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INTRA-ABDOMINAL BLEEDING COMPLICATING PERITONEAL DIALYSIS
190 an
Such preto lower portal pressure be tried. might blunt the proposed rise of portal pressure
attempt
treatment
to the bicarbonate infusion. Department of Medicine, Los Angeles County-U.S.C. Medical Center, Los Angeles, California.
secondary
GLENN TISMAN.
RIFAMYCIN ANTIBIOTICS IN CHRONIC BRONCHITIS SIR,-Dr. Gleckman (Dec. 27, p. 1424) appears not to have read our paper very carefully. Rifamide serum levels, possibly because of rapid clearance in the bile, were trivial in each of our patients and it is therefore inappropriate to make any comparison with ampicillin, which normally gives substantial concentrations in serum-very substantial if given intramuscularly as rifamide has to be. Further, although we believe that purulence of sputum at present provides the only objective measure of activity of bacterial infection in the bronchi, we did state also that rifamide produces " no clinical improvement". Decreased frequency of cough, diminution of dyspnoea, improved appetite, &c., which Dr. Gleckman suggests should be taken into account when assessing the value of an antibiotic, are notoriously unreliable as guides to the success of chemotherapy, since they often occur as a result simply of careful nursing in hospital without any antibiotic being given -
Brompton Hospital and Institute of Diseases of the Chest, London S.W.3.
K. M. CITRON J. ROBERT MAY.
the dialysis fluid had no effect. Following the advice of Dr. Thompson and Dr. Uldall, 250,000 units of streptokinase was instilled into the peritoneal cavity through the catheter. After one hour dialysis was resumed. The fluid was grossly bloody at first but ran without interruption, and dialysis After eight was completed without further complications. to ten cycles the fluid was rose-pink in colour, and remained so during the rest of the dialysis. There was no recurrence of bleeding. When dialysis was completed, the hmmoglobin level was the same as on admission. This method should, of course, only be used in cases of bleeding from the abdominal wall-i.e., only if bleeding from intra-abdominal sites can be ruled out with reasonable certainty. Medical Department P, Division of Nephrology, Rigshospitalet, Copenhagen, Denmark.
JØRGEN LADEFOGED IB STEINESS.
PROSTAGLANDINS FOR INDUCTION OF THERAPEUTIC ABORTION SiR,—The techniques at present used for inducing therapeutic abortion after the 12th week of pregnancy are not entirely satisfactory. This is true of surgical methods and of intra-amniotic injection of hypertonic solutions. It would be preferable to induce labour-like uterine contractions by intravenous or subcutaneous injection of a substance with strong oxytocic activity. Uterine sensitivity to oxytocin is low during early and mid pregnancy, and intravenous infusions of oxytocin, even when given continuously for two or three days, only rarely result in abortion.
INTRA-ABDOMINAL BLEEDING COMPLICATING PERITONEAL DIALYSIS SIR,-We owe a debt of thanks to Dr. Thompson and Dr. Uldall for their letter3 recommending the use of intraperitoneal streptokinase to break down clotted blood, so
USE OF PROSTAGLANDINS FOR THERAPEUTIC ABORTION
making it possible to continue peritoneal dialysis. We have recently been faced with the same problem, and benefited from their advice. A man of 27 was admitted with terminal renal failure and malignant hypertension due to chronic glomerulonephritis. He was severely ursemic, hyperkalsemic, and overhydrated. When the peritoneal catheter pierced the abdominal wall there was vigorous bleeding. During the first three cycles (2000 ml. each) the dialysis fluid became increasingly bloodstained, and finally the catheter became obstructed. The catheter was removed, a suture was inserted, and the site of puncture was compressed for about 10 minutes. The patient went into shock and four blood-transfusions had to be given. There were several reasons for avoiding haemodialysis in this patient. Heparinisation during hxmodialysis would have carried the serious risk of repeated bleeding. The question of early renal transplantation had not been explored, either from the medical viewpoint or in regard to a possible donor; therefore, a long period of intermittent haemodialysis had to be anticipated. Under these circumstances we prefer to use an arteriovenous fistula; but this, unlike a Scribner shunt, cannot be used immediately for hoemodialysis. Lastly, we decided against trying to evacuate the blood from the peritoneal cavity because of the
patient’s hyperkalaemia. A further peritoneal puncture was done, but blood-clots in the peritoneal cavity obstructed the outflow through the catheter. The addition of heparin, 400 units per litre, to Y. 1065.
During recent years some of the prostaglandins have been found to have a potent stimulating effect on the pregnant human uterus.1-5 Some also are reported to have strong luteolytic effects in the primate.6 The possibility of using prostaglandins for termination of pregnancy has been investigated in this department. Intravenous infusions or repeated subcutaneous injections of prostaglandin El (P.G.El) or prostaglandin F2(( (P.G.F2C>:) were given to 11 women admitted for therapeutic abortion in the 13th to 18th weeks of pregnancy. Uterine contractility was recorded by the micro-balloon technique or by transabdominal recording of amniotic pressure. Initially the infusions induced considerable uterine hyper1. 2. 3. 4.
J., Moffat, R. C., Walt, A. J. J. Am. med. Ass. 1969, 210
5.
Lancet, 1969, ii, 603.
6.
2.
Silva,
3.
Thompson, N., Uldall,
R.
Wiqvist, N., Bygdeman, M., Kwon, S. U., Mukherjee, T., Roth-Brandel, U. Am. J. Obstet. Gynec. 1968, 102, 327. Bygdeman, M., Kwon, S. U., Mukherjee, T., Wiqvist, N. ibid. p. 317. Embrey, M. P. J. Obstet. Gynæc. Br. Commonw. 1969, 76, 783. Karim, S. M. M., Trusell, R. R., Hillier, K., Patel, R. C. ibid. p. 769. Bygdeman, M., Kwon, S. U., Mukherjee, T., Roth-Brandel, U., Wiqvist, N. Am. J. Obstet. Gynec. (in the press). Pharriss, B. B. Nature, Lond. (in the press).
Such preto lower portal pressure be tried. might blunt the proposed rise of portal pressure
attempt
treatment
to the bicarbonate infusion. Department of Medicine, Los Angeles County-U.S.C. Medical Center, Los Angeles, California.
secondary
GLENN TISMAN.
RIFAMYCIN ANTIBIOTICS IN CHRONIC BRONCHITIS SIR,-Dr. Gleckman (Dec. 27, p. 1424) appears not to have read our paper very carefully. Rifamide serum levels, possibly because of rapid clearance in the bile, were trivial in each of our patients and it is therefore inappropriate to make any comparison with ampicillin, which normally gives substantial concentrations in serum-very substantial if given intramuscularly as rifamide has to be. Further, although we believe that purulence of sputum at present provides the only objective measure of activity of bacterial infection in the bronchi, we did state also that rifamide produces " no clinical improvement". Decreased frequency of cough, diminution of dyspnoea, improved appetite, &c., which Dr. Gleckman suggests should be taken into account when assessing the value of an antibiotic, are notoriously unreliable as guides to the success of chemotherapy, since they often occur as a result simply of careful nursing in hospital without any antibiotic being given -
Brompton Hospital and Institute of Diseases of the Chest, London S.W.3.
K. M. CITRON J. ROBERT MAY.
the dialysis fluid had no effect. Following the advice of Dr. Thompson and Dr. Uldall, 250,000 units of streptokinase was instilled into the peritoneal cavity through the catheter. After one hour dialysis was resumed. The fluid was grossly bloody at first but ran without interruption, and dialysis After eight was completed without further complications. to ten cycles the fluid was rose-pink in colour, and remained so during the rest of the dialysis. There was no recurrence of bleeding. When dialysis was completed, the hmmoglobin level was the same as on admission. This method should, of course, only be used in cases of bleeding from the abdominal wall-i.e., only if bleeding from intra-abdominal sites can be ruled out with reasonable certainty. Medical Department P, Division of Nephrology, Rigshospitalet, Copenhagen, Denmark.
JØRGEN LADEFOGED IB STEINESS.
PROSTAGLANDINS FOR INDUCTION OF THERAPEUTIC ABORTION SiR,—The techniques at present used for inducing therapeutic abortion after the 12th week of pregnancy are not entirely satisfactory. This is true of surgical methods and of intra-amniotic injection of hypertonic solutions. It would be preferable to induce labour-like uterine contractions by intravenous or subcutaneous injection of a substance with strong oxytocic activity. Uterine sensitivity to oxytocin is low during early and mid pregnancy, and intravenous infusions of oxytocin, even when given continuously for two or three days, only rarely result in abortion.
INTRA-ABDOMINAL BLEEDING COMPLICATING PERITONEAL DIALYSIS SIR,-We owe a debt of thanks to Dr. Thompson and Dr. Uldall for their letter3 recommending the use of intraperitoneal streptokinase to break down clotted blood, so
USE OF PROSTAGLANDINS FOR THERAPEUTIC ABORTION
making it possible to continue peritoneal dialysis. We have recently been faced with the same problem, and benefited from their advice. A man of 27 was admitted with terminal renal failure and malignant hypertension due to chronic glomerulonephritis. He was severely ursemic, hyperkalsemic, and overhydrated. When the peritoneal catheter pierced the abdominal wall there was vigorous bleeding. During the first three cycles (2000 ml. each) the dialysis fluid became increasingly bloodstained, and finally the catheter became obstructed. The catheter was removed, a suture was inserted, and the site of puncture was compressed for about 10 minutes. The patient went into shock and four blood-transfusions had to be given. There were several reasons for avoiding haemodialysis in this patient. Heparinisation during hxmodialysis would have carried the serious risk of repeated bleeding. The question of early renal transplantation had not been explored, either from the medical viewpoint or in regard to a possible donor; therefore, a long period of intermittent haemodialysis had to be anticipated. Under these circumstances we prefer to use an arteriovenous fistula; but this, unlike a Scribner shunt, cannot be used immediately for hoemodialysis. Lastly, we decided against trying to evacuate the blood from the peritoneal cavity because of the
patient’s hyperkalaemia. A further peritoneal puncture was done, but blood-clots in the peritoneal cavity obstructed the outflow through the catheter. The addition of heparin, 400 units per litre, to Y. 1065.
During recent years some of the prostaglandins have been found to have a potent stimulating effect on the pregnant human uterus.1-5 Some also are reported to have strong luteolytic effects in the primate.6 The possibility of using prostaglandins for termination of pregnancy has been investigated in this department. Intravenous infusions or repeated subcutaneous injections of prostaglandin El (P.G.El) or prostaglandin F2(( (P.G.F2C>:) were given to 11 women admitted for therapeutic abortion in the 13th to 18th weeks of pregnancy. Uterine contractility was recorded by the micro-balloon technique or by transabdominal recording of amniotic pressure. Initially the infusions induced considerable uterine hyper1. 2. 3. 4.
J., Moffat, R. C., Walt, A. J. J. Am. med. Ass. 1969, 210
5.
Lancet, 1969, ii, 603.
6.
2.
Silva,
3.
Thompson, N., Uldall,
R.
Wiqvist, N., Bygdeman, M., Kwon, S. U., Mukherjee, T., Roth-Brandel, U. Am. J. Obstet. Gynec. 1968, 102, 327. Bygdeman, M., Kwon, S. U., Mukherjee, T., Wiqvist, N. ibid. p. 317. Embrey, M. P. J. Obstet. Gynæc. Br. Commonw. 1969, 76, 783. Karim, S. M. M., Trusell, R. R., Hillier, K., Patel, R. C. ibid. p. 769. Bygdeman, M., Kwon, S. U., Mukherjee, T., Roth-Brandel, U., Wiqvist, N. Am. J. Obstet. Gynec. (in the press). Pharriss, B. B. Nature, Lond. (in the press).