injection of prostaglandin F,,, or hyperosmolar glucose can be used with considerable success. Prostaglandin F2,, increases tubal smooth muscle motility and causes powerful contractions,4 which explains its mode of action. Hyperosmolar glucose is thought to act as a noxious agent, dehydrating the cells and causing necrobiosis and thus ending the ectopic gestation. Although methotrexate and prostaglandins are associated with side effects, none were found when hyperosmolar glucose was used.' In this group subsequent hysterosalpingography showed that seven of the eight patients had normal tubal configuration and patency, and three later had a normal intrauterine pregnancy.
anywhere-some love it, some hate it, and some will find the administration to be an easy target. Being a member of the army medical service is not a cheap and easy way to obtain higher medical qualifications. It is a commitment during which time officers will certainly be given the opportunity to advance their professional medical skills and may find themselves in a position to develop a better insight into the importance of Remembrance Sunday.
ALVAN PRIDDY HELENE BRANDON
(10 November.) 2 Villar R. Medicine in the armcd forces. BM7 1990;301:721-3. (3 October.,
D S JOLLIFFE
Army MIedical D)ircctorate, London WCIV! 6HE 1 Mabin DC. Mcdicine in the armed forces. BA1j 1990;301:1103.
St Mary's Hospital, Manchester M 13 OJH 1 D)rife JO. 1ubal pregnancy. BMJ,7 1990;301:1057-8. (10 November.) 2 Lindblom B, Hahlin 1\1, K~llfelt B, Hamberger I. Local prostaglandin F,,, injection for termination of ectopic pregnancv. Lancet 1987;i:776-7. 3 Lang PF, Weiss PAM, Mayer HO, Hass JGi, Hinigi W. Conservatisve treatment of ectopic pregnancy with lorcal injection of hyperosmolar glucose solution or prostaglandin F,, a prospective randomised study. Lancet 1990;336:78-81. 4 Lindblom B, Hamberger L, Wiqvist N. Differentiated contractile effects of prostaglandins E and F on the isolated circular and longitudinal smooth musclc of thc htuman oviduct. Fcrti/ 'Steril
1978;30:553-9.
Medicine in the armed services SIR,-I agree with Dr D C Mabin that joining the army medical services either as a cadet or as a qualified doctor is not a career move to be taken lightly. ' It is a commitment to the Queen, to serve her by caring for the medical needs of her soldiers and their dependants, wherever they may be stationed, in time ofpeace and conflict. In exchange for this commitment, the service provides financial support during undergraduate years for cadets and postgraduate training of the highest quality for registered medical officers. In addition, the service provides job security and a way of life that is in sharp contrast with that available to those working in the health service. What Mr Richard Villar remembered,2 and what Dr David Mabin clearly forgot, was that the primary role of the service is to provide medical care for the army; catering for the personal professional aspirations of its officers must, of necessity, be secondary. The British army is the peace insurance policy of the British people. Like all insurance policies, it is there to prepare and wait for something that we all hope will never happen. When nothing does happen it is very easy for army medical officers to forget why they are employed and it is neither unnatural nor uncommon for them to be concerned when they are called away from routine peace time work to face a combination of fear, separation from family, and disruption of a well prepared professional training programme. I know this to be true from personal experience at the time of the Falklands war and, to a lesser extent, during service in Northern Ireland. Dr Mabin's colleague who was whisked away at short notice went to the Gulf to support British troops. He did not go alone. Many of the medical officers already deployed or warned for deployment to the Gulf have had some form of postgraduate training interrupted. If we are not available for operational duty above all other things what are we being paid for? I am unhappy about Dr Mabin's generous use of poetic licence (uneconomical precourse medical examinations such as "fit for typing" were abolished early in Dr Mabin's service, and we are all aware that things do happen in the border country of Northern Ireland), but when it is read alongside Mr Villar's article it does prove that being a doctor in the army is very much like being a doctor
1280
Surely a natural cancer remedy can't be dangerous SIR,-Further to Dr J Tobias's article on the possible danger of a natural cancer remedy' and my response,2 I should like to comment on the recent publication of information suggesting that the original study was flawed. I would also like to suggest that some of the "personal view" expressed by Dr Tobias was opinion masquerading as fact. The authors of the report on the British Cancer Help Centre admit in a letter to the Lancet that in their first analysis they did not take into account local recurrence, which is prognostic, especially for patients treated with mastectomy. In a revised analysis this reduces the relative risk of distant recurrence rate; this is now put at RR= 179 (p=007) as opposed to the original estimate of RR=2 85 (p=001).3 They acknowledge that the differences between patients and controls are likely to have been inflated by self referral-that is, selection bias in a non-randomised trial influences the result. In a letter to the Lancet my colleague, Dr T Sheard,4 pointed out that inaccuracies had been found, indicating that of the women described as free of disease, three had already had a relapse when they came to Bristol; one had bone secondary tumours and two had supraclavicular and cervical lymph node involvement. On the basis of the above facts and others mentioned in letters to the Lancet, Sir Walter Bodmer, director of research at the Imperial Cancer Research Fund, states: "Their own evaluation is that the study's results can be explained by the fact that women going to Bristol had more severe disease than the controls; in particular, they had a much higher rate of local recurrence." The publicity in the lay press has been damaging enough. Many people have lost confidence in some of the methods they had successfully been using to cope with the difficulties that a diagnosis of cancer brings. The number of patients booking to come to the Cancer Help Centre has also dropped substantially. Unfortunately, the suggestion that harm could be done by such approaches was perpetuated by the medical as well as the lay press, and was based on flawed and now discredited evidence. The Cancer Help Centre has clear goals, focusing on quality of life but not excluding the possibility that the focus may have secondary advantages as to survival (something which only a long term randomised study could seriously evaluate). We are also members of a group of doctors and nurses looking at how services in the NHS might creatively be improved by offering a more holistic approach to the cancer
patient. Certainly, questions have been raised by the study. I trust that the damage done by a flawed report and inaccurate publicity will be redressed by a withdrawal of that report and by mutual cooperation, which will ensure the continuation of
pioneering approaches such as those at Bristol and their corporation into a caring NHS. MICHAEL J WETZLER
Bristol Cancer Help Ccntrc, Bristol BS8 4PG I Tobias J. Surelv a natural cancer remedy can't bc dangcrouscan it? BMJ 1990;301:613. (22 September.) 2 Wetzler Mj. Surely a natural cancer remedy can't he dangerous. BMj 1990;301:929. (20 October.) 3 Chilvers CED, Easton DF, Bagenal FS, Harris E, McElwain TJ. Bristol Cancer Help Centre. Lancet 1990;336:1186. 4 Sheard T. Bristol Cancer Help Centre. Lancet 1990;336:1 185.
AUTHOR'S REPLY,-As Dr Wetzler points out, a revised analysis of the original data from the Bristol Cancer Help Centre study, taking account of differences between the control and treatment groups, still showed a higher relative risk of distant recurrence in the centre's patients. A relative risk of recurrence of 1 79 in those attending compared with those not attending the centre cannot be ignored even though this difference is not statistically significant. There is certainly no evidence that the many recommendations of the centre have a positive effect on patients' probability of surviving their cancer. As I pointed out in my article, which was quite clearly a piece reflecting my own opinions and not "masquerading as fact," much of the advice from the Bristol Cancer Help Centre is of unproved benefit yet clearly disruptive of a patient's life, sometimes to the most unfortunate degree.' How curious that Dr Wetzler should still insist that though the chief emphasis at the centre is now on quality of life, there still exists "the possibility that the focus may have secondary advantages as to survival." This is surely now an impossibility even on the reanalysis of the data that Sheard2 and others have attempted. Of course it is unfortunate for the Bristol Cancer Help Centre that patients are no longer flocking there for help, but, as we have seen in the political arena over the past few weeks, intelligent people are well able to make decisions for themselves. The reported cost of a week's stay at the Bristol centre (in the region of £600) may also be regarded by many as a major disincentive, and by its own admission on a recent television programme the centre has always appealed chiefly to a limited, middle class section of the community. As Professor Baum and I pointed out recently,' it is extremely unfortunate that the initial recommendation of a prospectively randomised study was rejected as all other types of comparison, including the present one, are open to bias and misinterpretation. JEFFREY S TOBIAS University College Hospital, London WC 1 E 6AU I 'I'obias J. Surelv a natural cancer remedy can't be dangerous. BMJ,7 1990;301:613. (22 September.) 2 Sheard TAB. Bristol cancer help centre. Lantcet 1990;336: 1185-6. 3 Tobias JS, Baum M. Bristol canccr help ccntre. I.ancet 1990;336: 1323.
DrugPoints Toxic epidermal necrolysis associated with indapamide Drs R J BLACK, P MURPHY, T J ROBINSON, and K W SCOTT (Craigavon Area Hospital, Craigavon BT63 5QQ) write: Toxic epidermal necrolysis is characterised by the widespread loss of epidermis with formation of subepidermal blisters and severe constitutional symptoms.' 2 It has several causes, one of the well recognised being a drug reaction. A 65 year old woman with a long history of essential hypertension who was taking atenolol was started on indapamide 2 5 mg daily for ad-
BMJ
VOLUME
301
1
DECEMBER
1990
ditional blood pressure control. She was also taking triazolam 0-25 mg at night and dothiepin hydrochloride 25 mg at night, both of which she had taken for many vears. Seven days after starting taking indapamide she developed a generalised, erythematous pruritic rash, confusion, and fever and was admitted to hospital. Over the next three days widespread peeling of the epidermis developed and Nikolsky's sign was present. The areas worst affected were the upper trunk, limbs, and buttocks. Among the mucosal surfaces only the buccal mucosa was affected. She concurrently had fever with a temperature of 40 5°C, confusion, hypotension (systolic blood pressure 60 mm Hg), acute renal failure (urea concentration 46 mmoUl/), and disseminated intravascular coagulation (concentration of fibrin degradation products 64 mg/I, platelet count 51 x 109/l). Supportive treatment was started with intravenous fluids, fresh frozen plasma, and intravenous hvdrocortisone 200 mg four times a day for 10 days, after which time the treatment was reduced. She was nursed on a ripple bed and silver sulphadiazine was applied daily to the areas of skin loss. After five days her condition began to improve, and after a further two weeks her renal function and coagulation had returned to normal and epidermal regeneration was complete. Indapamide is a non-thiazide diuretic used to treat essential hypertension. It is prepared by condensing a chlorosulphonariide acid chloride with an indole amine. Rashes associated with indapamide have been reported and, though usually mild, can be severe." Though toxic epidermal necrolysis is a well known side effect of sulphonamide drugs,5 it has not previously been associated with indapamide to our knowledge. As indapamide is a commonly used drug we believe that the possibility of this side effect should be borne in mind. We thank Mrs G Cully for typing and Dr T A J Dawson for his advice. I Lvell A. Toxic cpidermal necrolvsis: an cruption resembling scalding of the skin. Br.7 Dermatol 1956;68:355-61. 2 Pve RJ. Toxic epidermal necrolysis. In: Rook A, Wilkinson DS, Ebling FJG, Champion RH, Burton JL, eds. lextbook of dermatologv. Vol 2. 4th ed. Oxford: Blackwell Scientific, 1986:1658-9. 3 Association of the British Pharmaceutical Industry. ABPI data sheet compenzdium 1990-91. London: Data Pharm Publications, 1990:1602. 4 Stricker BHCh, Biriell C. Skin reactions and fever with indapa-
mide. BMJ 1987;295:1313-4. 5 Guillaume JC, Rouleau JC, Penso D, Reuz J, Touraine R. The culprit drugs in 87 cases of toxic epidermal necrolysis (Lvell's syndrome). Arch Dermatol 1987;123:1166-70.
Cholestasis associated with cinnarizine Drs STEVEN F Moss and JULIAN R F WALKER and Ms KATE A TONGE (Royal Postgraduate Medical School, London W12 ONN) write: A 70 year old man was admitted to hospital with a three week history of progressive jaundice associated with pruritus, anorexia, loss of 12 kg, dark urine, and pale stools. He had no risk factors for infectious hepatitis and no relevant history. He had been taking triazolam for insomnia for seven months, and cinnarizine 15 mg three times a day had been prescribed for dizzy spells three weeks before jaundice developed. He had no known drug allergy and was teetotal. On examination he was deeply jaundiced and had no fever. His abdomen was soft with no palpable masses or organomegaly and a rectal examination showed clay coloured faeces. Investigations showed an elevated bilirubin concentration of 117 tmol/l, alkaline phosphatase activity 281 IU/l (normal range 30-130 IU/1), aspartate aminotransferase activity 71 IU/1, and y-glutamyltransferase activity 291 IU/1. He had normal renal function and electrolyte concentration. His white BMJ
VOLUME 301
1 DECEMBER 1990
cell count was 38x 109/1 with a normal differential, erythrocyte sedimentation rate was 46 mm in the first hour, and concentration of C reactive protein 9 mg/l. Coagulation studies gave normal results. Screens for haemolysis gave negative results and antibodies to hepatitis A and B viruses were not detected. An autoantibody screen showed a low titre of antibodies to smooth muscle cells (
anywhere-some love it, some hate it, and some will find the administration to be an easy target. Being a member of the army medical service is not a cheap and easy way to obtain higher medical qualifications. It is a commitment during which time officers will certainly be given the opportunity to advance their professional medical skills and may find themselves in a position to develop a better insight into the importance of Remembrance Sunday.
ALVAN PRIDDY HELENE BRANDON
(10 November.) 2 Villar R. Medicine in the armcd forces. BM7 1990;301:721-3. (3 October.,
D S JOLLIFFE
Army MIedical D)ircctorate, London WCIV! 6HE 1 Mabin DC. Mcdicine in the armed forces. BA1j 1990;301:1103.
St Mary's Hospital, Manchester M 13 OJH 1 D)rife JO. 1ubal pregnancy. BMJ,7 1990;301:1057-8. (10 November.) 2 Lindblom B, Hahlin 1\1, K~llfelt B, Hamberger I. Local prostaglandin F,,, injection for termination of ectopic pregnancv. Lancet 1987;i:776-7. 3 Lang PF, Weiss PAM, Mayer HO, Hass JGi, Hinigi W. Conservatisve treatment of ectopic pregnancy with lorcal injection of hyperosmolar glucose solution or prostaglandin F,, a prospective randomised study. Lancet 1990;336:78-81. 4 Lindblom B, Hamberger L, Wiqvist N. Differentiated contractile effects of prostaglandins E and F on the isolated circular and longitudinal smooth musclc of thc htuman oviduct. Fcrti/ 'Steril
1978;30:553-9.
Medicine in the armed services SIR,-I agree with Dr D C Mabin that joining the army medical services either as a cadet or as a qualified doctor is not a career move to be taken lightly. ' It is a commitment to the Queen, to serve her by caring for the medical needs of her soldiers and their dependants, wherever they may be stationed, in time ofpeace and conflict. In exchange for this commitment, the service provides financial support during undergraduate years for cadets and postgraduate training of the highest quality for registered medical officers. In addition, the service provides job security and a way of life that is in sharp contrast with that available to those working in the health service. What Mr Richard Villar remembered,2 and what Dr David Mabin clearly forgot, was that the primary role of the service is to provide medical care for the army; catering for the personal professional aspirations of its officers must, of necessity, be secondary. The British army is the peace insurance policy of the British people. Like all insurance policies, it is there to prepare and wait for something that we all hope will never happen. When nothing does happen it is very easy for army medical officers to forget why they are employed and it is neither unnatural nor uncommon for them to be concerned when they are called away from routine peace time work to face a combination of fear, separation from family, and disruption of a well prepared professional training programme. I know this to be true from personal experience at the time of the Falklands war and, to a lesser extent, during service in Northern Ireland. Dr Mabin's colleague who was whisked away at short notice went to the Gulf to support British troops. He did not go alone. Many of the medical officers already deployed or warned for deployment to the Gulf have had some form of postgraduate training interrupted. If we are not available for operational duty above all other things what are we being paid for? I am unhappy about Dr Mabin's generous use of poetic licence (uneconomical precourse medical examinations such as "fit for typing" were abolished early in Dr Mabin's service, and we are all aware that things do happen in the border country of Northern Ireland), but when it is read alongside Mr Villar's article it does prove that being a doctor in the army is very much like being a doctor
1280
Surely a natural cancer remedy can't be dangerous SIR,-Further to Dr J Tobias's article on the possible danger of a natural cancer remedy' and my response,2 I should like to comment on the recent publication of information suggesting that the original study was flawed. I would also like to suggest that some of the "personal view" expressed by Dr Tobias was opinion masquerading as fact. The authors of the report on the British Cancer Help Centre admit in a letter to the Lancet that in their first analysis they did not take into account local recurrence, which is prognostic, especially for patients treated with mastectomy. In a revised analysis this reduces the relative risk of distant recurrence rate; this is now put at RR= 179 (p=007) as opposed to the original estimate of RR=2 85 (p=001).3 They acknowledge that the differences between patients and controls are likely to have been inflated by self referral-that is, selection bias in a non-randomised trial influences the result. In a letter to the Lancet my colleague, Dr T Sheard,4 pointed out that inaccuracies had been found, indicating that of the women described as free of disease, three had already had a relapse when they came to Bristol; one had bone secondary tumours and two had supraclavicular and cervical lymph node involvement. On the basis of the above facts and others mentioned in letters to the Lancet, Sir Walter Bodmer, director of research at the Imperial Cancer Research Fund, states: "Their own evaluation is that the study's results can be explained by the fact that women going to Bristol had more severe disease than the controls; in particular, they had a much higher rate of local recurrence." The publicity in the lay press has been damaging enough. Many people have lost confidence in some of the methods they had successfully been using to cope with the difficulties that a diagnosis of cancer brings. The number of patients booking to come to the Cancer Help Centre has also dropped substantially. Unfortunately, the suggestion that harm could be done by such approaches was perpetuated by the medical as well as the lay press, and was based on flawed and now discredited evidence. The Cancer Help Centre has clear goals, focusing on quality of life but not excluding the possibility that the focus may have secondary advantages as to survival (something which only a long term randomised study could seriously evaluate). We are also members of a group of doctors and nurses looking at how services in the NHS might creatively be improved by offering a more holistic approach to the cancer
patient. Certainly, questions have been raised by the study. I trust that the damage done by a flawed report and inaccurate publicity will be redressed by a withdrawal of that report and by mutual cooperation, which will ensure the continuation of
pioneering approaches such as those at Bristol and their corporation into a caring NHS. MICHAEL J WETZLER
Bristol Cancer Help Ccntrc, Bristol BS8 4PG I Tobias J. Surelv a natural cancer remedy can't bc dangcrouscan it? BMJ 1990;301:613. (22 September.) 2 Wetzler Mj. Surely a natural cancer remedy can't he dangerous. BMj 1990;301:929. (20 October.) 3 Chilvers CED, Easton DF, Bagenal FS, Harris E, McElwain TJ. Bristol Cancer Help Centre. Lancet 1990;336:1186. 4 Sheard T. Bristol Cancer Help Centre. Lancet 1990;336:1 185.
AUTHOR'S REPLY,-As Dr Wetzler points out, a revised analysis of the original data from the Bristol Cancer Help Centre study, taking account of differences between the control and treatment groups, still showed a higher relative risk of distant recurrence in the centre's patients. A relative risk of recurrence of 1 79 in those attending compared with those not attending the centre cannot be ignored even though this difference is not statistically significant. There is certainly no evidence that the many recommendations of the centre have a positive effect on patients' probability of surviving their cancer. As I pointed out in my article, which was quite clearly a piece reflecting my own opinions and not "masquerading as fact," much of the advice from the Bristol Cancer Help Centre is of unproved benefit yet clearly disruptive of a patient's life, sometimes to the most unfortunate degree.' How curious that Dr Wetzler should still insist that though the chief emphasis at the centre is now on quality of life, there still exists "the possibility that the focus may have secondary advantages as to survival." This is surely now an impossibility even on the reanalysis of the data that Sheard2 and others have attempted. Of course it is unfortunate for the Bristol Cancer Help Centre that patients are no longer flocking there for help, but, as we have seen in the political arena over the past few weeks, intelligent people are well able to make decisions for themselves. The reported cost of a week's stay at the Bristol centre (in the region of £600) may also be regarded by many as a major disincentive, and by its own admission on a recent television programme the centre has always appealed chiefly to a limited, middle class section of the community. As Professor Baum and I pointed out recently,' it is extremely unfortunate that the initial recommendation of a prospectively randomised study was rejected as all other types of comparison, including the present one, are open to bias and misinterpretation. JEFFREY S TOBIAS University College Hospital, London WC 1 E 6AU I 'I'obias J. Surelv a natural cancer remedy can't be dangerous. BMJ,7 1990;301:613. (22 September.) 2 Sheard TAB. Bristol cancer help centre. Lantcet 1990;336: 1185-6. 3 Tobias JS, Baum M. Bristol canccr help ccntre. I.ancet 1990;336: 1323.
DrugPoints Toxic epidermal necrolysis associated with indapamide Drs R J BLACK, P MURPHY, T J ROBINSON, and K W SCOTT (Craigavon Area Hospital, Craigavon BT63 5QQ) write: Toxic epidermal necrolysis is characterised by the widespread loss of epidermis with formation of subepidermal blisters and severe constitutional symptoms.' 2 It has several causes, one of the well recognised being a drug reaction. A 65 year old woman with a long history of essential hypertension who was taking atenolol was started on indapamide 2 5 mg daily for ad-
BMJ
VOLUME
301
1
DECEMBER
1990
ditional blood pressure control. She was also taking triazolam 0-25 mg at night and dothiepin hydrochloride 25 mg at night, both of which she had taken for many vears. Seven days after starting taking indapamide she developed a generalised, erythematous pruritic rash, confusion, and fever and was admitted to hospital. Over the next three days widespread peeling of the epidermis developed and Nikolsky's sign was present. The areas worst affected were the upper trunk, limbs, and buttocks. Among the mucosal surfaces only the buccal mucosa was affected. She concurrently had fever with a temperature of 40 5°C, confusion, hypotension (systolic blood pressure 60 mm Hg), acute renal failure (urea concentration 46 mmoUl/), and disseminated intravascular coagulation (concentration of fibrin degradation products 64 mg/I, platelet count 51 x 109/l). Supportive treatment was started with intravenous fluids, fresh frozen plasma, and intravenous hvdrocortisone 200 mg four times a day for 10 days, after which time the treatment was reduced. She was nursed on a ripple bed and silver sulphadiazine was applied daily to the areas of skin loss. After five days her condition began to improve, and after a further two weeks her renal function and coagulation had returned to normal and epidermal regeneration was complete. Indapamide is a non-thiazide diuretic used to treat essential hypertension. It is prepared by condensing a chlorosulphonariide acid chloride with an indole amine. Rashes associated with indapamide have been reported and, though usually mild, can be severe." Though toxic epidermal necrolysis is a well known side effect of sulphonamide drugs,5 it has not previously been associated with indapamide to our knowledge. As indapamide is a commonly used drug we believe that the possibility of this side effect should be borne in mind. We thank Mrs G Cully for typing and Dr T A J Dawson for his advice. I Lvell A. Toxic cpidermal necrolvsis: an cruption resembling scalding of the skin. Br.7 Dermatol 1956;68:355-61. 2 Pve RJ. Toxic epidermal necrolysis. In: Rook A, Wilkinson DS, Ebling FJG, Champion RH, Burton JL, eds. lextbook of dermatologv. Vol 2. 4th ed. Oxford: Blackwell Scientific, 1986:1658-9. 3 Association of the British Pharmaceutical Industry. ABPI data sheet compenzdium 1990-91. London: Data Pharm Publications, 1990:1602. 4 Stricker BHCh, Biriell C. Skin reactions and fever with indapa-
mide. BMJ 1987;295:1313-4. 5 Guillaume JC, Rouleau JC, Penso D, Reuz J, Touraine R. The culprit drugs in 87 cases of toxic epidermal necrolysis (Lvell's syndrome). Arch Dermatol 1987;123:1166-70.
Cholestasis associated with cinnarizine Drs STEVEN F Moss and JULIAN R F WALKER and Ms KATE A TONGE (Royal Postgraduate Medical School, London W12 ONN) write: A 70 year old man was admitted to hospital with a three week history of progressive jaundice associated with pruritus, anorexia, loss of 12 kg, dark urine, and pale stools. He had no risk factors for infectious hepatitis and no relevant history. He had been taking triazolam for insomnia for seven months, and cinnarizine 15 mg three times a day had been prescribed for dizzy spells three weeks before jaundice developed. He had no known drug allergy and was teetotal. On examination he was deeply jaundiced and had no fever. His abdomen was soft with no palpable masses or organomegaly and a rectal examination showed clay coloured faeces. Investigations showed an elevated bilirubin concentration of 117 tmol/l, alkaline phosphatase activity 281 IU/l (normal range 30-130 IU/1), aspartate aminotransferase activity 71 IU/1, and y-glutamyltransferase activity 291 IU/1. He had normal renal function and electrolyte concentration. His white BMJ
VOLUME 301
1 DECEMBER 1990
cell count was 38x 109/1 with a normal differential, erythrocyte sedimentation rate was 46 mm in the first hour, and concentration of C reactive protein 9 mg/l. Coagulation studies gave normal results. Screens for haemolysis gave negative results and antibodies to hepatitis A and B viruses were not detected. An autoantibody screen showed a low titre of antibodies to smooth muscle cells (
