714
We suggest that the association between P.B.c. and coeliac disease reported by Dr Logan and his colleagues may also encompass C.A.H. with features of P.B.c. plus dermatitis herpetiformis. Unless these associations are shown to be due to chance a search for malabsorption will be indicated in all patients with P.B.c. and C.A.H. who show steatorrhoea and/or moderate anaemia. ANTONIO CRAXÌ 3rd Institute of Medical Pathology,
GIOVAMBATTISTA PINZELLO LORENZO OLIVA LUIGI PAGLIARO
University of Palermo, Division of Internal Medicine, 180 Palermo, Italy
PULMONARY ŒDEMA AFTER CONTRAST MEDIA
SiR,—The aetiology of the pulmonary oedema reported by (Feb. 25, p. 413) in 5 of 68 patients undergoing retrograde femoral arteriography is, as Malins states, probably multifactorial, but a potent factor was the use of inappropriate contrast media. 3 of the patients were given ’Conray 325’ and the other 2 ’Conray 420’: neither formulation is recommended for peripheral arteriography, and this is clearly stated in the Dr Malins
company’s literature. Both conray 325 and conray 420 are injections of sodium iothalamate and their osmolality is considerably higher than that of ’Conray 280’ injection containing meglumine iothalamate. It is this, added to the apparently excessive dosage of 200 ml in the case of conray 420, rather than any antecedent history of myocardial disease, which was probably the major cause of the pulmonary oedema. I agree with Malins’ comments on the need for preoperative cardiological assessment, attention to fluid balance, and monitoring of the volume of infusion fluid in patients undergoing any form of arteriography. Medical Information Department, May & Baker Ltd, Dagenham, Essex RM10 7XS
‘
z This letter has been shown
J. GOULTON
to
Dr
Malins, whose reply fol-
lows.-ED.L.
ALCOHOLICS ANONYMOUS
SIR,-Dr Henry and Dr Robinson’s survey of Alcoholics Anonymous (Feb. 18, p. 372) provides useful insight into how that organisation operates. However, we need much more information before we can properly assess its therapeutic value for individual clients. In assuming efficacy without providing evidence Henry and Robinson would seem to be perpetuating an uncritical attitude to A.A., an attitude which bedevils alcoholism treatment as a whole. Only a tiny minority of British alcoholics seem to find A.A. helpful.’·2 Thus in 1970 there was a total U.K. active group membership of 7740 out of a probable alcoholic population of half a million.3 Henry and Robinson (despite their hope that their paper will help doctors make better-informed referrals) tell us virtually nothing of the patient characteristics likely to predict benefit from A.A. attendance. For instance, are high social class or i.Q., single status, or religious proclivity relevant to outcome? There is no convincing scientific evidence that adherence to A.A. in general4 or any particular component of the.A.A. programme (e.g., the "twelve steps")s improves on natural remission-rates. Not only have most studies used inadequate improvement criteria (e.g., abstinence alone) but also methodological difficulties (e.g., self-selection of the better motivated and low follow-up penetration) have rendered interpretation of results equivocal, to say the least. Where methodology has been satisfactory, 6, no advantage has accrued to A.A. membership. A.A. seem very reluctant to allow scientific study of their approach or to keep adequate records. There are even data suggesting that A.A. attendance can be harmful. In one study9 7% of relapsers blamed A.A. for their most recent relapse. And, at least in the U.S.A., the organisation seems antipathetic to alcohol clinic attendance. In short, A.A. is sorely in need of prospective, controlled studies of its value and efficacy. Northgate Hospital, Morpeth, Northumberland NE61 3BP
SiR,—The valuable survey by Dr Henry and Dr Robinson doctors "to make better-informed judgrecommend A.A. to particular alcoholic patients". Having found close collaboration with A.A. very valuable over a period of over 25 years"," I feel that doctors could make it easier for patients to accept A.A. if they were to . discuss with their patients the problems and misconceptions should
ments
SiR,—Iagree with Dr Davies (March 11, p. 556) that pulmonary oedema is a toxic effect of contrast media and should not be confused with an adverse reaction of unknown aetiology. The outstanding features in the five patients with pulmonary oedema were not only a history of myocardial disease and the use of hypertonic contrast media but also the inappropriate use of large volumes of arterial flush solution which was neither monitored nor closely controlled by the radiologist. On the question of dosage, the manufacturers said that there was "no apparent maximum safe dose" of contrast media. If 1 ml/kg is widely accepted, should it not be included on the manufacturers’ literature? Their information to users of ’Conray’ (280, 325 and 420) specifically precludes the use of conray 325 and 420 for direct femoral arteriography, but not for radiological visualisation of the distal descending aorta and peripheral vascular tree, the procedure done in all sixty-eight patients in the series in which the five complications were noted. Patients investigated by translumbar aortography were excluded from the series. The relationship between the adverse effects on the cardiovascular system and the use of hypertonic contrast media should act as a spur to the perfection of non-invasive techniques for investigation of patients with peripheral vascular disease. Department of Anæsthetics, Queen Elizabeth Hospital, Birmingham B15 2TH
A. F. MALINS
H. G. KINNELL
certainly help
...
newcomers
whether
to
may encounter.
A.A. groups vary greatly, and newcomers should attend several until they find the most congenial one. Some groups favour informal, free discussion; others rely on more formal talks. Patients who object to a "confessional" approach, for example, will probably prefer the discussion groups. A newcomer should try to be sober at his first A.A. meeting, otherwise little may sink in and he may misinterpret what is said. This is important because the ambivalent alcoholic may be keen to find faults with a fellowship aimed at helping him to stop drinking. If he finds many things wrong at his first 1. McCance, C., McCance, P. F. Br. J. Psychiat. 1969, 115, 189. 2. Timsovic, M. Hosp. Commun. Psychiat. 1970, 21, 94. 3. Kissin, B., Begleiter, H. The Biology of Alcoholism; vol. v, p.
445. New
York,1977. 4. Bebbington, P. E. Br. J. Psychiat. 1976, 128, 579. 5. Kissin, B., Begleiter, H. The Biology of Alcoholism; vol. v,
p. 465.
New
York,1977. 6. Williams, T. K. Doctoral dissertation. Western Michigan University, 1970. 7. Oakley, S., Holden, P. H. Inventory, N.C. 1971, 20, 2. 8. Strayer, R. Q. Jl Stud. Alcohol, 1961, 22, 9. Ludwig, A. M. ibid. 1972, 33, 91. 10. Glatt, M. M. Lancet, 1955, i, 1318. 11. Glatt, M. M. Br. J. Addict. 1955, 52, 55.
471.
We suggest that the association between P.B.c. and coeliac disease reported by Dr Logan and his colleagues may also encompass C.A.H. with features of P.B.c. plus dermatitis herpetiformis. Unless these associations are shown to be due to chance a search for malabsorption will be indicated in all patients with P.B.c. and C.A.H. who show steatorrhoea and/or moderate anaemia. ANTONIO CRAXÌ 3rd Institute of Medical Pathology,
GIOVAMBATTISTA PINZELLO LORENZO OLIVA LUIGI PAGLIARO
University of Palermo, Division of Internal Medicine, 180 Palermo, Italy
PULMONARY ŒDEMA AFTER CONTRAST MEDIA
SiR,—The aetiology of the pulmonary oedema reported by (Feb. 25, p. 413) in 5 of 68 patients undergoing retrograde femoral arteriography is, as Malins states, probably multifactorial, but a potent factor was the use of inappropriate contrast media. 3 of the patients were given ’Conray 325’ and the other 2 ’Conray 420’: neither formulation is recommended for peripheral arteriography, and this is clearly stated in the Dr Malins
company’s literature. Both conray 325 and conray 420 are injections of sodium iothalamate and their osmolality is considerably higher than that of ’Conray 280’ injection containing meglumine iothalamate. It is this, added to the apparently excessive dosage of 200 ml in the case of conray 420, rather than any antecedent history of myocardial disease, which was probably the major cause of the pulmonary oedema. I agree with Malins’ comments on the need for preoperative cardiological assessment, attention to fluid balance, and monitoring of the volume of infusion fluid in patients undergoing any form of arteriography. Medical Information Department, May & Baker Ltd, Dagenham, Essex RM10 7XS
‘
z This letter has been shown
J. GOULTON
to
Dr
Malins, whose reply fol-
lows.-ED.L.
ALCOHOLICS ANONYMOUS
SIR,-Dr Henry and Dr Robinson’s survey of Alcoholics Anonymous (Feb. 18, p. 372) provides useful insight into how that organisation operates. However, we need much more information before we can properly assess its therapeutic value for individual clients. In assuming efficacy without providing evidence Henry and Robinson would seem to be perpetuating an uncritical attitude to A.A., an attitude which bedevils alcoholism treatment as a whole. Only a tiny minority of British alcoholics seem to find A.A. helpful.’·2 Thus in 1970 there was a total U.K. active group membership of 7740 out of a probable alcoholic population of half a million.3 Henry and Robinson (despite their hope that their paper will help doctors make better-informed referrals) tell us virtually nothing of the patient characteristics likely to predict benefit from A.A. attendance. For instance, are high social class or i.Q., single status, or religious proclivity relevant to outcome? There is no convincing scientific evidence that adherence to A.A. in general4 or any particular component of the.A.A. programme (e.g., the "twelve steps")s improves on natural remission-rates. Not only have most studies used inadequate improvement criteria (e.g., abstinence alone) but also methodological difficulties (e.g., self-selection of the better motivated and low follow-up penetration) have rendered interpretation of results equivocal, to say the least. Where methodology has been satisfactory, 6, no advantage has accrued to A.A. membership. A.A. seem very reluctant to allow scientific study of their approach or to keep adequate records. There are even data suggesting that A.A. attendance can be harmful. In one study9 7% of relapsers blamed A.A. for their most recent relapse. And, at least in the U.S.A., the organisation seems antipathetic to alcohol clinic attendance. In short, A.A. is sorely in need of prospective, controlled studies of its value and efficacy. Northgate Hospital, Morpeth, Northumberland NE61 3BP
SiR,—The valuable survey by Dr Henry and Dr Robinson doctors "to make better-informed judgrecommend A.A. to particular alcoholic patients". Having found close collaboration with A.A. very valuable over a period of over 25 years"," I feel that doctors could make it easier for patients to accept A.A. if they were to . discuss with their patients the problems and misconceptions should
ments
SiR,—Iagree with Dr Davies (March 11, p. 556) that pulmonary oedema is a toxic effect of contrast media and should not be confused with an adverse reaction of unknown aetiology. The outstanding features in the five patients with pulmonary oedema were not only a history of myocardial disease and the use of hypertonic contrast media but also the inappropriate use of large volumes of arterial flush solution which was neither monitored nor closely controlled by the radiologist. On the question of dosage, the manufacturers said that there was "no apparent maximum safe dose" of contrast media. If 1 ml/kg is widely accepted, should it not be included on the manufacturers’ literature? Their information to users of ’Conray’ (280, 325 and 420) specifically precludes the use of conray 325 and 420 for direct femoral arteriography, but not for radiological visualisation of the distal descending aorta and peripheral vascular tree, the procedure done in all sixty-eight patients in the series in which the five complications were noted. Patients investigated by translumbar aortography were excluded from the series. The relationship between the adverse effects on the cardiovascular system and the use of hypertonic contrast media should act as a spur to the perfection of non-invasive techniques for investigation of patients with peripheral vascular disease. Department of Anæsthetics, Queen Elizabeth Hospital, Birmingham B15 2TH
A. F. MALINS
H. G. KINNELL
certainly help
...
newcomers
whether
to
may encounter.
A.A. groups vary greatly, and newcomers should attend several until they find the most congenial one. Some groups favour informal, free discussion; others rely on more formal talks. Patients who object to a "confessional" approach, for example, will probably prefer the discussion groups. A newcomer should try to be sober at his first A.A. meeting, otherwise little may sink in and he may misinterpret what is said. This is important because the ambivalent alcoholic may be keen to find faults with a fellowship aimed at helping him to stop drinking. If he finds many things wrong at his first 1. McCance, C., McCance, P. F. Br. J. Psychiat. 1969, 115, 189. 2. Timsovic, M. Hosp. Commun. Psychiat. 1970, 21, 94. 3. Kissin, B., Begleiter, H. The Biology of Alcoholism; vol. v, p.
445. New
York,1977. 4. Bebbington, P. E. Br. J. Psychiat. 1976, 128, 579. 5. Kissin, B., Begleiter, H. The Biology of Alcoholism; vol. v,
p. 465.
New
York,1977. 6. Williams, T. K. Doctoral dissertation. Western Michigan University, 1970. 7. Oakley, S., Holden, P. H. Inventory, N.C. 1971, 20, 2. 8. Strayer, R. Q. Jl Stud. Alcohol, 1961, 22, 9. Ludwig, A. M. ibid. 1972, 33, 91. 10. Glatt, M. M. Lancet, 1955, i, 1318. 11. Glatt, M. M. Br. J. Addict. 1955, 52, 55.
471.
