- Email: [email protected]
BEREAVEMENT AND SEVERE DEMENTIA
405 37°C overnight in C02. The coverslip was then washed in phosphate-buffered saline and fixed in acetone. 25 1 of a 1 in 20 dilution of the monoclonal antibody (anti-CMV early nuclear protein, NEA 9221, Du Pont)2 was applied to the coverslip which was further incubated at 37°C for 30 min. After washing, a fluorescein isothiocyanate-labelled goat anti-mouse IgG conjugate (Tago) was applied, and incubation at 37°C continued for a further 30 min. After a final wash the cells were examined under incident fluorescent light. Fluorescence was confined to the nucleus of infected cells and background staining was negligible, which made the coverslips easy to read even when small numbers of positive nuclei were present. Conventional culture was done by inoculating three tubes of MRe5 cells with the urine suspension. The tubes were incubated at 37°C for up to 28 days, and examined daily for appearance of a typical cytopathic effect. COMPARISON OF DETECTION OF EARLY ANTIGEN FLUORESCENT FOCI AND CONVENTIONAL CULTURE
Plasma ANP during angiotensin sensitivity test in 12 pregnant women between weeks 28 and 32 of gestation. Mean and SEM.
There was a significant increase in ANP levels from a mean of 199’(SEM 15-3) pg/ml before the AST to 256.5 (25-3) pg/ml after the AST (figure; p < 0-001, Wilcoxon matched-pairs test). 30 min after the test ANP levels were still increased (234-2 [21’1], p < 0.05). In all patients during the test the diastolic blood pressure increased significantly from 49-8 [3’2] to 67-3 [3’2] mm Hg after the AII-amide infusion (p < 0 001). We have shown a significant increase in plasma ANP levels in pregnant women after infusion of AII-amide and during a controlled increase in diastolic blood pressure.
CMV was isolated from 30% of specimens (table). The mean tiine to development of a cytopathic effect was 10 days (range 7-13). There was complete agreement between early antigen detection by fluorescence and conventional culture. Although the number of specimens was small, the initial results are promising and the technique has now been made routine. Not only is the method rapid compared with culture, but it is also economical. The cost of the monoclonal antibody is L135/ml, but this is sufficient for up to 800 tests.
Departments of Obstetrics and Gynaecology, Medical School of Hannover, D-3000 Hannover, West Germany
City Hospital of Remscheid, Remscheid, West Germany
STEFAN NIESERT HAMS HEINRICH GÜNTER HELMUT KAULHAUSEN
1. Cusson JR, Gutkowska J, Rey E, et al. Plasma concentration of atrial natriuretic factor m normal pregnancy. N Engl J Med 1985; 313: 1230-31.
2. Laragh JH. Atrial natriuretic hormone, the renin-aldosterone axis and blood pressure-electrolyte homeostasis. N Engl J Med 1985; 313: 1330-40. 3. Gant NF, Daley GL, Chand S, et al. A study of angiotensin II pressor response throughout primigravid pregnancy. J Clin Invest 1973; 52: 2682-89. 4. Öney T, Kaulhausen H. The value of the angiotensin sensitivity test in early diagnosis of hypertensive disorders in pregnancy. Am J Obstet Gynecol 1982; 142: 17-20. 5. Juppner H, Brabant G, Kapteina U, et al. Direct radioimmunoassay for human atrial natriuretic peptide and its clinical evaluation. Biochem Biophys Res Commun 1986; 139: 1215-23.
RAPID DIAGNOSIS OF CYTOMEGALOVIRUS INFECTION BY DETECTION OF EARLY ANTIGEN FLUORESCENT FOCI can cause severe infections in and immunosuppressed patients. Diagnosis by conventional cell culture is slow and often too late to affect management of the patient. Detection of early antigen fluorescent foci is a convenient and rapid method for the diagnosis of CMV infection.1 However, the method is not routine in virus laboratories because of the lack of a readily available antibody. We have compared our routine culture system for CMV with the early detection of antigen by a commercially available monoclonal
SIR,-Cytomegalovirus (CMV)
neonates
antibody. 69 urine samples in CMV transport medium were obtained from unselected renal transplant patients attending for routine follow-up. The urine was centrifuged at 1000 g for 10 min, the pellet was resuspended in one-tenth the volume of supernatant, and 0.25 ml of suspension was inoculated onto a monolayer of MRCs cells on a coverslip in a plastic vial. After centrifugation at 1000 g for 1 h at 33°C, maintenance medium was added and the vial was incubated at
We thank Dr R. P. Burden and Dr A. G. Morgan for allowing us their patients. Public Health Laboratory, Queen’s Medical Centre, Nottingham NG7 2UH
to
study
MICHAEL L. HAWKINS ANDREW MCKENZIE SIMON PUGH
PD, Panjwani DD, Stirk PR, et al. Rapid diagnosis of cytomegalovirus infection in immunocompromised patients by detection of early antigen fluorescent foci. Lancet 1984; ii: 1242-44. 2. Shuster EA, Beneke JS, Tegtmeier GE, et al. Monoclonal antibody for rapid laboratory detection of cytomegalovirus infections: Characterization and diagnostic application. Mayo Clin Proc 1985; 60: 577-85. 1. Griffiths
BEREAVEMENT AND SEVERE DEMENTIA
SIR,-Dr Summerfield and Sister Smellie have written about bereavement and severe dementia (May 9, p 1097). I would like to add a personal anecdote to theirs and some reflections. My mother developed severe memory difficulty in her 70s and probable Alzheimer’s disease was diagnosed, which her mother had had before her. She came to a point where she did not recognise me although when I was present she seemed to know I was important to her. Her speech was dysphasic and her understanding rudimentary. It was in this state that she learned of my father’s death after four days of pneumonia. To everyone’s surprise she made a suicide attempt with an overdose of unknown pills. She was in a coma briefly and recovered. Coming out of the coma she tried to swallow the coins from her purse. I believe she thought they were pills because they were circular. I recalled her saying years before that she did not want to outlive my father. They were very close. The first day after my father’s death she asked me many times, "He’s gone, isn’t he?" and every time when I responded with "Yes, he is gone" she would look stricken and sometimes she wept. She attended the funeral and burial service, and afterwards asked me once more if he were gone and then seemed reconciled. Over the next three or four days she gradually resumed her usual manner and as the years went by her mental state worsened. She never asked about my father again. I think my mother grieved for him in that one
406 short period. It was not as long as it would have been had she not been demented, but she recognised the loss and what it meant to her. Pronouncements are often made about the demented which come from what one might expect a priori, but not from observation and experience. Clinical work with the demented tells me that the sense of sequence, context, and organisation is interfered with along with loss of memory traces themselves. Given a powerful stimulus or an effective prompting a demented person might recall and perform appropriately. For instance, one demented man I knew would often stare blankly and helplessly at his meal, not being able to eat it. However, if the fork were put into his hand and the hand guided once to his mouth, he could then happily dine on his own. Bereavement is a powerful stimulus and so is the example set by mourners around a person. I feel this may initiate a sequence of grief in a demented person with resolution and reconciliation, although perhaps abbreviated. Dr Summerfield and Sister Smellie, in reporting their observations, add depth and insight into the mind and feelings of demented patients and encourage us to be alert to them. 97 Mt Vemon Street, Boston, Massachusetts 02108, USA
JAMES A. HAYCOX
Medicine and the Law
order. During her stay in hospital, the patient had worked hard to become more self-sufficient. She was now able to get from her wheelchair to the toilet; she could wash herself adequately; and, with some support from the nursing and social services, she seemed ready for discharge. The community physician argued that further deteriorations necessitating readmission were so predictable that an order should be made on a prophylactic basis. EMERGENCY PROVISIONS OF NATIONAL ASSISTANCE ACT
The Act provides for the "removal to suitable premises of persons in need of care and attention" who are defined by s47(l) as: "(a) are suffering from grave chronic disease or, being aged, infirm or physically incapacitated, are living in insanitary conditions, and (b) are unable to devote to themselves, and are not receiving from other persons, proper care and attention". The "proper officer" (here the community physician appointed by the London Borough of Hounslow) must certify that he is satisfied after thorough inquiry that removal and/or detention is necessary "in the interests of any such person ... or preventing injury to the health of, or serious nuisance to, other persons". It seems reasonably clear that a person who is old, infirm, and physically incapacitated and living in insanitary conditions while also bearing misfortunes defined by s47(b) does qualify for removal under the Act. However, it is not clear whether someone with a grave chronic disease must also be living in insanitary conditions, as well as suffering the indignities defined under s47(b), before he or she could be said to qualify. And does "grave chronic disease" mean a potentially terminal condition or one that is merely painful and/or .
Involuntary Hospital Admission under Section 47 of the National Assistance Act ON July 24, 1987, a community physician applied to have a physically handicapped woman made the subject of a three month order detaining her in hospital. The order would be potentially renewable every three months, resulting in loss of liberty. When the patient sought to challenge the application, with the support of the consultant geriatrician in charge of her case, Dr James Andrews, legal aid was not available. A contribution towards a solicitor’s court fees was eventually made out of the "poor box" by Feltham magistrates. The case sheds a worrying light on "welfare" legislation. BACKGROUND
A mentally competent but immobile, heavy, and arthritic woman of 69 with oedematous legs lived on her own in rented accommodation she had occupied for 68 years. A sister of 55 and a spry mother of 92 lived nearby and visited her and helped with shopping, and the woman got on well with her home help. However, she had at times great difficulty in transferring from her wheelchair to her bed and/or to the outside toilet, though a commode was available indoors. There was no suggestion that the
though unmodemised, was insanitary. Unfortunately the patient did not always get on well with some of the district nurses, and on several occasions, as a result of disputes, she had stayed in her wheelchair for many days and nights. As a consequence, her health deteriorated. Her legs became ulcerated with swelling of the legs and joints, and she was admitted to a geriatric ward from Jan 22 to May 28,1986. She subsequently came into hospital for day treatment until Oct 8, but otherwise remained fairly well. However, the previous sequence of events having recurred, she was admitted to hospital again, from Jan 5 to March 16,1987. On April 8, the community physician, at the official behest of the local authority (but probably prompted by the district nursing service) applied to have her removed to hospital under the emergency provisions of the National Assistance Act 1948, s47 (as amended by the Act of 1951). The order lasted for three weeks but the woman stayed on in hospital as a voluntary patient until June 9. One week later, her condition again deteriorated because of lack of care when at home and on June 16 she was the subject of a second three-week emergency order, renewed on July 6. However, the patient and the consultant geriatrician decided to challenge an application to make her the subject of a three-month renewable accommodation,
,
debilitating? In this case the patient had a chronic condition which, if neglected, became grave but was not grave when the three-month order was sought. It was not alleged that she lived in insanitary conditions. The community physician contended that the patient required more nursing than the district service could then offer. The consultant’s evidence, on the other hand, was that it was not in the patient’s interests to be kept indefinitely in an institution against her will; she was perfectly amenable to reason and persuasion. She had agreed to remain in hospital until her home help was back from holiday, but thereafter there was no reason to detain her. She was an appropriate case for care in the community: her condition was once again under control, her mobility was much improved, and she required a district nurse to call only once or twice a week. (The council did not suggest a move to sheltered accommodation, so this was not considered as an option.) APPLICATION REFUSED
The magistrates refused to make the order. They were not satisfied that the criteria under the Act had been met and they took into account the fact that the patient wished to return home. However, the result might have been different had the woman not had the support of her consultant and a solicitor. The consultant, it should be emphasised, was employed by the regional health authority not the district health authority whose nursing service had instigated the complaint. It could become all too easy to move awkward, elderly, feeble, invalid people into hospital "for their own good" (and administrative convenience), sapping their independence. Financial cuts and staff shortages could well increase the frequency of situations in which such applications would seem
tempting. Fortunately,
the s47
provisions
are
used
rarely. Three
or
four
per year is the experience of the local geriatric unit, and in the past ten years no applications have been contested in Hounslow. cases
Ironically, the Act is not invoked when it should be-to care for those people who really need accommodation, shelter, or medical care. Large numbers of former patients of mental hospitals and other inadequates, many of whom suffer from tuberculosis, addictions, and other problems, are left to doss down under the railway bridges, while others who cause a nuisance or commit crimes go to prison because there are no beds in appropriate institutions.
DIANA BRAHAMS, Barrister-at-law
Plasma ANP during angiotensin sensitivity test in 12 pregnant women between weeks 28 and 32 of gestation. Mean and SEM.
There was a significant increase in ANP levels from a mean of 199’(SEM 15-3) pg/ml before the AST to 256.5 (25-3) pg/ml after the AST (figure; p < 0-001, Wilcoxon matched-pairs test). 30 min after the test ANP levels were still increased (234-2 [21’1], p < 0.05). In all patients during the test the diastolic blood pressure increased significantly from 49-8 [3’2] to 67-3 [3’2] mm Hg after the AII-amide infusion (p < 0 001). We have shown a significant increase in plasma ANP levels in pregnant women after infusion of AII-amide and during a controlled increase in diastolic blood pressure.
CMV was isolated from 30% of specimens (table). The mean tiine to development of a cytopathic effect was 10 days (range 7-13). There was complete agreement between early antigen detection by fluorescence and conventional culture. Although the number of specimens was small, the initial results are promising and the technique has now been made routine. Not only is the method rapid compared with culture, but it is also economical. The cost of the monoclonal antibody is L135/ml, but this is sufficient for up to 800 tests.
Departments of Obstetrics and Gynaecology, Medical School of Hannover, D-3000 Hannover, West Germany
City Hospital of Remscheid, Remscheid, West Germany
STEFAN NIESERT HAMS HEINRICH GÜNTER HELMUT KAULHAUSEN
1. Cusson JR, Gutkowska J, Rey E, et al. Plasma concentration of atrial natriuretic factor m normal pregnancy. N Engl J Med 1985; 313: 1230-31.
2. Laragh JH. Atrial natriuretic hormone, the renin-aldosterone axis and blood pressure-electrolyte homeostasis. N Engl J Med 1985; 313: 1330-40. 3. Gant NF, Daley GL, Chand S, et al. A study of angiotensin II pressor response throughout primigravid pregnancy. J Clin Invest 1973; 52: 2682-89. 4. Öney T, Kaulhausen H. The value of the angiotensin sensitivity test in early diagnosis of hypertensive disorders in pregnancy. Am J Obstet Gynecol 1982; 142: 17-20. 5. Juppner H, Brabant G, Kapteina U, et al. Direct radioimmunoassay for human atrial natriuretic peptide and its clinical evaluation. Biochem Biophys Res Commun 1986; 139: 1215-23.
RAPID DIAGNOSIS OF CYTOMEGALOVIRUS INFECTION BY DETECTION OF EARLY ANTIGEN FLUORESCENT FOCI can cause severe infections in and immunosuppressed patients. Diagnosis by conventional cell culture is slow and often too late to affect management of the patient. Detection of early antigen fluorescent foci is a convenient and rapid method for the diagnosis of CMV infection.1 However, the method is not routine in virus laboratories because of the lack of a readily available antibody. We have compared our routine culture system for CMV with the early detection of antigen by a commercially available monoclonal
SIR,-Cytomegalovirus (CMV)
neonates
antibody. 69 urine samples in CMV transport medium were obtained from unselected renal transplant patients attending for routine follow-up. The urine was centrifuged at 1000 g for 10 min, the pellet was resuspended in one-tenth the volume of supernatant, and 0.25 ml of suspension was inoculated onto a monolayer of MRCs cells on a coverslip in a plastic vial. After centrifugation at 1000 g for 1 h at 33°C, maintenance medium was added and the vial was incubated at
We thank Dr R. P. Burden and Dr A. G. Morgan for allowing us their patients. Public Health Laboratory, Queen’s Medical Centre, Nottingham NG7 2UH
to
study
MICHAEL L. HAWKINS ANDREW MCKENZIE SIMON PUGH
PD, Panjwani DD, Stirk PR, et al. Rapid diagnosis of cytomegalovirus infection in immunocompromised patients by detection of early antigen fluorescent foci. Lancet 1984; ii: 1242-44. 2. Shuster EA, Beneke JS, Tegtmeier GE, et al. Monoclonal antibody for rapid laboratory detection of cytomegalovirus infections: Characterization and diagnostic application. Mayo Clin Proc 1985; 60: 577-85. 1. Griffiths
BEREAVEMENT AND SEVERE DEMENTIA
SIR,-Dr Summerfield and Sister Smellie have written about bereavement and severe dementia (May 9, p 1097). I would like to add a personal anecdote to theirs and some reflections. My mother developed severe memory difficulty in her 70s and probable Alzheimer’s disease was diagnosed, which her mother had had before her. She came to a point where she did not recognise me although when I was present she seemed to know I was important to her. Her speech was dysphasic and her understanding rudimentary. It was in this state that she learned of my father’s death after four days of pneumonia. To everyone’s surprise she made a suicide attempt with an overdose of unknown pills. She was in a coma briefly and recovered. Coming out of the coma she tried to swallow the coins from her purse. I believe she thought they were pills because they were circular. I recalled her saying years before that she did not want to outlive my father. They were very close. The first day after my father’s death she asked me many times, "He’s gone, isn’t he?" and every time when I responded with "Yes, he is gone" she would look stricken and sometimes she wept. She attended the funeral and burial service, and afterwards asked me once more if he were gone and then seemed reconciled. Over the next three or four days she gradually resumed her usual manner and as the years went by her mental state worsened. She never asked about my father again. I think my mother grieved for him in that one
406 short period. It was not as long as it would have been had she not been demented, but she recognised the loss and what it meant to her. Pronouncements are often made about the demented which come from what one might expect a priori, but not from observation and experience. Clinical work with the demented tells me that the sense of sequence, context, and organisation is interfered with along with loss of memory traces themselves. Given a powerful stimulus or an effective prompting a demented person might recall and perform appropriately. For instance, one demented man I knew would often stare blankly and helplessly at his meal, not being able to eat it. However, if the fork were put into his hand and the hand guided once to his mouth, he could then happily dine on his own. Bereavement is a powerful stimulus and so is the example set by mourners around a person. I feel this may initiate a sequence of grief in a demented person with resolution and reconciliation, although perhaps abbreviated. Dr Summerfield and Sister Smellie, in reporting their observations, add depth and insight into the mind and feelings of demented patients and encourage us to be alert to them. 97 Mt Vemon Street, Boston, Massachusetts 02108, USA
JAMES A. HAYCOX
Medicine and the Law
order. During her stay in hospital, the patient had worked hard to become more self-sufficient. She was now able to get from her wheelchair to the toilet; she could wash herself adequately; and, with some support from the nursing and social services, she seemed ready for discharge. The community physician argued that further deteriorations necessitating readmission were so predictable that an order should be made on a prophylactic basis. EMERGENCY PROVISIONS OF NATIONAL ASSISTANCE ACT
The Act provides for the "removal to suitable premises of persons in need of care and attention" who are defined by s47(l) as: "(a) are suffering from grave chronic disease or, being aged, infirm or physically incapacitated, are living in insanitary conditions, and (b) are unable to devote to themselves, and are not receiving from other persons, proper care and attention". The "proper officer" (here the community physician appointed by the London Borough of Hounslow) must certify that he is satisfied after thorough inquiry that removal and/or detention is necessary "in the interests of any such person ... or preventing injury to the health of, or serious nuisance to, other persons". It seems reasonably clear that a person who is old, infirm, and physically incapacitated and living in insanitary conditions while also bearing misfortunes defined by s47(b) does qualify for removal under the Act. However, it is not clear whether someone with a grave chronic disease must also be living in insanitary conditions, as well as suffering the indignities defined under s47(b), before he or she could be said to qualify. And does "grave chronic disease" mean a potentially terminal condition or one that is merely painful and/or .
Involuntary Hospital Admission under Section 47 of the National Assistance Act ON July 24, 1987, a community physician applied to have a physically handicapped woman made the subject of a three month order detaining her in hospital. The order would be potentially renewable every three months, resulting in loss of liberty. When the patient sought to challenge the application, with the support of the consultant geriatrician in charge of her case, Dr James Andrews, legal aid was not available. A contribution towards a solicitor’s court fees was eventually made out of the "poor box" by Feltham magistrates. The case sheds a worrying light on "welfare" legislation. BACKGROUND
A mentally competent but immobile, heavy, and arthritic woman of 69 with oedematous legs lived on her own in rented accommodation she had occupied for 68 years. A sister of 55 and a spry mother of 92 lived nearby and visited her and helped with shopping, and the woman got on well with her home help. However, she had at times great difficulty in transferring from her wheelchair to her bed and/or to the outside toilet, though a commode was available indoors. There was no suggestion that the
though unmodemised, was insanitary. Unfortunately the patient did not always get on well with some of the district nurses, and on several occasions, as a result of disputes, she had stayed in her wheelchair for many days and nights. As a consequence, her health deteriorated. Her legs became ulcerated with swelling of the legs and joints, and she was admitted to a geriatric ward from Jan 22 to May 28,1986. She subsequently came into hospital for day treatment until Oct 8, but otherwise remained fairly well. However, the previous sequence of events having recurred, she was admitted to hospital again, from Jan 5 to March 16,1987. On April 8, the community physician, at the official behest of the local authority (but probably prompted by the district nursing service) applied to have her removed to hospital under the emergency provisions of the National Assistance Act 1948, s47 (as amended by the Act of 1951). The order lasted for three weeks but the woman stayed on in hospital as a voluntary patient until June 9. One week later, her condition again deteriorated because of lack of care when at home and on June 16 she was the subject of a second three-week emergency order, renewed on July 6. However, the patient and the consultant geriatrician decided to challenge an application to make her the subject of a three-month renewable accommodation,
,
debilitating? In this case the patient had a chronic condition which, if neglected, became grave but was not grave when the three-month order was sought. It was not alleged that she lived in insanitary conditions. The community physician contended that the patient required more nursing than the district service could then offer. The consultant’s evidence, on the other hand, was that it was not in the patient’s interests to be kept indefinitely in an institution against her will; she was perfectly amenable to reason and persuasion. She had agreed to remain in hospital until her home help was back from holiday, but thereafter there was no reason to detain her. She was an appropriate case for care in the community: her condition was once again under control, her mobility was much improved, and she required a district nurse to call only once or twice a week. (The council did not suggest a move to sheltered accommodation, so this was not considered as an option.) APPLICATION REFUSED
The magistrates refused to make the order. They were not satisfied that the criteria under the Act had been met and they took into account the fact that the patient wished to return home. However, the result might have been different had the woman not had the support of her consultant and a solicitor. The consultant, it should be emphasised, was employed by the regional health authority not the district health authority whose nursing service had instigated the complaint. It could become all too easy to move awkward, elderly, feeble, invalid people into hospital "for their own good" (and administrative convenience), sapping their independence. Financial cuts and staff shortages could well increase the frequency of situations in which such applications would seem
tempting. Fortunately,
the s47
provisions
are
used
rarely. Three
or
four
per year is the experience of the local geriatric unit, and in the past ten years no applications have been contested in Hounslow. cases
Ironically, the Act is not invoked when it should be-to care for those people who really need accommodation, shelter, or medical care. Large numbers of former patients of mental hospitals and other inadequates, many of whom suffer from tuberculosis, addictions, and other problems, are left to doss down under the railway bridges, while others who cause a nuisance or commit crimes go to prison because there are no beds in appropriate institutions.
DIANA BRAHAMS, Barrister-at-law