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COMMUNICATION PROBLEM
1424 TABLE II-CLEARANCE OF LEUCINE DURING PERITONEAL DIALYSIS
peritoneum is similar
to that of creatinine, and that the relative contribution of the urinary excretion of leucine is less than that of the dialysate, even allowing for considerable urine losses during collection. The findings document efficacy of peritoneal dialysis in the management of M.S.U.D., and emphasise the advantage of this technique compared with exchange transfusion or the dietary elimination of the branched-chain aminoacids.
We are grateful to the department of chemical pathology for their assistance in the preparation of this report. The Hospital for Sick Children, STEPHEN E. SALLAN Great Ormond Street, DENNIS COTTOM. London W.C.1.
COMMUNICATION PROBLEM often see women who have had hysterectomies SiR,—I but who voice that all-too-common complaint, " They don’t tell nobody nothing, Doctor ". Surely every gynaecologist, when he does the operation, should himself tell the patient in simple terms whether the ovaries have been left, whether the cervix has been conserved, and whether the appendix has been removed. If, in addition, he could find time to explain the implications of the operation, so much the better; but at least let him give this minimum information, and then see that it is also passed to the general practitioner in exact terms-i.e., avoiding unsatisfactory words like pan-hysterectomy, which are apt to mean different things to different people. H. J. FRIEND. London E.C.4.
RIFAMYCIN ANTIBIOTICS IN CHRONIC BRONCHITIS SIR,-Dr. Citron and Professor May (Nov. 8, p. 982) conclude that rifamide should not be used in chronic non-tuberculous bronchopulmonary infections. They suggest that the lack of efficacy of this drug could be attributed to its poor sputum penetration. Professor May has, however, demonstrated previously that ampicillin concentrations in the serum regularly exceed those in the sputum by many times, and that on occasion no antibiotic can be detected in the sputum despite therapeutic serum levels. Although there is no clear correlation between peak serum levels and the concentration of ampicillin in the sputum/ ampicillin has been found to reduce the frequency of early relapse in patients in hospital with exacerbations of chronic bronchitis.22 Chloramphenicol, a drug which penetrates sputum in high concentrations,3 has been found to reduce the number of infectious exacerbations when administered to patients with chronic pulmonary emphysema as part of a long-term prophylactic regimen, but it has no over-all effect on the purulence of the sputum.4 Certainly antibiotic penetration May, J. R., Delves, D. M. Lancet, 1965, i, 929. Elmer, P. C., King, T. K. C., Langlands, J. G. M., Mackay, J. A., Wallace, W. F. M., Wade, O. L., Wilson, T. S. ibid. 1965, ii, 904. 3. Mulder, J., Goslings, W. R. O., Van der Plas, M. C., Cordozo, P. L. Acta med. scand. 1952, 143, 32. 4. Davis, A. L., Grobow, E. J., Kaminski, T., Tompsett, R., McClement, J. H. Am. Rev. resp. Dis. 1965, 92, 900. 1. 2.
of sputum is only one of the many factors which influence the response of chronic purulent bronchitis to treatment. One also wonders whether the sole criterion for effectiveness-namely, sputum purulence-should not be supplemented with others, such as decreased frequency of cough, diminution of dyspnoea, improved appetite, reduction in frequency of acute bacterial exacerbations, reduction in hospital stay, and increased employability, before any chemotherapeutic agent is condemned. Although there is a correlation between clinical improvement and attainment of mucoid sputum, it is far from complete. Biologic Laboratories, Commonwealth of Massachusetts Department of Public Health, Boston, Mass.
RICHARD GLECKMAN.
HÆMOLYTIC-URÆMIC SYNDROME: FAILURE TO DEMONSTRATE CIRCULATING ENDOTOXIN SIR,-The aetiology and pathogenesis of the hasmolyticuraemic syndrome (H.u.s.) of infancy has not been determined. In an annotation last year 1 you suggested that the necrotising action of adrenaline on the skin of the rabbit, in the presence of endotoxin, might be used in order to demonstrate the presence of circulating endotoxin. We have been unable to detect endotoxin in the plasma of 4 patients, with the H.u.s., employing the method described by Douglas et al. for the demonstration of circulating endotoxin in cases of septic abortion. It should be pointed out that we do not know whether this method will detect the toxic parent material or detoxified endotoxin. The time of collection of the plasma in relation to the onset of the prodromal phase (diarrhoea in each case), and the onset of features of H.u.s., is shown in the accompanying table. Patient 2 was admitted to hospital with a prolapsed OF TIME OF OBTAINING PLASMA TO ONSET OF DIARRHCEA AND ONSET OF THE HILMOLYTIC-URIEMIC SYNDROME RELATIONSHIP
He developed the characteristic picture of the while in hospital. Plasma was thus obtained within 24 hours of the onset of the acute H.u.s. in this child. Possible objections to these negative findings are (a) that there is no longer any circulating endotoxin by the time the patient is seen, and (b) that 7 ml. of plasma (as used by Douglas et al.) is too small a vehicle for what may only be minute amounts of circulating endotoxin. An answer to these problems is not readily forthcoming. Detoxified endotoxin,3 in contrast to the toxic parent material, is not taken up immediately by the reticulo-endothelial system but circulates for a longer period. We were able to obtain plasma early in the course of the disease in one case, but, as mentioned above, we do not know whether the method we used detects detoxified endotoxin. Therefore we cannot state unequivocally, on the basis of these observations, that circulating endotoxin is not present in the plasma of cases of the H.u.s. It is our opinion, however, that theories of the pathogenesis of the H.u.s. will change in
rectum. H.u.s.
1. Lancet, 1968, ii, 271. 2. Douglas, G. W., Beller, F. K., Debrovner, C. H. Am. J. Obstet. Gynec. 1963, 87, 780. 3. Golub, S., Gröschel, D., Nowotny, A. J. Reticuloendothelial Soc. 1968, 5, 324.
peritoneum is similar
to that of creatinine, and that the relative contribution of the urinary excretion of leucine is less than that of the dialysate, even allowing for considerable urine losses during collection. The findings document efficacy of peritoneal dialysis in the management of M.S.U.D., and emphasise the advantage of this technique compared with exchange transfusion or the dietary elimination of the branched-chain aminoacids.
We are grateful to the department of chemical pathology for their assistance in the preparation of this report. The Hospital for Sick Children, STEPHEN E. SALLAN Great Ormond Street, DENNIS COTTOM. London W.C.1.
COMMUNICATION PROBLEM often see women who have had hysterectomies SiR,—I but who voice that all-too-common complaint, " They don’t tell nobody nothing, Doctor ". Surely every gynaecologist, when he does the operation, should himself tell the patient in simple terms whether the ovaries have been left, whether the cervix has been conserved, and whether the appendix has been removed. If, in addition, he could find time to explain the implications of the operation, so much the better; but at least let him give this minimum information, and then see that it is also passed to the general practitioner in exact terms-i.e., avoiding unsatisfactory words like pan-hysterectomy, which are apt to mean different things to different people. H. J. FRIEND. London E.C.4.
RIFAMYCIN ANTIBIOTICS IN CHRONIC BRONCHITIS SIR,-Dr. Citron and Professor May (Nov. 8, p. 982) conclude that rifamide should not be used in chronic non-tuberculous bronchopulmonary infections. They suggest that the lack of efficacy of this drug could be attributed to its poor sputum penetration. Professor May has, however, demonstrated previously that ampicillin concentrations in the serum regularly exceed those in the sputum by many times, and that on occasion no antibiotic can be detected in the sputum despite therapeutic serum levels. Although there is no clear correlation between peak serum levels and the concentration of ampicillin in the sputum/ ampicillin has been found to reduce the frequency of early relapse in patients in hospital with exacerbations of chronic bronchitis.22 Chloramphenicol, a drug which penetrates sputum in high concentrations,3 has been found to reduce the number of infectious exacerbations when administered to patients with chronic pulmonary emphysema as part of a long-term prophylactic regimen, but it has no over-all effect on the purulence of the sputum.4 Certainly antibiotic penetration May, J. R., Delves, D. M. Lancet, 1965, i, 929. Elmer, P. C., King, T. K. C., Langlands, J. G. M., Mackay, J. A., Wallace, W. F. M., Wade, O. L., Wilson, T. S. ibid. 1965, ii, 904. 3. Mulder, J., Goslings, W. R. O., Van der Plas, M. C., Cordozo, P. L. Acta med. scand. 1952, 143, 32. 4. Davis, A. L., Grobow, E. J., Kaminski, T., Tompsett, R., McClement, J. H. Am. Rev. resp. Dis. 1965, 92, 900. 1. 2.
of sputum is only one of the many factors which influence the response of chronic purulent bronchitis to treatment. One also wonders whether the sole criterion for effectiveness-namely, sputum purulence-should not be supplemented with others, such as decreased frequency of cough, diminution of dyspnoea, improved appetite, reduction in frequency of acute bacterial exacerbations, reduction in hospital stay, and increased employability, before any chemotherapeutic agent is condemned. Although there is a correlation between clinical improvement and attainment of mucoid sputum, it is far from complete. Biologic Laboratories, Commonwealth of Massachusetts Department of Public Health, Boston, Mass.
RICHARD GLECKMAN.
HÆMOLYTIC-URÆMIC SYNDROME: FAILURE TO DEMONSTRATE CIRCULATING ENDOTOXIN SIR,-The aetiology and pathogenesis of the hasmolyticuraemic syndrome (H.u.s.) of infancy has not been determined. In an annotation last year 1 you suggested that the necrotising action of adrenaline on the skin of the rabbit, in the presence of endotoxin, might be used in order to demonstrate the presence of circulating endotoxin. We have been unable to detect endotoxin in the plasma of 4 patients, with the H.u.s., employing the method described by Douglas et al. for the demonstration of circulating endotoxin in cases of septic abortion. It should be pointed out that we do not know whether this method will detect the toxic parent material or detoxified endotoxin. The time of collection of the plasma in relation to the onset of the prodromal phase (diarrhoea in each case), and the onset of features of H.u.s., is shown in the accompanying table. Patient 2 was admitted to hospital with a prolapsed OF TIME OF OBTAINING PLASMA TO ONSET OF DIARRHCEA AND ONSET OF THE HILMOLYTIC-URIEMIC SYNDROME RELATIONSHIP
He developed the characteristic picture of the while in hospital. Plasma was thus obtained within 24 hours of the onset of the acute H.u.s. in this child. Possible objections to these negative findings are (a) that there is no longer any circulating endotoxin by the time the patient is seen, and (b) that 7 ml. of plasma (as used by Douglas et al.) is too small a vehicle for what may only be minute amounts of circulating endotoxin. An answer to these problems is not readily forthcoming. Detoxified endotoxin,3 in contrast to the toxic parent material, is not taken up immediately by the reticulo-endothelial system but circulates for a longer period. We were able to obtain plasma early in the course of the disease in one case, but, as mentioned above, we do not know whether the method we used detects detoxified endotoxin. Therefore we cannot state unequivocally, on the basis of these observations, that circulating endotoxin is not present in the plasma of cases of the H.u.s. It is our opinion, however, that theories of the pathogenesis of the H.u.s. will change in
rectum. H.u.s.
1. Lancet, 1968, ii, 271. 2. Douglas, G. W., Beller, F. K., Debrovner, C. H. Am. J. Obstet. Gynec. 1963, 87, 780. 3. Golub, S., Gröschel, D., Nowotny, A. J. Reticuloendothelial Soc. 1968, 5, 324.