bradycardia, Atenolol No delay _ + No delay + .. .. + + shivering, and dyspnoea; one patient ruptured Acebutalol .. Delayed .. _ + _ Metoprolol her uterus and in retrospect was probably Propranolol Delayed .. .. + _ unsuitable for the technique since she was a
