273 wall damage, and stagnation of flow8-have been identified, little is known about those precise factors which favour release of formed thrombi into the blood. I suggest that trauma may be one of these and that it would be prudent to forego repeated opplication of such diagnostic manoeuvres as the sphygmomanometer test in a patient with apparent deep-venous thrombosis. The statement that "there is no risk of major pulmonary embolus from thrombi that remain confined to the calf veins"9 is untenable. Naval Regional Medical Center, San Diego, California 92134, U.S.A.
S. E. WARREN
VASOPRESSIN IN AFFECTIVE ILLNESS
be 70 i.u. per bag,’ representing 30-33% A.H.F. recovery from the starting plasma. A significant improvement in the quality of production would be of incalculable benefit, both to patient (a reduction in cryoprecipitate volume that has to be infused) and to the blood-banks (fewer donated units have to be processed, releasing valuable fresh plasma for fractionation for purified factor-vin concentrates ideally necessary for home treatment and prophylaxis). The continuous thaw-syphoning process described by Mr Mason (July 1, p. 15) may be significant. This simple system consists of snap freezing fresh plasma at —30°C, thawing at 4°C, allowing the supernatant to be continually syphoned off for about an hour leaving about 35 ml cryoprecipitate in the bag. Our preliminary experience with this system suggests an average recovery in excess of 48% with over 200 LV. A.H.F. per to
bag:
SIR,-Dr Gold and his colleagues postulate that vasopresplays a role in disorders of human behaviour, particularly
Rudolf Magnus Institute for Medical Faculty, University of Utrecht, Utrecht, Netherlands
Pharmacology, DAVID
DE
WIED
THAW-SIPHON TECHNIQUE FOR FACTOR-VIII CRYOPRECIPITATE
SIR,-Cryoprecipitate
is the main
source
for factor
vm
(A.H.F.) because of its relatively high yield and ease of preparation in blood banks. In 1977 we made 32 171 bags to support sixty haemophiliac A patients in this region. Although the mean A.H.F. content of a single donation cryoprecipitate prepared in this centre is 110 1. u. per bag, the average norm seems 8
Ratnoff, O. D., Botti, R.
E.
Pulmonary Embolic Disease; p. 23.
New
York,
1965. 9. 1. 2.
Sagar, S., Nairn, D. Lancet, 1976, i, 1151. Gold, P. W., Goodwin, F. K., Reus, V. I. Lancet, 1978, i, 1233. Walter, R., van Ree, J. M., de Wied, D. Proc. nat. Acad. Sci. U.S.A. (in the press). 3. de Wied, D. Life Sci. 1976, 19, 685. 4. de Wied, D., Greven, H. M., Lande, S., Witter, A. Br. J. Pharma. 1972, 45, 118. 5.
Schulz, H., Kovács, G. L., Telegdy, G. in Cellular and Molecular Bases of Neuroendocrine Processes (edited by E. Endröczi); p. 555. Budapest,
6.
Bohus, B., Urban, I., van Wimersma Greidanus, T. B., de Wied, pharmacol, 1978, 17, 239.
1976. D. Neuro-
Cryoprecipitate
Plasma
sin
manic-depressive illness. After marshalling data from the literature to substantiate their ideas, they end their interesting article by suggesting how the hypothesis might be verified. One test would be specific treatment with the vasopressin analogue 1-deamino-8-D-arginine vasopressin (D.D.A.V.P.) which is free of vasoactive properties, is available for administration to man, and could be given to patients with diminished central vasopressin functions. Gold et al. also suggest trying specific inhibitors of vasopressin functions, such as vasopressinoic acid, to treat disorders due to augmented central vasopressin functions. However, we have found that D.D.A.v.p. has negligible. "memory" effects;2 furthermore, vasopressinoic acid may not be a specific inhibitor of vasopressin functions in the brain.3 After central administration vasopressinoic acid is nearly as potent as the whole vasopressin molecule in increasing resistance to extinction of pole-jumping avoidance behaviour. A vasopressin analogue which is almost free of the classical endocrine effects (vasoactivity, antidiuresis, A.C.T.H. release, and so on) is 9-desglycinamide-8-lysine vasopressin (D.G. L.v.p.). The same holds for the 8-arginine analogue D.G.A.V.P. These peptides are behaviourally only slightly less active than the parent compounds. Peptides which specifically inhibit vasopressin functions in the brain are as yet not known, but oxytocin given by intraventricular injection has an effect opposite to that of vasopressin. This hormone may thus be regarded as an amnesic agent.1,6
’
weight (g)
Weight (g)
207 233 246 258 235
61 47 45 37 28
236
(mean)
44
z
I. U. 100 244 529 227 274
% recovery
275
115
48 105 215 88 117
We are now investigating the introduction of such tive improvement into routine cryoprecipitate production.
qpalita-
We thank Mr Mason, Blood Transfusion Service, Brisbane, AustraDr Prowse, Blood Transfusion Service, Edinburgh, for support and advice.
lia, and
Red Cross Blood Bank
Groningen-Drenthe, Groningen, Netherlands
P. C. DAS C. TH. SMIT SIBINGA
SEAT BELTS AND POLYCYSTIC KIDNEYS
SIR,-Intra-abdominal and musculoskeletal injuries second-
wearing of seat belts during automobile collisions sufficiently well characterised to be designated as the "seatbelt syndrome". In adults with polycystic kidney disease the wearing of aircraft seat belts and nothing more than rapid deceleration of the aircraft on landing may cause symptomatic rupture.’ Twenty years ago, Bricker and Patton-’ reported that surgical decompression of the kidneys of patients with polycystic kidney disease did not preserve renal function and might even be detrimental to long-term function. A case of polycystic kidneys and the seat-belt syndrome that I have seen suggests some additional points of advice to be given to individuals with polycystic kidney disease. A 25-year-old man with known polycystic kidneys (right 18 cm, left 22 cm in length) was involved in a rear-end automobile accident while wearing a lap seat belt. Before the accident he had normal renal function, no urinary abnormalities, and easily controlled mild hypertension. When seen in renal consultation a week after the accident, he complained of bilateral flank discomfort with the left side being worse than the right. Urinalysis showed, for the first time, 50 mg/dl proteinuria. No ary to the are
hsmaturia was detectable. In 3-4 weeks the proteinuria decreased to trace amounts, but in 4 years of follow-up virtually all random urinalyses have revealed trace proteinuria. However, creatinine clearance has remained normal. The correlation between the automobile accident and seatbelt-induced trauma to the polycystic kidneys (which extended well below the costal margins) appears to be clear cut. In view of the report by Bricker and Patton2 the long-term implication Jones, P. and others. Br. med. J. 1978, i, 1447. Amend, W. J., Galen, M. Ann. intern Med. 1973, 79, 287. 3. Bricker, N.S., Patton, J.F. New Engl. J. Med. 1957, 256, 212.
1. 2.
274 of the traumatic cyst rupture is less certain. In such cases traumatic cyst rupture may be significant to the prognosis of renal
function.
Perhaps patients with polycystic kidneys should use a heavily padded or cushioned seat belt with a shoulder restraint mechanism which would decrease the force delivered exclusively to the flank in an accident. Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, U.S.A.
ANDREW WHELTON
Commentary from Westminster From
Parliamentary Correspondent Care of Children with Mental Handicap our
FoR some time there has been much dissatisfaction with the national policy for mentally handicapped children. Not only have the services come in for criticism but also the fact that many children are in hospital when they should not be has been a cause for concern. Now the Government has asked local and health authorities jointly to set dates after which no mentally handicapped child will be inappropriately admitted to hospital. A circular outlining a programme of action has gone out from the Department of Health and Social Security. The number of children under 16 in mental-handicap hospitals has been falling steadily. It was over 5000 in 1974 and is around 4000 now, lower than the 1971 white-paper, Better Services for the Mentally Handicapped, suggested it should be in 1991. But among this number are many who should not be there at all. The Development Team for the Mentally Handicapped visited 700 children in these hospitals during its first year, 1976-77, and estimated that some 25% did not require long-term residential care of this kind. On this basis there could be as many as 1000 children now in these hospitals who should be elsewhere. The D.H.S.S. circular reminds authorities that family and social conditions do not of themselves justify the admission of a child to long-term hospital care. Where no health-care need is identified, hospital admission is inappropriate, and many such needs can be met in the child’s own home or in the outpatient department. A child who is physically as well as mentally handicapped, exhibits disruptive behaviour, or is epileptic or incontinent should not for these reasons alone be regarded as requiring long-term hospital care. The key to the problem of inappropriate admissions is the provision of alternative facilities. Health and local authorities have been asked to assess the extent and nature of the additional provision needed and in doing so to take account of the wide range of alternatives to hospital, such as community homes, domiciliary services backed up by planned emergency short-stay care, fostering, and adoption. The importance of voluntary organisations is also emphasised and authorities are reminded that they have statutory powers to make grants to voluntary bodies. In estimating what alternative services are likely to be needed in the future, authorities have been asked to arrange for each mental-handicap hospital to identify the area of origin of its long-term child residents and of
those children on its waiting-list for long-term admission and to approach the local authorities to arrange for a joint review to identify how many children were inappropriately admitted to hospital in the past. At the same time social-service departments have been asked to estimate the number and ages of mentally handicapped children in their area who are neither in hospital nor on a waiting-list but who are likely to require residential
domiciliary support. Preventing inappropriate admissions is the first priority in this programme; identifying the scale of future
care or
needs is the second. When these will be in a better position to act.
Health
are
known the D.H.S.S.
Charges
Conservative Party plans for increasing existing health charges and levying new ones are likely to be the most controversial health issue at the General Election. The Tories are committed to increasing prescription charges in line with inflation, the Labour Party is pledged to abolish them, and the Government is committed to phasing them out when economic circumstances permit. So all sides are digesting some interesting new figures published last week from the D.H.S.S. These estimate that there would be no deterrent effect from an increase of 25% in the current charge of 20p, that a 50% increase might result in a drop of less than 1% in the number of prescriptions issued, and that a 100% increase might produce a fall of about 2%. The total estimated savings would be 7, 18, and 38 million respectively. This analysis by the Department, published for the first time as evidence to a Commons committee, is likely to find more favour with the Tories than with Labour, since it seems to undermine the argument that increasing the charge would amount to a considerable disincentive. Those contemplating doubling the charge, which has remained at 20p since 1971, argue that since 63% of prescriptions are anyway free of charge because of the widespread exemptions, the increase would apply to only 37% of all prescriptions. Meanwhile, Labour Nt.P.s are bringing fresh pressure to bear on the Government to abolish prescription charges altogether. As a first step to include such a commitment in the Party’s election manifesto, Labour M.p.s on the Party’s Parliamentary health group are seeing Mr Roland Moyle, Minister of State for Health, to impress their views on him. They argue that since the charge raises such a small amount and since such a large proportion of prescriptions are free of charge, continuing with it is barely worth while. The D.H.S.S. analysis was prompted by the all-Party Commons expenditure committee which has for some time been urging a public debate on the issue. In a report last year it posed the question of whether the public would be prepared to pay more in health charges if this meant shorter hospital waiting-lists. Now that the D.H.S.S. has produced some figures on the implications of increasing the charge by varying amounts the committee hopes that an informed debate will follow. It recognises that such an analysis cannot resolve the argument of principle about prescription charges, which divided the committee as it divides the Commons. But it does indicate the practical implications.
S. E. WARREN
VASOPRESSIN IN AFFECTIVE ILLNESS
be 70 i.u. per bag,’ representing 30-33% A.H.F. recovery from the starting plasma. A significant improvement in the quality of production would be of incalculable benefit, both to patient (a reduction in cryoprecipitate volume that has to be infused) and to the blood-banks (fewer donated units have to be processed, releasing valuable fresh plasma for fractionation for purified factor-vin concentrates ideally necessary for home treatment and prophylaxis). The continuous thaw-syphoning process described by Mr Mason (July 1, p. 15) may be significant. This simple system consists of snap freezing fresh plasma at —30°C, thawing at 4°C, allowing the supernatant to be continually syphoned off for about an hour leaving about 35 ml cryoprecipitate in the bag. Our preliminary experience with this system suggests an average recovery in excess of 48% with over 200 LV. A.H.F. per to
bag:
SIR,-Dr Gold and his colleagues postulate that vasopresplays a role in disorders of human behaviour, particularly
Rudolf Magnus Institute for Medical Faculty, University of Utrecht, Utrecht, Netherlands
Pharmacology, DAVID
DE
WIED
THAW-SIPHON TECHNIQUE FOR FACTOR-VIII CRYOPRECIPITATE
SIR,-Cryoprecipitate
is the main
source
for factor
vm
(A.H.F.) because of its relatively high yield and ease of preparation in blood banks. In 1977 we made 32 171 bags to support sixty haemophiliac A patients in this region. Although the mean A.H.F. content of a single donation cryoprecipitate prepared in this centre is 110 1. u. per bag, the average norm seems 8
Ratnoff, O. D., Botti, R.
E.
Pulmonary Embolic Disease; p. 23.
New
York,
1965. 9. 1. 2.
Sagar, S., Nairn, D. Lancet, 1976, i, 1151. Gold, P. W., Goodwin, F. K., Reus, V. I. Lancet, 1978, i, 1233. Walter, R., van Ree, J. M., de Wied, D. Proc. nat. Acad. Sci. U.S.A. (in the press). 3. de Wied, D. Life Sci. 1976, 19, 685. 4. de Wied, D., Greven, H. M., Lande, S., Witter, A. Br. J. Pharma. 1972, 45, 118. 5.
Schulz, H., Kovács, G. L., Telegdy, G. in Cellular and Molecular Bases of Neuroendocrine Processes (edited by E. Endröczi); p. 555. Budapest,
6.
Bohus, B., Urban, I., van Wimersma Greidanus, T. B., de Wied, pharmacol, 1978, 17, 239.
1976. D. Neuro-
Cryoprecipitate
Plasma
sin
manic-depressive illness. After marshalling data from the literature to substantiate their ideas, they end their interesting article by suggesting how the hypothesis might be verified. One test would be specific treatment with the vasopressin analogue 1-deamino-8-D-arginine vasopressin (D.D.A.V.P.) which is free of vasoactive properties, is available for administration to man, and could be given to patients with diminished central vasopressin functions. Gold et al. also suggest trying specific inhibitors of vasopressin functions, such as vasopressinoic acid, to treat disorders due to augmented central vasopressin functions. However, we have found that D.D.A.v.p. has negligible. "memory" effects;2 furthermore, vasopressinoic acid may not be a specific inhibitor of vasopressin functions in the brain.3 After central administration vasopressinoic acid is nearly as potent as the whole vasopressin molecule in increasing resistance to extinction of pole-jumping avoidance behaviour. A vasopressin analogue which is almost free of the classical endocrine effects (vasoactivity, antidiuresis, A.C.T.H. release, and so on) is 9-desglycinamide-8-lysine vasopressin (D.G. L.v.p.). The same holds for the 8-arginine analogue D.G.A.V.P. These peptides are behaviourally only slightly less active than the parent compounds. Peptides which specifically inhibit vasopressin functions in the brain are as yet not known, but oxytocin given by intraventricular injection has an effect opposite to that of vasopressin. This hormone may thus be regarded as an amnesic agent.1,6
’
weight (g)
Weight (g)
207 233 246 258 235
61 47 45 37 28
236
(mean)
44
z
I. U. 100 244 529 227 274
% recovery
275
115
48 105 215 88 117
We are now investigating the introduction of such tive improvement into routine cryoprecipitate production.
qpalita-
We thank Mr Mason, Blood Transfusion Service, Brisbane, AustraDr Prowse, Blood Transfusion Service, Edinburgh, for support and advice.
lia, and
Red Cross Blood Bank
Groningen-Drenthe, Groningen, Netherlands
P. C. DAS C. TH. SMIT SIBINGA
SEAT BELTS AND POLYCYSTIC KIDNEYS
SIR,-Intra-abdominal and musculoskeletal injuries second-
wearing of seat belts during automobile collisions sufficiently well characterised to be designated as the "seatbelt syndrome". In adults with polycystic kidney disease the wearing of aircraft seat belts and nothing more than rapid deceleration of the aircraft on landing may cause symptomatic rupture.’ Twenty years ago, Bricker and Patton-’ reported that surgical decompression of the kidneys of patients with polycystic kidney disease did not preserve renal function and might even be detrimental to long-term function. A case of polycystic kidneys and the seat-belt syndrome that I have seen suggests some additional points of advice to be given to individuals with polycystic kidney disease. A 25-year-old man with known polycystic kidneys (right 18 cm, left 22 cm in length) was involved in a rear-end automobile accident while wearing a lap seat belt. Before the accident he had normal renal function, no urinary abnormalities, and easily controlled mild hypertension. When seen in renal consultation a week after the accident, he complained of bilateral flank discomfort with the left side being worse than the right. Urinalysis showed, for the first time, 50 mg/dl proteinuria. No ary to the are
hsmaturia was detectable. In 3-4 weeks the proteinuria decreased to trace amounts, but in 4 years of follow-up virtually all random urinalyses have revealed trace proteinuria. However, creatinine clearance has remained normal. The correlation between the automobile accident and seatbelt-induced trauma to the polycystic kidneys (which extended well below the costal margins) appears to be clear cut. In view of the report by Bricker and Patton2 the long-term implication Jones, P. and others. Br. med. J. 1978, i, 1447. Amend, W. J., Galen, M. Ann. intern Med. 1973, 79, 287. 3. Bricker, N.S., Patton, J.F. New Engl. J. Med. 1957, 256, 212.
1. 2.
274 of the traumatic cyst rupture is less certain. In such cases traumatic cyst rupture may be significant to the prognosis of renal
function.
Perhaps patients with polycystic kidneys should use a heavily padded or cushioned seat belt with a shoulder restraint mechanism which would decrease the force delivered exclusively to the flank in an accident. Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, U.S.A.
ANDREW WHELTON
Commentary from Westminster From
Parliamentary Correspondent Care of Children with Mental Handicap our
FoR some time there has been much dissatisfaction with the national policy for mentally handicapped children. Not only have the services come in for criticism but also the fact that many children are in hospital when they should not be has been a cause for concern. Now the Government has asked local and health authorities jointly to set dates after which no mentally handicapped child will be inappropriately admitted to hospital. A circular outlining a programme of action has gone out from the Department of Health and Social Security. The number of children under 16 in mental-handicap hospitals has been falling steadily. It was over 5000 in 1974 and is around 4000 now, lower than the 1971 white-paper, Better Services for the Mentally Handicapped, suggested it should be in 1991. But among this number are many who should not be there at all. The Development Team for the Mentally Handicapped visited 700 children in these hospitals during its first year, 1976-77, and estimated that some 25% did not require long-term residential care of this kind. On this basis there could be as many as 1000 children now in these hospitals who should be elsewhere. The D.H.S.S. circular reminds authorities that family and social conditions do not of themselves justify the admission of a child to long-term hospital care. Where no health-care need is identified, hospital admission is inappropriate, and many such needs can be met in the child’s own home or in the outpatient department. A child who is physically as well as mentally handicapped, exhibits disruptive behaviour, or is epileptic or incontinent should not for these reasons alone be regarded as requiring long-term hospital care. The key to the problem of inappropriate admissions is the provision of alternative facilities. Health and local authorities have been asked to assess the extent and nature of the additional provision needed and in doing so to take account of the wide range of alternatives to hospital, such as community homes, domiciliary services backed up by planned emergency short-stay care, fostering, and adoption. The importance of voluntary organisations is also emphasised and authorities are reminded that they have statutory powers to make grants to voluntary bodies. In estimating what alternative services are likely to be needed in the future, authorities have been asked to arrange for each mental-handicap hospital to identify the area of origin of its long-term child residents and of
those children on its waiting-list for long-term admission and to approach the local authorities to arrange for a joint review to identify how many children were inappropriately admitted to hospital in the past. At the same time social-service departments have been asked to estimate the number and ages of mentally handicapped children in their area who are neither in hospital nor on a waiting-list but who are likely to require residential
domiciliary support. Preventing inappropriate admissions is the first priority in this programme; identifying the scale of future
care or
needs is the second. When these will be in a better position to act.
Health
are
known the D.H.S.S.
Charges
Conservative Party plans for increasing existing health charges and levying new ones are likely to be the most controversial health issue at the General Election. The Tories are committed to increasing prescription charges in line with inflation, the Labour Party is pledged to abolish them, and the Government is committed to phasing them out when economic circumstances permit. So all sides are digesting some interesting new figures published last week from the D.H.S.S. These estimate that there would be no deterrent effect from an increase of 25% in the current charge of 20p, that a 50% increase might result in a drop of less than 1% in the number of prescriptions issued, and that a 100% increase might produce a fall of about 2%. The total estimated savings would be 7, 18, and 38 million respectively. This analysis by the Department, published for the first time as evidence to a Commons committee, is likely to find more favour with the Tories than with Labour, since it seems to undermine the argument that increasing the charge would amount to a considerable disincentive. Those contemplating doubling the charge, which has remained at 20p since 1971, argue that since 63% of prescriptions are anyway free of charge because of the widespread exemptions, the increase would apply to only 37% of all prescriptions. Meanwhile, Labour Nt.P.s are bringing fresh pressure to bear on the Government to abolish prescription charges altogether. As a first step to include such a commitment in the Party’s election manifesto, Labour M.p.s on the Party’s Parliamentary health group are seeing Mr Roland Moyle, Minister of State for Health, to impress their views on him. They argue that since the charge raises such a small amount and since such a large proportion of prescriptions are free of charge, continuing with it is barely worth while. The D.H.S.S. analysis was prompted by the all-Party Commons expenditure committee which has for some time been urging a public debate on the issue. In a report last year it posed the question of whether the public would be prepared to pay more in health charges if this meant shorter hospital waiting-lists. Now that the D.H.S.S. has produced some figures on the implications of increasing the charge by varying amounts the committee hopes that an informed debate will follow. It recognises that such an analysis cannot resolve the argument of principle about prescription charges, which divided the committee as it divides the Commons. But it does indicate the practical implications.
